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The $800 Million Pill : The Truth behind the Cost of New Drugs

From Publishers Weekly
In this fascinating critical look at drug and biotech companies, Goozner pulls back the curtain on the process of new drug development and answers two important questions: "where do new drugs come from?" and "what do they cost to invent?" Using case studies that recount the discovery, development and eventual commercialization of a number of significant drugs, including Epogen and the AIDS cocktail, Goozner dismantles the pharmaceutical industry?s assertion that drug prices must be kept high in order to stimulate cutting edge research. The cost of each new discovery averages $800 million, industry officials have claimed. But Goozner argues that citizens are already paying much of that bill: taxpayer-financed medical research, he finds, has played a major role in each important medical discovery. Goozner convincingly argues that new drugs get into the hands of the sick not thanks to drug and biotech companies, but to the passion of dedicated scientists?in both the private sector and the public. A former Chief Economics Correspondent for the Chicago Tribune and an award-winning journalist, Goozer writes with skill and elegance, incorporating anecdote and history in a way that enlivens his research and makes his book an engrossing read. Though the issue of drug costs has been discussed extensively in the media, Goozer?s study puts all the political chatter, news coverage and analysts? reports into a context where they finally make sense.
Copyright ? Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

From the New England Journal of Medicine, July 22, 2004
The pharmaceutical industry claims that it can continue playing a key role in the development of new weapons against disease only if Americans pay prices for medicines that yield very high profits. It also claims that price controls would cause the stream of new products to dry up. Merrill Goozner, a former chief economics correspondent at the Chicago Tribune, comes to a conclusion that is very different from the views espoused by the drug companies. He does so on the basis of a detailed review of the development of drugs to combat cancer and the human immunodeficiency virus, a description of the early successes of therapies developed by the biotechnology industry, and a review of the economics of "me-too" products, such as H(sub 2) antagonists, proton-pump inhibitors, and allergy medications. He believes that the private sector's main role is to develop and commercialize therapies that are based on knowledge generated by independent researchers in academia and in government. In his opinion, high prices and big profits are not the key ingredients in pharmaceutical breakthroughs. On one hand, this book gives the reader lots of interesting and useful background about the people and organizations involved in expanding medical knowledge and in developing drugs. On the other hand, it falls short of what I expected from the title. It is not a detailed forensic accounting of the true cost of developing individual drugs as compared with industry claims. Indeed, the only real discussion of the $800 million pill (the alleged average cost of developing a new drug in the United States) comes in a brief review of a study by the Tufts University Center for the Study of Drug Development that was first published in 1991 and then updated in 2001. There is a brief rebuttal from other organizations in the penultimate chapter of the book, but for a reader looking for definitive "proof" or data, this book falls short. Written in the typical style of investigative journalism, the book comes across as an author's attempt to prove a point, rather than an impartial scientist's effort to answer a question. Goozner repeatedly comes back to one central theme: that medical innovations start with dedicated and passionate people, most of whom are not employed by the pharmaceutical industry, who are investigating scientific questions. Without these dedicated scientists, none of the innovations described in this book would have occurred. In other words, the development of drugs is not exclusively driven by high profits but, rather, is a collection of efforts. Goozner goes on to suggest some very useful methods for improving the process of drug development with the support of government-funded research (e.g., randomized trials comparing new and existing products, such as the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, known as ALLHAT). Although the approach Goozner uses in this book is not scientific, I think he makes a persuasive case. The passion of individual scientists pursuing an activity they truly enjoy, not the profit motive, has led to the major technological advances of the past century. I will end by saying that I am not one who enjoys reading books slowly. I often skim. In order to read a book from cover to cover, I have to find it truly interesting. I can tell you that I read every word of this book. Allan S. Detsky, M.D., Ph.D.
Copyright ? 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

