FIXING AMERICAN HEALTHCARE

Through the use of a simple quadrant device, Fogoros gives consumers an understanding of how various healthcare systems work, and their multifarious–not to mention nefarious–implications.

Draw a cross: The horizontal axis represents who makes healthcare decisions, with individuals to the right and a centralized authority to the left. The vertical axis measures the quality of those decisions: high at the top and low at the bottom. Onto this four-quadrant model, Fogoros can plot the healthcare universe. For many years we lived in the lower right, the realm of entitlement and no limits and simply not sustainable. As HMOs entered the scene, we shifted to the lower left, which Fogoros describes in withering, and all-too-familiar, detail: The realm in which the doctor-patient relationship went to die and covert rationing unleashed its many ills through the Wonko bureaucrats and Gekko greedheads. The upper right, where the patient makes individualized decisions for the best care, is the province, these days, of the superrich. The upper left, with some form of institutional oversight seeking the wisest healthcare decisions raises a necessity anathema to the American sense of autonomy: rationing. The "option is to give up either our notion that healthcare is an essential entitlement or our conviction that there can be no limits on healthcare." Fogoros proceeds–with gin-clear specifics, propped by ample research, and with an abiding sense of decency–to straddle the top two quadrants (hedging to the left). The rub is rationing. Centralized authorities control a pool of money; while the pool is limited, there are potentially no limits on what can be spent on healthcare. Besides calling for universal healthcare, incentives for doing science, patient participation and returning the doctor-patient relationship, he makes brave forays into the ethics of end-of-life decisions and rationing that seeks to balance fairness with the common good. Not every reader will be sanguine with the mathematics of "quality-adjusted life-year," but at least it’s a stab at a sane measure.

Informed and humane. Some presidential candidate would be smart to sign this gentleman up as a healthcare adviser.