HEALTHECONOMICS, VOL. 4: 147-151 (1995)

BOOK REVIEWS

BOOK REVIEWS

Understanding Health Care Reform by THEODORE R. MARMOR. Yale University Press, New Haven and London, 1994. No. of pages xv + 284. ISBN 0-300- 05879-9.

The advertiser’s blurb on the front of this book quotes a US senator’s claim that this work is crucial reading for those wishing to understand the current debate about US health care. For once the advertisers have not exagger- ated. This collection of essays, reprinting essays published in the last few years, mixes analysis and advocacy and is always fun to read, as well as providing lessons for policy analysts, health economists and political reformers.

For policy analysts Marmor’s lessons are primarily methodological. They consist in demonstrating the importance of defining alternative policy options carefully, and thinking of policy choices not simply in terms of overarching labels but also in terms of their component parts. In the US health debate, for example, perceptions about alternatives polarised around notions of managed competition and single-payer schemes. But, as Marmor so clearly shows, when the details of the schemes are looked at, options often considered as sharp alternatives come to look very similar to one another in certain crucial respects.

The methodological problems become particularly important when making cross-national comparisons. Marmor reprints his critique of Aaron and Schwartz’s Painful Prescription, written jointly with Rudolf Klein, in which one of their central themes was the need to be clear about the purposes for which comparisons are being made. If they are being made for the purposes of policy learning, then a most similar system design is needed, whereas if they are being made for the pur- poses of explanation then a least similar design is often needed. Neglect of these methodological issues leads to a misdiagnosis by Aaron and Schwartz of the impli- cations of the UK’s rationing practice for the US.

For health economists the lessons are primarily concerned with the importance of institutional and political factors in the application of economic analysis to health care systems. This theme is most clearly illustrated in an excellent essay I had not read before entitled ‘Cutting Waste by Making Rules’. Here Mar- mor and his co-author Jan Blustein analyse the claim that large cost savings in medical care can be secured by eliminating wasteful practices in medicine. They

highlight the ambiguous nature of the claims that are often made under this heading, where critics are some- times talking about ineffective or harmful treatments, sometimes about treatments of uncertain effectiveness, sometimes about treatments that are ethically troubling and at other times about treatments with a high ratio of cost to benefit. In the last case, they show how institu- tionally difficult and politically controversial it is to suppose that ‘waste’ can be reduced. This essay should be compulsory reading on all health economics courses.

Similar issues arise in the case of implementation. Although only the final essay is explicitly devoted to the problems of implementation, there is a sense in which the themes it touches on pervade the whole work. Analysis of policy alternatives and courses of action with no attention to the circumstances in which solu- tions have to be implemented is not only a waste of time, but can lead to situations in which reforms are counter-productive or have quickly to be undone. For British readers I suspect the words ‘poll-tax’ will spontaneously spring to mind.

For those engaged in the US health care debate as reformers Marmor speaks as a committed partisan of the single-payer Canadian approach, and he argues that the Canadian model was taken off the Clinton policy agenda for no good intellectual reasons. He points to the failure of the US media, staffed by political reporters who do not understand health care issues, to identify alternatives properly, and highlights the dispropor- tionate power of the insurance industry in opposing single-payer plans. He advocates the view that Clinton should have taken the opportunity to pursue bold change, since such opportunities come only infrequently.

But much though I enjoyed Marmor’s exercise in advocacy I felt at some points that his instincts as a reformer were running ahead of his analysis as a political scientist. The bold reforms of the Roosevelt years owed much to the deep impact of the depression on public attitudes and the restless personality of the President in ways that created the conditions for a broad based coalition for reform. The Clinton presidency operated in an environment where the policy space was much more crowded, leading to a fracturing of feasible alternatives, and without the sense of general social crisis that Roosevelt could appeal to. Moreover, even if Clinton had said ‘we have nothing to fear but fear itself’, would anyone have believed him?

