by David M. Cutler
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Product Description
The problems of medical care confront us daily: a bureaucracy that makes a trip to the doctor worse than a trip to the dentist, doctors who can't practice medicine the way they choose, more than 40 million people without health insurance. "Medical care is in crisis," we are repeatedly told, and so it is. Barely one in five Americans thinks the medical system works well. Enter David M. Cutler, a Harvard economist who served on President Clinton's health care task force and later advised presidential candidate Bill Bradley. One of the nation's leading experts on the subject, Cutler argues in Your Money or Your Life that health care has in fact improved exponentially over the last fifty years, and that the successes of our system suggest ways in which we might improve care, make the system easier to deal with, and extend coverage to all Americans. Cutler applies an economic analysis to show that our spending on medicine is well worth it--and that we could do even better by spending more. Further, millions of people with easily manageable diseases, from hypertension to depression to diabetes, receive either too much or too little care because of inefficiencies in the way we reimburse care, resulting in poor health and in some cases premature death. The key to improving the system, Cutler argues, is to change the way we organize health care. Everyone must be insured for the medical system to perform well, and payments should be based on the quality of services provided not just on the amount of cutting and poking performed. Lively and compelling, Your Money or Your Life offers a realistic yet rigorous economic approach to reforming health care--one that promises to break through the stalemate of failed reform.
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Average Customer Review:
3 of 6 people found the following review helpful:
 Prescribes more of the same, 2008-03-10
The first part of the book is probably informative for a novice reader on the topic, but hardly original. There are many other sources about how medical care has improved over the years due to surgical techniques, diagnostics, and drug therapies. There are many other sources about some of the economic aspects, like fee-for-service and HMOs. He skips the part about government intrusion.
When the author gets around to advocacy, his politics shows. His "strong medicine" is more government controls by politicians and bureaucrats. He is apparently blind to the consequences, which have put America's health care system in its current state. Those with political power and influence, like general hospitals and huge "nonprofit" insurers, control the system in their way.
He says the present system lacks incentives for quality of care. Yet he offers no workable solutions that would survive political infighting, not be manipulable, or how much more they would cost. He advocates pay-for-performance, which in the hands of bureaucrats becomes pay-for-conformance. Private insurers have experimented with it for several years, with no clear results.
He says little about consumer choice. You can easily guess the author's politics and outlook. He is a Harvard econ professor, worked on the HillaryCare plan -- a fiasco -- and is now a health care advisor to Barack Obama. Technocrats are bent on rationing. They lack innovative medical knowledge and skills. The rules they want stifle innovation and individual consumer choice. Consumers are simply numbers or like cattle.
3 of 3 people found the following review helpful:
 Four and a Half Stars..., 2008-01-19
since nothing is perfect.
Authoritative, clearly written, and quite interesting; I recommend to anyone -- professionals, academics, laypersons -- interested in these issues.
Specifics:
1) The first 5 chapters convincingly argue that the enormous increases in health care spending are first attributable to new technology and treatments, and well justified, benefits substantially exceed the costs. The arguments are based in substantial part on Cutler's own academic research. By themselves, these chapters are sufficient to justify the book. Cutler does a good job of explaining both the technical economic concepts and the medical issues, and I suspect anyone interested in the topic will find the chapters fascinating, eye-opening.
He reaches a very important conclusion: we ought to spend MORE, not less.
2) Subsequent chapters survey sources of waste and problems of distribution. I found these helpful in outlining some important problems, and well worth reading, but incomplete (see below). In part these explore the incentives created by different systems of paying for health care; this helps explain why some sorts of technologies and procedures are favored over others in any particular case.
3) The concluding chapter contains his solution to the problems, a system of universal insurance (mostly private) coverage, subsidized and supervised by the federal gov't; worth reading, but inadequate. Cutler focuses on a subset of problems & proposes a solution, with little consideration for other problems or possible solutions.
For example, he ignores 'public choice' issues: how would his proposal work in a world of self-interested government official, bureaucrats, insurers, medical professionals, patients, etc.? The system he proposes might work on paper, but is quite susceptible to "gaming." USDA crop insurance is a real world example, and its poor performance should make us hesitant to expand this approach to health care.
