A Second Opinion: Rescuing America's Health Care, by Arnold S. Relman, M.D. (The Century Foundation)
Health Care at Risk: A Critique of the Consumer-Driven Movement, by Timothy Stoltzfus Jost (Duke University Press)
Health Care Reform Now! A Prescription for Change, by George C. Halvorson (John Wiley & Sons, Inc.)

During 2007, some new books on health reform offered the same old message of single-payer, government-monopoly health care. Others offered market-based solutions but, unfortunately, rely too much on "top-down" technical innovation instead of "bottom-up" consumer preference to improve American health care. Three books not only show the wide spectrum of views, but they also typify the tendency of scholars and practitioners to offer idealist solutions to health care problems and with less diversity of individual choice.

Timothy Stoltzfus Jost, for example, admits that he doesn't know what consumer-driven health care (CDHC) might bring, but he knows he's afraid of it. That concern drives Health Care at Risk: A Critique of the Consumer-Driven Movement, a defense of government-monopoly medicine. Jost is a professor of law at Washington and Lee University, and his health care proposal includes (as usual) expanding federal health insurance, prohibiting private insurers from evaluating health risk, and lowering doctors' incomes. As for CDHC, he claims that it failed the first time around.

Jost evaluates the current consumer-driven health care effort against a "consumer" model of the 1920s, before Medicare, Medicaid, or "the Blues" existed. Even when costs were much lower, people with major illnesses were unlikely to have saved enough money to pay for treatment. True, but this was before anyone had seriously attempted to insure catastrophic health risks. Today's CDHC endeavor is vastly different, based on modern insurance theory and social and medical norms that demand innovative, high quality, and often expensive health services.

Nevertheless, today's CDHC advocates understand that allowing patients to save and spend more of their own dollars on health care will reduce prices and increase quality through competition. As for the poor, CDHC advocates propose tax credits to ensure that they have the broadest choice of health care possible.

Reluctantly, Jost notes the evidence of the positive impacts of consumer-driven health care to date. Patients who control more of their healthcare dollars are using doctors and emergency rooms less often, and more Americans are switching to generic drugs. Enrollees are searching for information on doctors. Jost admits these truths indicate cost savings in the long term, but persists in condemning CDHC: "But we must not just look at positive effects of CDHC, however, but also at its potential problems." These "potential" problems comprise the bulk of his 200-page harangue.

Remarkably, Jost also owns up to the troubles with "solidarity based" health care delivery: poor access, long waiting lists, and obsolete technology, with rapid care for ruling politicians and high incomes for powerful healthcare interests. And he knows that "governments seldom increase the efficiency of markets and are often unproductive, if not corrupt." Why, then, does he arrive at a conclusion so at odds with his evidence?

In fact, Jost expresses distaste for all economic freedom and the wealth it generates - the money we could spend on health care, he quips, we waste on toys, SUVs, and exotic coffee. Jost should rely more on his evidence. The facts are looking good for CDHC: Health Savings Accounts and high deductible health plans are gaining popularity among Americans. Consumers are becoming more knowledgeable about health care services and products. Patients are enjoying more control of their health care, and relying less on third parties for payment.

This is not good enough for Professor Jost, who fundamentally disbelieves in competition, and in each individual's capacity to be free. Those who cherish their freedom, and their health, should be wary of Health Care at Risk.

We can always consider a second opinion, but Dr. Arnold S. Relman sings the same tune. The Harvard Medical School professor and former editor-in-chief of The New England Journal of Medicine, presents A Second Opinion: Rescuing America's Health Care, which begins with convenient summaries of all the chapters so you don't have to sift through the details -- and the devil is in them.

A physician, Relman seeks to restore the purity of the patient-doctor relationship, which he says is corrupted by high costs, driven by administrative paperwork, which is in turn caused by profit-making motives in health care. Relman's nostalgia for medicine's "fundamental nature" is impractical, because health care delivery and medicine are irreversibly different today.

Relman fantasizes that Americans are held captive by a "medical industrial complex," referring to investor-driven, entrepreneurial providers. Relman extols a time before health care became "commercialized," but the evidence he cites is insufficient to determine whether not-for-profit, or for-profit health care is superior.