0 1995 by John Wiley & Sons, Ltd.

148 SOOKREWWS

Inevitably in a collection of reprinted essays there are overlaps, repeats and even at times inconsisten- cies. But, despite these, you should read the collection for yourself, even if you know little about US health care policy. If you are provoked and

entertained as much as I was, you will find them worth the time.

ALBERTWEALE Department of Government, University of Essex

Concepts and Measurement of Quality of Life in Health Care edited by LENNART NORDENFELT. Kluwer Academic Publishers, Dordrecht, Boston and London, 1994. No. of pages:283. ISBN 0-7923-2824-8.

This book combines a number of papers presented at a 1991 symposium on quality of life with later contri- butions written especially as book chapters. In the first of 3 sections, the definition of quality of life (QoL) and its relationship to other concepts is discussed. Various authors argue for the importance of Aristotle’s concept of ‘eudaimonia’ (more than just happiness, also the realisation of mental potential), the separation of the concept of happiness or well-being from that of (physical, external) welfare, and for an analysis of logical relationship between needs or goals and QoL. The chapters are quite diverse in their idea and there is no general conclusion or consensus but there are several recurring themes: a person’s happiness or well- being is influenced by the life-situation (welfare) and by wants and goals in life (called by one author happiness-as-equilibrium); different people have different wants/desires/goals although there is often a common core; wantslpleasures etc should be in the present, although past and future ones can also be taken into account; how do we compare and rank different pleasureslwantslneeds; who should be the judge? The last paper is particularly interesting, offer- ing comment on why people report greater happiness than they probably have and the consequences for social relationships.

The second section brings us closer to health care, and several of the papers refer to factors that have caused QoL to be such a topical issue for measure- ment and debate. These include changing patterns of health towards chronic illnesses with an ageing population and greater treatment possibilities, the need to control rising health care expenditure, the desire to have ‘value for money’, the demand for more collective and explicit decisions, the desire to address matters of human respect and autonomy. The opposing views of ‘utilitarians’ and ‘deontologists’ are discussed, with the former proposing rational prioritisation of health care based on explicit measurement of benefits (e.g using such concepts as QALYs), and the latter arguing that it is impossible

for one life to have more or less value than another and thus they cannot be compared in such a way. It is noted that peoples’ preference (e.g for health states) may change according to their current situation and perception thus making comparison difficult. The last chapter reflects on the use of QoL measurement in determining the effectiveness of medical treatments and in the area of euthanasia.

Fitzpatick and Albrecht, starting the third section, set out well the diversity of contexts in which QoL measurement can be applied in health care. They identify clinical trials and evaluation research as producing most acceptance, where assessment is seen as remaining close to patients’ own subjective judge- ments and where data can allow more informed choice by patients and clinicians regarding treatment options. They argue that there is as yet no clear evidence that QoL measurement is of value in health needs assess- ment and in clinical care, although it may improve the awareness of health authorities and health profes- sionals of the extent and nature of health-related problems to be addressed. It is the area of resource allocation where QoL measurement is most controver- sial, with the requirement of a single number to reflect the value of each possible health state and the use of utilitarian approach that may clash with principles of equity and fairness. Methods for assessing the validity of QoL measures are outlined, including content and construct validity. Further developments in QoL assessment include instruments personalised to include only the domains that fit an individual’s own prefer- ences, and the use of patients’ own judgements of change. The last two chapters in this section relate to QoL measurement in psychiatry, commenting on the effects of changing levels of aspirations, the knowl- edge of alternatives and the Pollyanna phenomenon as discussed in the first section.

The main thrust of the book is philosophical and it offers the reader interesting insights into alternative theories on QoL and its relationship with other concepts, particularly in the broad picture of human life and aspirations. The title is somewhat misleading-issues relating more specifically to health care are not met until the second section and there are few chapters which deal with actual applied measure- ment of QoL in health care. There is little mention of