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Health Care Politics, Policy, and Distributive Justice: The Ironic Triumph.

The interesting dimension of this wide-ranging book on U.S. health policy is pointedly conveyed by its subtitle. From humble, struggling beginnings less than a century ago, health care-medical science, at least, and even societal support of care for major segments of the population-has emerged as one of our culture's most prestigious, powerful, and growing enterprises. To our health care we devote the highest percentage of the largest GNP and the largest amount per capita of any nation on earth; despite our capitalist learnings, we governmentally support the largest medical research establishment and the most expensive medical care for the elderly.

Robert Rhodes, however, grinds the luster off these triumphs by noting their many ironies. A political scientist at Edinboro University (Pennsylvania), he not only nods to the common ones-that we are not the healthiest population by a long shot, that we have an unconscionable thirty-seven-plus million uninsured citizens, or that the triumph of medical science over fatalism has led to an incredible, reverse denial of death-but also claims more controversial and interesting ironies. The policies, or lack of policies, behind our great expenditures now divert resources from the very needs (many of them nonmedical) that may be more vital to our health than acute-care medicine. Such decent encouragements of access as we have (Medicare, primarily, and the huge tax break for employer-paid premiums) are funded in a way that threatens to rob coming generations of any similar share of resources. And were we more truthful with ourselves, the prescientific fatalism of earlier eras might now have to be replaced by an even more frustrating political-economic fatalism: special interest groups and budget deficit politics effectively block the possibility of reforming the health system so as to guarantee access. (We might, of course, get reform by giving up on the containment of costs and unjustly loading them onto future generations, but that would constitute its own intergenerational injustice. Furthermore, it would be yet more directly ironic; it would even harm our health, for a healthy economy that is politically capable of reducing poverty is one of the first requirements for population health.) And so on.

We need to be brought up straight in our seats by a (healthy?) dose of realism about our political culture and structure. Rhodes's chapters, "Congress and the Bureaucracy" and "Budget Politics," are alone worth the price of admission. They alert us to our terrible unwillingness to support government unless someone else pays more of the bill than we do. They call our attention to the simply disgusting duplicity of the administration and most of both parties in Congress in disguising real budget deficits with saved-ahead Social Security Trust Funds to "meet" Gramm-Rudman targets-a practice that does matter, economically and morally, because we're making future workers pay back what we have proudly claimed we were now investing. And they force us to recognize the political box of even stronger and more hamstringing interest groups that we created for ourselves when we bought Medicare entitlements back in 1967 for the awful price of letting fees and aggregate budgets go virtually unregulated.

Health Care Politics is certainly not an elegant book: too many unfocused background ramblings, for one, and it badly needs a concluding chapter to pull the whole thesis together. Much of the book is also not very original, documentation is sometimes weak, and the conceptually pivotal chapter on distributive justice and equal access is hardly philosophy at its best. Yet the book's many striking, politically blunt observations about the health policy formation process contribute something immensely valuable to our view of how we formulate health policy. Rhodes invites us to take note. Maybe "successful" politics solves no more problems than it creates or avoids.
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Author:Menzel, Paul T.
Publication:The Hastings Center Report
Article Type:Book Review
Date:Mar 1, 1993
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