The Truth About the Drug Companies: How They Deceive Us and What to Do About It

Amazon.com
Many Americans have wondered why prescription drugs have become so expensive while advertising for those drugs seems to grow exponentially. Former New England Journal of Medicine Editor Marcia Angell has some answers. The pharmaceutical industry, according to Angell, is fraught with corruption and doing a disservice to customers, the federal government, and to the medical establishment itself. In The Truth About the Drug Companies, Angell explains how a huge portion of the revenue generated by "Big Pharma" goes not into research and development but into aggressive marketing campaigns to sell their product. She describes how, even though the drug companies claim that it costs them an average of 802 million dollars per drug to develop new medicines, that figure is obscenely inflated since it factors in marketing as well as expected interest the company would have received had they invested the money in the open market. Meanwhile, Angell says, most of the R & D work is done by colleges and universities funded by the government. There are also problems with the drugs themselves, Angell indicates, since a majority are "me-too drugs", slightly modified versions of existing products which meant to address concerns of consumers most likely to spend money on pharmaceuticals. Thus, the market is filled with remarkably similar drugs to treat depression and high cholesterol while potentially life-saving medicines for diseases afflicting third-world countries are discontinued because they aren't profitable. In the books most damning passage, Angell tells of the high-priced junkets offered to doctors, ostensibly offered as educational opportunities that seem to constitute little more than bribes. The prognosis for reform is a grim one, Angell indicates, due to the massive cash reserves and lobbying efforts of "Big Pharma." Indeed, that lobby was hard at work trying to discredit her claims immediately upon the book's publication. But for anyone who's paid a pharmacy bill, The Truth About the Drug Companies is a fascinating read. --John Moe

From Publishers Weekly
In what should serve as the Fast Food Nation of the drug industry, Angell, former editor of the prestigious New England Journal of Medicine, presents a searing indictment of "big pharma" as corrupt and corrupting: of Congress, through huge campaign contributions; of the FDA, which is funded in part by the very companies it oversees; and, perhaps most shocking, of members of the medical profession and its institutions. Angell delineates how the drug giants, such as Pfizer and AstraZeneca, pay physicians to prescribe their products with gifts, junkets and marketing programs disguised as "professional education." According to Angell, the cost of marketing, both to physicians and consumers, far outweighs expenditures on research and development, though drug makers invoke R&D as the reason drug prices are so high. In fact, says Angell, with combined 2002 profits of $35.9 billion for the Fortune 500's top 10 drug companies, the drug industry is America's most profitable by far, thanks to disproportionately high prices, generous tax breaks and manipulation of patents to extend exclusive marketing rights to blockbuster drugs like Prozac and Claritin. Angell mounts a powerful case (and offers specific suggestions) for reform of this essential industry?a case worth bearing in mind as "big pharma" continues to oppose importing cheaper drugs from Canada.
Copyright ? Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

The Big Fix: How the Pharmaceutical Industry Rips Off American Consumers

Washington Post Book World, July 13, 2003.
"a highly informative description of how and why drug companies are such powerful, successful businesses."

Book Description
A meticulously reported expose uncovers exactly how the drug industry boosts sales and bilks consumers in the most lucrative prescription drug market in the world.
As the pharmaceutical industry invests more and more in the development of new drugs, true breakthroughs are few and far between. Into the breach comes a panoply of product-line extensions and me-too drugs aimed at grabbing market share. The industry plows its high profits back into research, but invests an equal or greater sum in flogging its products in every imaginable venue. Research studies are designed to support marketing claims. Many doctors all over the country get their first information about new drugs from a salesperson. And, increasingly, prescription drugs are pitched to consumers on TV and the internet with images of hope, terror, or chic. Evidence-based practice guidelines, which endeavor to get the right medicines to those who will benefit most, can't be heard over the din.

Having created an unprecedented number of "megabrands"--blockbuster drugs with huge sales--and undergone an extraordinary wave of consolidation, some drug companies now find themselves in a precarious position. Patents are expiring on flagship products. In order to sustain the growth Wall Street has come to expect, these companies must produce billions of dollars worth of new revenue--fast. But can Americans continue to bankroll Operation Grow Big Pharma? Must we swallow the bad with the good?

Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All into Patients

From Publishers Weekly
This accessible study about the collusion between medical science and the drug industry emphasizes how drug companies market their products by either redefining problems as diseases (like female sexual dysfunction) or redefining a condition to encompass a greater percentage of the population. Moynihan, a health journalist for the New England Journal of Medicine and the Lancet, and Cassels, a Canadian science writer, note, for instance, that eight of the nine specialists who wrote the 2004 federal guideline on high cholesterol, which substantially increased the number of people in that category, have multiple financial ties to drug manufacturers. Physicians now routinely prescribe cholesterol-lowering pills (statins) that may have perilous side effects, when many people could lower their risk of heart attack with less costly and dangerous steps, such as exercise and improved diet. Through aggressive merchandising, funding of medical conferences and expensive perks, drug companies win doctors over to diagnosing these "diseases" and prescribing drugs for them. Unfortunately for these authors, much of this territory has been covered by several books in the past year, most notably Marcia Angell's The Truth About the Drug Companies
Copyright ? Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

From Booklist
Science and medicine writers Moynihan and Cassels conjecture that most Americans believe, based on information gleaned from a deluge of pharmaceutical-company advertisements, that conditions such as hypertension, high cholesterol, menopause, and chronic constipation are bona fide diseases. They quote reputable medical experts, however, who refute such understandings. What's more, they suggest that billions of precious and diminishing health-care dollars are squandered treating those nondiseases of healthy, wealthy Americans and would be better spent treating the legitimately sick poor and fighting the international AIDS epidemic. Quoting former Merck CEO Henry Gadsen--who, in a 1976 Fortune article, confessed that "it had long been his dream to make drugs for healthy people. Because then, Merck would be able to 'sell to everyone'"--they lay the blame for the misdirected billions at the feet of just such pharmaceutical giants as Merck. Finally, they counterpoint glossy pharmaceutical ad campaigns with alternatives that consumers may consider before asking their doctors for prescription drugs they saw touted on TV. Donna Chavez
Copyright ? American Library Association. All rights reserved

On The Take: How Medicine's Complicity with Big Business Can Endanger Your Health

From Publishers Weekly
"Some physicians become known as whores." This is strong language in Kassirer's mostly temperate but tough look at how big business is corrupting medicine?but according to Kassirer, one doctor's wife used the word "whore" to describe her husband's accepting high fees to promote medical products. Such personal anecdotes distinguish Kassirer's look at the conversion of America's health-care system into a commercial enterprise. Kassirer, former editor-in-chief of the prestigious New England Journal of Medicine, notes the range of conflicts of interest between profit-centered business and people-centered medicine, such as the drug industry's huge expenditures (in the billions) for courting doctors to use their products, for recruiting physicians to tout their drugs or, more slyly, to present seemingly objective medical discussions that, on closer examination, do favor the company's product over others. Kassirer also covers the abuses of both fee-for-service (which can lead doctors to perform unnecessary but lucrative tests and procedures) and HMOs (which reward doctors for keeping costs down). The author calls for more scrutiny of the health-care industry by Congress and a "sustained public outcry against inappropriate practices"; the banning of industry gifts to medical personnel; and?difficult to imagine?disclosure to patients by doctors of financial incentives they are receiving.
Copyright ? Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

