2005, New York: Oxford University Press, pp 382,
ISBN 0 19 517066 0
“Healthy, Wealthy and Fair” describes the healthcare system in the United States and makes a strong case for the need for policy reform and for a national healthcare system. The book consists of twelve chapters that fall into three main sections. The first section addresses inequality and poverty and how these impede access to healthcare in the United States, in other words it describes who the 70 million uninsured or underinsured Americans are. The second investigates the barriers to reform: political, historical, social, and economic, and describes how the system has become unfair. The last suggests some strategies for realising a National Healthcare System.
The book focuses on the population that “has not” and does not receive access to healthcare. There is no specific focus on the issue of integrated care: clearly patients with no access to care at all are not accessing integrated care. However, there is a lot of attention to integrated problems in the “has not” population. For example, lack of healthcare is associated with lack of income, lack of income with lack of education, lack of education with early pregnancies and low birth weight, low birth weight with lack of prenatal care and so on. In the concluding chapters on how to change the system, some references are made to small grass roots initiatives, which, however, have no modeling significance, as there are no statistically significant data on whether the experiences and results are replicable.
The book is excellently researched and well written, with a very full bibliography following each chapter. The book is written by fifteen different professors from nine fields of study, from public health to social epidemiology to political science. This myriad of perspectives enriches the reading experience, leaving the reader with the rich texture of a multi-professional effort. The section on inequality and poverty is extremely interesting for any reader interested in understanding the poverty of one of the richest countries in the world. The section on the barriers to reform is an interesting compilation of different professional perspectives, which together explain how the system is inherently unfair. However, it is not clear who the editors imagined the ideal reader of the whole book might be. The jacket suggests that it is “indispensable to all those who care about health, inequality and American democracy”. However, the length of the work (400 pages) and its level of detail require an extremely committed reader.
The last section of the book is a big disappointment: the concluding proposals on what to do to change things do not seem to have anything to do with the extensive research presented in the preceding sections of the book itself. After such minute research into the causes and the history of the US health system, the expectation of the reader is that all this research is going to have been useful for producing a compelling and great idea for change. Unfortunately, the proposals are extremely far away from the research itself.
The authors of the concluding section on how to change things promote a two-pronged approach. Minute incremental improvements on the one hand and sweeping federal healthcare reform on the other. Both need to happen at the same time. The authors point out that incremental improvements can already be observed on an extremely local level. The authors themselves suggest that it is unreasonable to expect such grass roots examples to solve a 70-million person problem, however, it is considered encouraging.
The authors then go on to observe that global markets have caused economic inequalities in household income everywhere. However, the inequalities have been much greater in the United States than in its European and Canadian counterparts, which have centralised systems for guaranteeing that wealth gets redistributed to contain extreme poverty.
The authors therefore suggest that along with the grass roots experiments, there needs to be a centralised reform. They even point to a very interesting paradox, which, however, is not explored in the book: there is a lack of evidence that government social policy inhibits economic growth through taxation and social responsibility.
The excellent extensive social, political and economic history and research provided by the authors of the first two sections are not drawn on by the authors of the concluding chapters. The book “Healthy, Wealthy and Fair” leaves the reader with little hope but to “dream on”, for a healthy, wealthy and fair healthcare system in the United States.