Misdiagnosed: why all the money in the world won't fix what's wrong with America's health care system.

• Author: Longman, Phillip
• Position: Sick: The Untold Story of America's Health Care Crisis--and the People Who Pay the Price - Book review

Sick: The Untold Story of America's Health Care Crisis--and the People Who Pay the Price By Jonathan Cohn HarperCollins, 320 pp.

In his new book, Sick: The Untold Story of America's Health Care Crisis--and the People Who Pay the Price, Jonathan Cohn, a senior editor at the New Republic, offers a series of chilling anecdotes about ordinary Americans who lack affordable medical care. There's the mother of three who, after her husband loses his high-tech job and family health benefits, puts off seeing a doctor and winds up dying of breast cancer. There's the security guard in Los Angeles who can't afford treatment for his diabetes and winds up partially losing his vision. There's the impecunious former nun hounded by bill collectors from a Catholic "charity" hospital. In all, Cohn fills eight chapters with similar tales of desperation, along the way pausing to provide policy analysis and historical background--all in an attempt to explain the larger forces at work in America's health care crisis.

Cohn tells his stories with compassion and rich detail, vividly demonstrating how the cost of health care threatens not only the finances of ordinary Americans but, quite literally, their very survival. For those who want to know how Medicare, Medicaid, managed care, or medical savings accounts came to be, Cohn provides an easy-to-read primer. Though generally critical of market forces in medicine, Cohn is completely fair. He describes why it is actuarial logic, and not necessarily greed, that compels insurance companies to discriminate against people with preexisting conditions or to charge the old more than the young. Cohn doesn't demonize corporate medicine; instead, he dispassionately describes its limited ability, particularly in an era of vicious price competition, to pursue a social ethos while at the same time earning a return on capital.

Cohn's book comes at a time when health care is once again rising to the top of the political agenda. Stung by the ever-rising cost of employer-provided health care, big business is at last beginning to put its weight behind health care reform. Wal-Mart's CEO, Lee Scott, is now on record favoring universal coverage. In January, America's Health Insurance Plans, a trade group of large insurers, rolled out a ten-year, $300 billion proposal to provide health insurance for all children and 95 percent of adults. Perhaps more important politically, the majority of Americans who have health insurance increasingly worry that they'll lose it--even as they resent having to pay an ever-rising share of its cost. All of the Democratic presidential candidates are vowing to achieve universal health care if elected. Some have very detailed plans. But unfortunately, the debate over health care continues to be poorly framed, and Cohn's book, for all its virtues, is another example of that problem.

Like most critics of the medical care system in this country, Cohn begins from the premise that the fundamental problem with American health care--widely held to be the best in the world--is financial in nature: the system costs too much, and leaves too many people uninsured. But that is a flawed premise.

As a group, uninsured patients like those Cohn chronicles in his book face real hardships. But when they do receive medical care--in emergency rooms, free clinics, community hospitals, and the like--they receive care that is as high or of higher quality as that of the insured.

Yes, you read that right. According to a recent RAND study published in the New England Journal of Medicine, uninsured patients receive only 53.7 percent of the care experts believe they should get--that is, appropriate, evidence-based treatment. But according to the same study, patients with private, fee-for-service insurance are even less likely to receive the proper care. Indeed, among Americans receiving acute care, those who lack insurance stand a slightly better chance of receiving proper treatment than patients covered by Medicaid, Medicare, or any form of private insurance.

How can this be? To answer that question, you need to understand what the insured are actually getting for their health care dollars. One answer: there's a lot of unnecessary treatment. Dr. Elliot S. Fisher, a Dartmouth Medical School researcher, estimates that 30 percent of all Medicare spending goes for unnecessary operations and procedures. For instance, under Medicare, the per capita cost of treating terminally ill patients in Miami is $50,000 more than the per capita cost of treating equally old terminal patients in Minneapolis, yet the patients in Miami don't live any longer. The explanation is simply that Miami's high concentration of specialists and hospitals is overtreating the city's patients.

To put a more...