While claiming to restore the true nature of medicine, Dr. Relman's proposal is simply to put the government in charge. His national insurance program would provide all patients with a so-called comprehensive insurance benefit. Funding would come from a health care tax, administered by the new National Medical Care Agency (NMCA) that would regulate but not "own" the private, not-for-profit multispecialty groups of physicians.

Dr. Relman's greatest fear is undoubtedly CDHC, which aims to streamline the health care system with market forces. Relman insists that CDHC effort will not reduce costs, and that it is fundamentally inconsistent with the realities of medical care. He also acknowledges that private capital has spurred the rise of new technology, important medical advancements, and better treatments for patients around the globe, Dr. Relman won't face the reality that these investors are driven by profit motives.

Another reality is that while most Americans may be cynical about profit-driven insurance companies, they feel the same about government monopolies. Americans know that the costs of implementing a government monopoly could be large for only a slight reduction of administrative costs, likely limiting their options to lower quality, less technology, and longer waits for care. A similar phenomenon has happened here with our giant government programs. Doctors are less likely to take patients covered by Medicaid, the joint federal and state program for the poor, because it consistently underpays hospitals compared to private insurers, and in many cases, even the uninsured.

Canada has a single-payer health system, and Brett Skinner of Canada's Fraser Institute has shown that health care in Canada only seems to cost less because public health insurance does not cover as many treatments, or as many advanced treatments as the U.S. Skinner also found that the Canadian system is not financially sustainable. Dr. Relman nevertheless claims that: "It is clear that except for the problem of waiting lists for elective procedures, Canada's government-financed health care insurance system has been able to provide good medical care to all."

Really? Even if patients can wait as long as 40 weeks between seeing a general practitioner and having surgical treatment? Even if a man in Quebec took his case all the way to the Canada Supreme Court in 2005 because he painfully waited for a year to get his hip joint replaced, a case that Relman grudgingly cites?

Dr. Relman is not comfortable with having doctors and hospitals conform to the needs of "consumers," but CDHC is not waiting. Rather than roping people into a government pool without choices, savings, self-sufficiency or innovative advancement, we need to help patients to save and pay for health care, with options. A government monopoly in health care is simply not capable of doing this job, which is why Dr. Relman's critique, while it may seem appealing, is not practical.

Lastly, we turn to a very different strategy for achieving "universal health care." George C. Halvorson, the chairman and CEO of Kaiser Foundation Health Plan and Hospitals demands Health Care Reform Now! A Prescription for Change. His data-based "process improvement techniques" seek to reshape the health care industry and create real health care markets. Halvorson calls for "connectivity" among doctors and patients with electronic records rather than an antiquated paper system, and correspondingly higher efficiency standards.

Halvorson foresees health care imitating other industries with wholesale and retail markets. His answer to Dr. Relman's government agency is infrastructure vendors (IVs), or the "Wal-Marts of health care." Existing health plans could serve as vendors. Large employers would be the primary "buyers" in Halvorson's proposal, because they are experienced purchasers who bear many of today's health care costs.

Halvorson's future in health care would depend on these buyers hiring IVs, which would contract with providers to create health packages. Individual buyers of health insurance would also buy health packages from IVs. The IVs would aggregate health data, track performance, and run websites where patients could choose health care and caregivers. Of course, such a data-rich environment depends on everybody playing along. Halvorson's plan assures this because health care coverage is "an entitlement of citizenship" that everyone should be mandated to buy - an interesting interpretation of "entitlement." Funding would come from a health care sales tax and an "in-lieu" tax on employers who don't offer insurance, tried unsuccessfully in Massachusetts and California.

The new money would expand Medicaid, and the remaining uninsured with higher incomes would enroll in a new program of guaranteed issue private health insurance, "HealthPrime." And so it seems that Halvorson's plan, with fancy technology, looks like a rerun from those whose lives would be easier if they could simply compel us to buy health insurance instead of restructuring it so more of us would choose to buy it. A businesslike model and market based, positive incentives are worth striving for, but I hesitate to recommend a great expansion of taxes, and government programs which have proven costly and inefficient thus far.

Diana Ernst is a health care policy analyst at GRIH and a public policy fellow in health care studies at the Pacific Research Institute.