Similarly, Cutler argues that gov't and insurers should develop a payment system that rewards providers for measurable health improvements. Cutler greatly underestimates the difficulty. Soviet planners wrestled this problem for 75 years and were unable to solve it, how to specify a set of desired production outcomes from above and then have them realized as one envisions. It's a very difficult problem, I think unsolvable. Cutler underestimates it, and devotes essentially no attention to possible solutions which would make the individual consumer directly responsible for payment, and evaluation, of health care services.
4) Cutler provides a lengthy set of citations from the scholarly literature, excellent for further study. He also features, on his website, a technical appendix. It's clear he's trying to spread light, not heat, in the health care debate. Good on him!
5) Despite any weaknesses, Cutler does a fine job of framing the issues. The book is accessible and a good read. OK, OK, 4.9 stars.
C.N. Steele Ph.D.
12 of 14 people found the following review helpful:
useful book on current healthcare economics, 2004-08-24
This book is probably an important addition to the literature on healthcare economics. It offers a good corrective to the politics out there. It reminds us that healthcare spending is not wasted spending, in the sense that it almost always adds value. It also points out that in many ways the costs of healthcare are FALLING.
The real question is how can we continue to improve the value of our healthcare dollar? Cutler concurs with many conservative healthcare analysts that the real problem is that the incentives in the American healthcare system are wrong. The incentives are aligned in favor of healthcare interventions rather than health. He proposes to address this incentive problem by having the government intervene in the market by providing the right incentives. In essence, the government would post-hoc realign the incentives by rewarding quality after-the-fact and beyond fees for services. In addition, he would subsidize insurance to create universal coverage.
This is an interesting idea. At the very least, it makes the important observations that the current system is rife with market failures due to the government-imposed structure of the market.
He does not seriously investigate other options. Both single-payer and conservative proposals are rejected with a single paragraph each. This probably misses some significant arguments from each. My sense is that he only sees one kind of market failure when there are at least two. The first problem has to do with incentives, which he sees.
The second problem has to do with information that is not efficiently used. Many of the conservative thinkers on this have argued that IT ought to provide significant cost-savings. In essence, 13% of our economy is still operating without the information processing that has revolutionalized the information economy.
7 of 27 people found the following review helpful:
 Tort Reform Ignored, 2004-08-03
While I found Dr Cutler's analysis penetrating, I was disappointed that he did not discuss in any detail the large impact on medical costs of medical malpractice lawsuits. Not only do these lawsuits increase malpractice insurance premiums of physicians and health insurance premiums of patients, they lead to wasteful defensive medicine, as physicians do unnecessary tests and procedures in order to reduce the risk of malpractice suits. Tort reform is essential to control rising medical costs.
12 of 15 people found the following review helpful:
compelling approach to fix the broken American health system, 2004-01-29
Forty million Americans lack health care insurance and costs leap three and four times the inflation rate yet few Americans feel the system provides adequate care. Harvard economics professor and health-care expert Dr. David M. Cutler believes that the problem lies with the inability for most people to understand opportunity costs based on choices that may not lead to an improved life quality. The government and medical leadership exacerbate the problem with saving money as their solution, ignoring effectiveness. He makes a strong case on how much health care has dramatically improved over the past five decades as dramatized by longer productive life spans. Dr. Cutler believes that more money should be spent on further medical advances and that universal coverage for all needs should be implemented so that the present day uninsured can afford care rather than drain at a more costly rate the system. The key is to change from a system that economically encourages doctors to choose techniques that are not always the best for the patient factoring in cost and life quality to a system that reimburses doctors for quality service (not as hard as it first sounds).Though at times the medical supply and demand is difficult to grasp, YOUR MONEY OR YOUR LIFE makes a powerful well written argument to reengineer a system in which political band aids fail everyone. The case for quality and the explanation of choices are well done and surprisingly easy to follow while offering a seemingly radical but compellingly logical approach to fixing the broken American health system. Harriet Klausner
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