Wanting It All: The Challenge of US Health System Reform

The background for this essay is hardly obvious. The Federal Reserve Board of Boston is not a group with which I have had any disciplinary or policy connection. I am a practicing political scientist with a long history of interest in health care and social insurance. I was, in short, surprised at being asked to introduce a conference on American health care reform that would be awash with papers by health economists. I also faced a personal challenge in how to approach my subject-the politics of struggles to reform American medical care. There was the undeniable impulse to settle scores. After all, I had debated with most of the health economists in the conference for more than three decades. I had reviewed their books or articles in ways neither their spouses nor their parents would have approved, arguing with them in print and in debates about the limits rather than the benefits of market instruments and free-market allocational principles in medical care. The question for me was, what constructive essay could come out of that background? Indeed, to be utterly candid, my first thought was to imagine a virus that took out "consumer choice" and "market forces" from Alain Enthoven's computer. Or perhaps I could do the same thing to David Cutler, but choose "paying physicians for improved health outcomes" as the object of his computer virus. There is undeniable competition in the health policy game, and one competes in that game partly by product differentiation-that is, differentiation in policy ideas. Due in part because I became Medicare-eligible last year, I thought this opening paper was a time for reflection, not retaliation. After all, I