From the New England Journal of Medicine, December 2, 2004
The profession of medicine encompasses a wide variety of ways in which a physician can dedicate his or her life within the traditional areas of clinical practice, research, education, and administration. In this book, Jerome Kassirer, a former editor-in-chief of the Journal, documents, with well-referenced examples, how conflicts of interest, primarily financial in nature, have infiltrated all areas of the profession. The audience for the book is clearly the U.S. public, who, the author writes, "must become involved if we are to change the greed culture that permeates medicine." I agree, in principle, with the author that there are substantial conflicts of interest within the medical profession. However, I question the potential effectiveness of this book as written for the public. The most obvious reason for a physician of Kassirer's stature as a clinician, academician, and former editor to write a book about conflicts of interest in medicine would be to continue his attempts to eliminate or at least decrease a problem that diminishes the profession. But is this book a good way to accomplish that goal? The book wavers between a scholarly work and a sensational expose. For example, the cover features a man wearing a white coat and a neat shirt and tie, with a stethoscope around his neck and a pricey pen and a few crisp $100 bills tucked in his pocket. I was taken aback by the image, which is clearly meant to depict a "fat cat doc" on the take. However, this jarring image is then tempered by the two opening sentences of the first chapter, which declare that most physicians are hard-working and dedicated to their patients and that perhaps even hundreds of thousands of physicians refuse to take any financial gift that might affect their clinical judgment. Then, aside from a few selected exceptions to that supposed rule, the rest of the book is dedicated to stories about physicians tainted by financial self-interest that altered how they cared for patients, how their research was conducted and reported, what they taught, and how they administered medical institutions, with evidence that all of these conflicts of interest led to the detriment of patient care. The final chapter discusses "what can be done," ending with a "possible roadmap" that includes 10 items for immediate implementation that would be possible primarily by legislation. The reader is asked to take a political stand to force the enactment of such legislation. If the reader were to take such action, the author would deserve a medal. However, if the reader's more likely reaction would be to view with distrust all physicians currently practicing in the United States, it would be unfortunate indeed and would undermine the very reason that the book was written. Catherine D. DeAngelis, M.D., M.P.H.
Copyright ? 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Big Pharma : How Modern Medicine is Damaging Your Health and What You Can Do About It

From Publishers Weekly
The drug business is the most profitable in all of capitalism, journalist Law notes in this scattershot indictment of the pharmaceutical industry, but what do consumers get for the money shoveled into it? A dwindling stream of exorbitantly expensive new drugs, she contends, most of them "me-too" competitors, patent-prolonging reformulations of existing products or marginally effective nostrums for diffuse complaints; vast marketing budgets to cajole consumers into demanding-and doctors into prescribing-unnecessary medications; biased scientific studies and corrupted or intimidated researchers; a regulatory system lobbied and suborned into allowing unsafe and ineffective drugs on the market; and a society that automatically pops a pill for every discontent, real or imagined. Law offers a comprehensive, if disorganized, rehash of a now familiar but still timely portrait of drug companies' perfidy and greed, studded with case studies of firestorms like the Vioxx scandal and the controversy over the possibly deadly side-effects of anti-depressants. She's on shakier ground when she dilates her case into a brief against conventional medicine and in favor of a murky "holistic" regimen of "complementary"-i.e. alternative-therapies that harmonize with "the body's natural intelligence" and exploit the "untapped healing power" of the placebo effect. Law's flirtations with fringe conceits weaken an otherwise serviceable science-based critique of the drug industry.
Copyright ? Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

From Booklist
*Starred Review* British journalist Law deconstructs the relationship between Big Pharma, on one hand, and medical professionals and patients, on the other, and declares it unhealthy for everybody, though not financially for a handful of major international pharmaceutical companies. How can it be healthy when those companies' annual marketing budgets outstrip the annual budgets of all of the medical schools in the U.S. combined? How can it be healthy when those companies pick and choose which clinical tests of new drugs will be made public? How can it be healthy when the regulating agencies in charge of protecting public health interests are inexorably tied to the pharmaceutical industry? On the other hand, who other than those with ties to pharmaceutical companies can decipher the science-speak of all their reports? And who is to speak for the everyman seeking relief from the pain of everything from real illness to aging? Law's conclusion won't be popular, since she lays the burden on doctors to advocate for their patients, often at the expense of Big Pharma. And while it is some comfort to know that the U.S. isn't alone in its health care woes, it is still darn little comfort. Donna Chavez
Copyright ? American Library Association. All rights reserved

