Understanding Health Care Reform.

• Author: Judis, John B.

Theodore R. Marmor's book of essays was completed before the Clinton administration's health reform proposal met its doom in Congress, but Marmor has nonetheless written its epitaph. Reflecting on the possibility of "systemic reform," Marmor writes, "The likelihood is that our politics will leave Americans with confused choices, escalating inflation, and considerable despair." Marmor's recent essays, collected under the title Understanding Health Care Reform, could have been more accurately titled Understanding the Failure of Health Care Reform.

Marmor, a professor at Yale's School of Organization and Management and an expert on health care policy, has been a leading proponent of a Canadian-style single-payer health insurance system, but like many health reform advocates, he tried to make the best of the Clinton effort. These essays, many of which were written during 1992-1993, record Marmor's attempt to explain what the choice of reforms entailed and why it would be difficult for any fundamental reform to be adopted. The essays range from outstanding to dispensable, and there is considerable repetition among them. But several themes emerge which are important to any future consideration of health care reform.

Marmor argues that, leaving aside political feasibility and the precise details of implementation, the Canadian system remains the best model for American health care reform. It provides its citizens with univrsal and high-quality care--in polls taken in Western Europe, North America, and Japan, Canadians are the most satisfied with their nation's health care system--at a price considerably less than that of the American system--about nine percent of Canada's GNP, compared to 12 percent of GNP in the U.S. Unlike its primary rival, managed competition, a single-payer system would preserve and even revive consumer choice. And also unlike managed competition, it has been tried and proven workable.

Marmor's support for a single-payer system, while controversial among lobyists on Washington's K Street, is widely shared by health and economic policy experts who have looked at the subject dispassionately. In the last five years, the General Accounting Office, the Congressional Budget Office, and, most recently, the Office of Technology Assessment (none of which are known for their reckless radicalism) have issued studies favorable to single-payer reform. And most health experts who favor other plans--from the Brookings Institution's Henry...