Jan Gregoire Coombs, The Rise and Fall of HMOs: An American Health Care Revolution.

Jan Gregoire Coombs, The Rise and Fall of HMOs: An American Health Care Revolution. Madison, WI: University of Wisconsin Press, 2005. $35.00 hardcover.

This insightful book covers in depth the historical development of Health Maintenance Organizations (HMOs) while interjecting the experience of the Wisconsin Marshfield Clinic as an HMO case study. The author carefully documents the broader context of national health care policy making as it relates to HMO development and actual health practices within the Marshfield Clinic. The book covers many topics including, but not limited to, a brief history of health insurance prior to the 1970's, the enactment of the HMO Act, health care in rural America, Antitrust Legislation, private and public sector HMO development, accountability, and health promotion strategies.

What is evident from the very first chapter is the careful research conducted by the author in documenting findings from multiple sources including individual researchers, governmental sources as in Health and Human Services, the Rand Study, and the Robert Wood Johnson Foundation. Of particular interest to the reader is the coverage on rural populations and the lack of a coordinated health care plan to address rural health care needs in the United States.

Coombs correctly points out that the development of the HMO movement was ignited due to a perceived health care crisis in the 1970's. The movement had utopian beliefs that a coordinated health care delivery system which focused on preventive care would address the escalating costs in health care as well as provide for easier health care access and a healthier American population. The increased HMO enrollments of the 1980's and 1990's have now been replaced by a decreased overall number of enrollments specifically within the private insurance sector. This decrease in enrollment numbers within the private insurance sector was primarily due to the public dissatisfaction with utilization restrictions placed on the health care consumer. Employers on the other hand desired cost effective and affordable health care for their employees and looked to the insurance industry to create health plans which were both affordable and desirable. The author concludes that the original HMO movement is dead due to a multiplicity of stakeholders and stake challengers, privatization, lobbying, technology, paperwork, the political marketplace, and chronic disease and illness. What is left of the HMO movement is a myriad of managed health care arrangements that have been designed to attract customers and resembles and includes features of other non HMO insurance plans. Coombs supports through her research and demographic data that the current health care crisis is more critical today than in the 1970's.

However, the author does suggest several strategies that could be used to address the problem, such as resolving the financing inequities of insurance within the private and public sectors and modeling our health delivery against other industrialized nations who spend far less for the health care and receive a far greater return.

I would take exception with the book's assertion that the HMO movement not only contributed but created our current health care crisis. Several caveats concerning our current health care crisis need to be addressed within this context. Policy experts for many decades have pointed to the Constitution and our policy making process in the United States as the focal point for health and welfare concerns in this country. Constitutional arguments regarding states rights vs. federal oversight for health care has resulted in a log jam of incremental legislation to address national health care needs. Coupled with these two opposite approaches in addressing the health and welfare needs of the population are our free market economy and the volatile political marketplace. As a pluralistic country we attempt to mediate between many differing viewpoints whenever we legislate. Within the larger context of health and welfare, we have been unable to construct a unified and consistent approach in addressing the overall health and welfare of our population. Other contributing factors such as the revolution of new medical discoveries, the breakdown of the American family (who traditionally provided most health care to its members), corporate health care industry mergers, and the penetration of health care into the community setting have all led to further complications. Until we address the underlying Constitutional interpretation of who provides health care and under what form, we will be ill prepared to develop a sustainable continuum of health care for the United States.

Most recently, several initiatives, such as the newly created Medicaid Advisory Commission, and the Integrated Care Program funded by the Robert Wood Johnson Foundation have taken on publicly funded health care issues. The Medicaid Advisory Commission has been set up to advise the federal government on future Medicaid funding and services while the Integrated Care Program has funded five state demonstration projects with the purpose to integrate the financing, delivery and administration of care under dual eligible patients who are covered under both Medicare and Medicaid. Since Medicaid HMO enrollment is the only sector that is growing at the present time, these initiatives will hopefully enlighten policy makers.

The corporate health care industry, academic professionals and doctoral level students who are in medical and allied health related professions will find this book extremely helpful. Coomb's book serves a valuable function in the thorough examination of a very complex subject. Since health care policy and practice continues to evolve at a fast pace it is hoped that the author of this book and others will continue to research its best practices.

Lisa S. Patchner

Ball State University