Powerful Medicines : The Benefits, Risks, and Costs of Prescription Drugs

Amazon.com
Profiteeering pharmaceutical companies and the FDA have met their match in Dr. Jerry Avorn, a Harvard Medical school researcher and clinician. In Powerful Medicines, he brilliantly combines patient vignettes, scientific critique, and statistics to create a risk/benefit balance for prescription drugs. His premise: "Every drug is a triangle with three faces--representing the healing it can bring, the hazards it can inflict and the economic impact of each." Avorn's gifts as a writer are apparent in the prologue, an edgy account of the mismanaged medications of several stroke patients. He then details the intellectual history of drug assessment and benefits, including the biblical food police in the Book of Daniel, the deer in the headlights Estrogen debacle and the current infatuation with Ginseng and other alternative medicines. Turning from benefits to risks, Avorn examines diet pills, Viagra, cold medicines and diabetes drugs with comparisons the decisions of Dr. Fautus--who makes life-changing bargains between safety and effectiveness. Other insightful chapters offer views of prescription drug economies, and comparative healthcare around the globe. The final chapters create an insightful template for emerging public policy. Throughout, Avorn pulls at common threads: the line between personal and public responsibility, the perils of drug promotion, and the marketplace that usurps the role of scientific evidence in selecting treatments. Anyone looking for a quick muckraking read will be disappointed. But Avorn's views, literate and complex, will frame the debate on prescription drugs for years to come. --Barbara Mackoff

From Publishers Weekly
In this pragmatic volume, Avorn sets out an impressive plan for the American health care system to get helpful drugs to those who need them, protect patients from dangerous side effects and keep costs within reasonable limits. Avorn, chief of the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women's Hospital in Boston, argues, "[F]or a sum no greater than our current drug budget, medications could provide all Americans with the most productive and cost-effective interventions in all of health care." Avorn claims, "[W]e waste billions of dollars a year on prescription drugs that are excessively priced, poorly prescribed, or improperly taken." To remedy this situation, reform is needed in how new drugs are approved and marketed. In addition, practicing physicians need access to state-of-the-art information about new medications, including how well they compare to established (and often cheaper) products. Computer technology, Avorn shows, can bring together the latest information on treatment options and drug contraindications. But changes in the pharmaceutical industry itself?of which Avorn does not hold a flattering view?may be necessary to eliminate pressure to prescribe the most heavily advertised and costly new product when old standbys are equally effective. Though this informative and witty book is overly long, it makes a compelling case for prescription sanity and shows how constructive change can realistically be achieved.
Copyright ? Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

Inside the FDA: The Business and Politics Behind the Drugs We Take and the Food We Eat

Download Description
"The forces that shape America's most powerful consumer agency
Because of the importance of what it regulates, the FDA comes under tremendous political, industry, and consumer pressure. But the pressure goes far beyond the ordinary lobbying of Washington trade groups. Its mandate-one quarter of the national economy-brings the FDA into the middle of some of the most important and contentious issues of modern society. From ""designer"" babies and abortion to the price of prescription drugs and the role of government itself, Inside the FDA takes readers on an intriguing journey into the world of today's most powerful consumer agency.
In a time when companies continue to accuse the FDA of nitpicking and needlessly delaying needed new drugs, and consumers are convinced that the agency bends to industry pressure by rushing unsafe drugs to market, Inside the FDA digs deep to reveal the truth. Through scores of interviews and real-world stories, Hawthorne also shows how and why the agency makes some of its most controversial decisions as well as how its recent reaction to certain issues-including the revolutionary cancer drug Erbitux, stem cell research, and bioengineering of food-may jeopardize its ability to keep up with future scientific developments.
Inside the FDA takes a closer look at the practices, people, and politics of this crucial watchdog in light of the competing pressures and trends of modern society, revealing what the FDA is supposed to do, what it actually does-and fails to do-who it influences, and how it could better fulfill its mandate. The decisions that the FDA makes are literally life and death. Inside the FDA provides a sophisticated account of how this vitally important agency struggles to balance bureaucracy and politics with its overriding mission to promote the country's health.
Fran Hawthorne (New York, NY) is a senior contributing editor of Institutional Investor and has connections deep within the business and finance communities. Hawthorne has been covering healthcare and business for more than twenty years for such publications as Fortune, BusinessWeek, and Crain's New York Business. She is the author of The Merck Druggernaut (cloth: 0-471-22878-8; paper: 0-471-67906-2)."

From the Inside Flap
"Americans count on this agency to make sure that we have a steady stream of wonderful new pills that are potent and perfectly safe at the same time, as well as a supermarket full of goodies we can gobble up without worrying about food poisoning."
?From the Introduction
Because of the importance of what it regulates, the FDA comes under tremendous pressure from powerful food and drug companies, determined consumer groups, and demanding politicians. But the pressure goes far beyond the ordinary lobbying of Washington trade groups. Its mandate?over one quarter of the national economy?brings the FDA into the middle of some of the most important and contentious issues of modern society.

From the price of prescription drugs and the dangers of genetically engineered food, to debates over teenage pregnancy and the role of government itself, Inside the FDA takes you on an intriguing journey into the world of today's most powerful consumer agency. Through scores of interviews with FDA employees and professionals familiar with the FDA, as well as real-world stories, healthcare and business expert Fran Hawthorne shows you how and why this agency makes some of its most controversial decisions. She discusses why the FDA fails to catch the dangers of drugs like Vioxx before they hit the market, and goes behind the story of Martha Stewart and the revolutionary cancer drug Erbitux to show how the FDA's handling of that drug may jeopardize its ability to keep up with future scientific developments.

In a time when companies continue to accuse the FDA of nitpicking and needless paperwork, while consumers complain that the agency bows to industry pressure by prematurely approving risky products, Inside the FDA digs deep to reveal the truth about an agency that affects our daily lives more than any other single entity in the world.

Inside you'll discover:

* How the FDA will face its first case of embryonic stem-cell research
* Why the FDA goes so easy on foods that are genetically engineered
* How dangerous drugs like Vioxx get past the FDA's safety measures
* When off-label prescribing?taking a drug that has been approved only for Condition A and prescribing it for Condition B?is dangerous, and when it may be lifesaving
* Why the FDA let drug ads on TV
* What it's like to launch a biotech firm and try to move a brand-new drug through the FDA
* Why the FDA's role is growing more and more beyond science and into public policy

Inside the FDA takes a closer look at the practices, people, and politics of this crucial watchdog in light of the competing pressures and trends of modern society, revealing what the FDA is supposed to do, what it actually does?and fails to do?who influences it, and how it could better fulfill its mandate. The decisions that the FDA makes are literally life and death. Inside the FDA provides a sophisticated account of how this vitally important agency struggles to balance bureaucracy and politics with its overriding mission to promote the country's health.

Innocent Casualties : The FDA's War Against Humanity

Dr. Ronald Hoffman - "Health Talk" - WOR Radio
"Innocent Casualties is a fascinating book that blows the whistle on the FDA."

Marianne J. Zale - Palo Verde Valley Times
"Though this sounds like an Oliver Stone movie, truth proves again to be stranger than fiction."

James F. Scheer - Health Freedom News
"Innocent Casualties" reads like frightening fiction. Unfortunately, it is fact, disclosing the cunning and underhanded means used by the FDA.

Book Description
Innocent Casualties: The FDA's War Against Humanity, documents the FDA's illegal suppression of nutrients and alternative treatments that are successfully used to treat serious illnesses in other countries. In 2006, Americans are still denied their constitutional right of freedom of choice in health care.
In order to protect the interests of the medical and pharmaceutical industries, the FDA has evolved into an undercover dictatorship. Innocent Casualties documents a government agency so radical, that it's agents burst into a doctor's office -- guns drawn -- to seize Vitamin B.

The U.S. medical monopoly could not exist without the enforcement powers of the FDA.

One Nation, Uninsured : Why the U.S. Has No National Health Insurance

From Publishers Weekly
According to Quadagno, the short answer to her subtitle is a fairly easy one: America lacks national health insurance because powerful interests have always managed to prevent Congress from passing the necessary legislation. As this slim history shows, however, those interest groups weren't always the obvious suspects. Although Quadagno, a sociologist and former presidential advisor, does write plenty about how organized physicians and insurance companies have lobbied to protect their interests over the last century, showing how the Clintons' disastrous attempt at health care reform is just the tip of the iceberg, she also offers insights into why labor unions rejected government-led solutions to the health care problem to focus on their own collective bargaining efforts. Other chapters detail conservative framing of national health care as "an insidious communist plot" and the fight southern doctors raised against the racial integration of medical facilities during the civil rights era. Quadagno unapologetically advocates for the sort of program that the United States has so far failed to adopt, but admits that it will never happen until health care is considered a "social right, not a consumer product." Her analysis of the repeated defeats is unlikely to find much traction with anyone besides the hardcore policy wonks, however, as her blow-by-blow accounts of the political battles fail to generate much heat.
Copyright ? Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.

From The Washington Post's Book World/washingtonpost.com
The troubles of the U.S. health care system make front-page news almost every day. As costs rise, employers are cutting back on coverage for employees or offering none at all. State governments say they can't pump more money into Medicaid to pick up the slack, while safety-net hospitals say they're maxed out, too. The result: Tens of millions of Americans cannot afford basic care.
It's a serious problem -- but not, Jill Quadagno reminds us in One Nation, Uninsured, a particularly novel one. On the contrary, similar health care "crises" cropped up repeatedly during the 20th century, always playing out in the same unfulfilling way. First, anxiety over affordable health care leads progressive politicians to push for universal health insurance. Then the campaign fails. Eventually, the private sector reforms itself, but in a limited way that makes the next crisis virtually inevitable.

One Nation, Uninsured attempts to explain why progressives keep losing -- and why, as a result, the United States remains the only industrialized nation without universal health insurance. The question could not be more timely, especially since a battered Democratic Party is now loudly casting about for "big ideas." And although Quadagno's answer is not exactly shocking, her briskly written history offers an excellent primer for anybody interested in picking up the reform banner today.

While acknowledging all the different factors that have blocked universal coverage in the past, Quadagno, a Florida State University sociologist, argues that the most significant obstacle has been the virulent opposition of special interests that profit from existing health care arrangements, however flawed. Different "stakeholders" led the charge against universal coverage in different eras: physicians before the 1970s, insurers and employers afterward. But, Quadagno shows, the campaigns took similar shape -- and produced similar results -- with each new battle. Particularly striking are the parallels between the fight against Harry Truman in the 1940s and the one against Bill Clinton in the 1990s, from the use of congressional investigations to distract the White House to the literal demonizing of individual reform proponents. ("We first thought of making President Truman the devil, but he's too popular," an American Medical Association strategist explained in 1949. "But [a key Truman adviser] is a perfect Devil and we're going to give him the works.")

Although the basic storylines here will be familiar to readers of such books as Paul Starr's Pulitzer Prize-winning The Social Transformation of American Medicine, Quadagno uses the personal recollections of past reformers (collected through oral histories and interviews) to construct a series of fresh, engaging historical narratives. But this approach also leads her to overemphasize the role of special interests -- who, understandably, loom large in the minds of those vanquished by them. A major reason for public ambivalence about the Clinton plan, for example, was middle-class Americans' fear that they would end up with coverage that was either more restrictive or more expensive than the generous, fee-for-service insurance plans that large employers had historically provided for their workers. (Of course, the public failed to realize that employers were already switching to managed care anyway.) While special interests certainly stoked these feelings with their infamous "Harry and Louise" advertisements, they were also playing to a very receptive audience.

Still, it's hard to quibble with Quadagno's thesis too much since, as she shows, virtually every major evolution in the financing of U.S. medical care has occurred only when special interests themselves demanded change -- and even then only in ways that conformed to their ideological and financial preferences. Private insurance began to spread in the 1930s, when hospitals were desperate for paying patients to fill their beds; managed care took off in the 1990s because employers were desperate to control the cost of employee benefits. But each development represented an alternative to proposals for universal health insurance, which, the special interests feared, would encourage government interference in medicine and beyond. (Medicare, the lone success in the campaign for universal coverage, could pass only because private insurance companies had found that insuring retirees was unprofitable and because hospitals figured that a government insurance program was better than nothing.)

Understandably glum about the immediate future, Quadagno suggests that today's reformers concentrate on incremental initiatives identical to the ones Sen. John F. Kerry proposed in the 2004 presidential campaign. But if Quadagno's book teaches anything, it's that such half-measures buy only modest relief and, even then, only for a little while. That's why the more important message of her book is about political strategy. Quadagno notes that in addition to outspending the proponents of universal coverage, special interests have also done a better job of grass-roots organizing (by, for example, using doctors and insurance agents to carry anti-reform messages within communities). And while the opponents of reform have maintained impressive ideological unity, coalitions on the left have frequently splintered. The United Mine Workers and other industrial unions abandoned Truman when they won generous private benefits for their memberships; labor sat out most of the "Clinton-care" fight because it was preoccupied with the North American Free Trade Agreement.

Quadagno's ultimate message seems to be that politics are more important than policy -- that progressives won't achieve universal coverage unless they learn to operate like the special interests of the right. She's probably correct -- which is why her richly constructed history could prove so handy in the months and years to come.

Reviewed by Jonathan Cohn
Copyright 2005, The Washington Post Co. All Rights Reserved.

Uninsured in America : Life and Death in the Land of Opportunity

From Booklist
Sered, an anthropologist, and Fernandopulle, a doctor specializing in public-health policy, provide a troubling look at Americans without health insurance, some of whom must choose between food and medical treatment. They interviewed more than 120 uninsured Americans in Texas, Mississippi, Idaho, Illinois, and Massachusetts as well as physicians, administrators, and health-policy officials. The result is a collection of heartrending stories of the "caste of the ill, the infirm, and the marginally employed." The authors describe the "death spiral" of people who lack insurance for myriad reasons--including self-employment and divorce--and whose illnesses cannot be adequately treated. Their medical conditions inevitably deteriorate--small tumors metastasize, diabetes leads to amputation or dialysis treatments--increasing both the costs and the dire consequences. Once individuals are caught in the death spiral, they are unlikely to find a way out. The ultimate impact of this shocking crisis is felt by all Americans in the form of higher health-care costs and more antibiotic-resistant bacteria as conditions go untreated. This is a stark and disturbing book. Vanessa Bush
Copyright ? American Library Association. All rights reserved

Book Description
..goes to the heart of why more than forty million americans are falling. throught the cracks in the health care system and what it means for society as a whole

The Health Care Mess : How We Got Into It and What It Will Take To Get Out

From Publishers Weekly
As Americans become healthier and live longer, we increasingly concentrate on preventing illness or injury from making some of those extra years an agony. We spend far more than any industrialized country on health care?and get far less for it. How did we get here? Former surgeon general Richmond and medical economist Fein offer a judicious, account making it blindingly clear that any decentralized system with multiple centers of influence (HMOs, employer-sponsored insurance plans, etc.) will force each segment of the health-care world to act in its own interest: the young and healthy opt out of mass coverage plans, which prevents their contributions from being spent on the aged and infirm; companies pass costs on to government or its own employees. In such a climate, what starts as rational self-interest inevitably morphs into a never-ending "quest for profits," which is where we are today. Bringing to this dry yet important subject authoritative knowledge and insight, the authors slice through the intricacies like an experienced surgeon. Their proposed solution is government-financed universal health insurance, though they admit our legislators have not had the stomach for it in the past. (Sept.)
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