Where Have We Failed? A Systemic Analysis of US Health Care By Roger K. Howe. 303 pp. Tampa, Fla, American College of Physician Executives, 2002. $55.00 (paper). ISBN 0/N924674–93/N8.

What is wrong with the American health care system? Almost everything. A quick list off the top of my head—insurance companies, managed care, drug companies, Medicare, Medicaid, physicians, overinformed patients, malpractice insurance, lawyers, uninsured patients, and so on. The manifestations are obvious. Physicians are unhappy, patients are unhappy, employers are unhappy, costs are rising to more than $1 trillion a year, and what do we have to show for it—44 million uninsured and an infant mortality rate that is 28th in the world (ranking lower than the Czech Republic).

Roger Howe’s book Where Have We Failed? offers a comprehensive accounting of the current state of American health care. Dr. Howe is a family physician turned physician executive. Informed by his experiences with physician groups and health maintenance organizations, he details challenges and dilemmas from several different aspects of the health care system. The book’s cover, a large red-encircled letter “F,” gives a not-so-subtle hint to the author’s primary thesis. He organizes the book into chapters on each of the major players in health care—insurers, purchasers, government, hospitals, lawyers, physicians, patients, media, and drug companies. The discussions are well written and complete, and they offer a fair analysis of the competing demands that face each of these groups. Each chapter is nicely supplemented with endnotes that reveal Dr. Howe’s entertaining editorialization.

The problem with the book, and American health care, is that almost everything is broken. If the fixes were easy, they would have been fixed by now. Instead, we are confronted with a growing crisis, one that generates and sucks up an enormous amount of money. After reading the book, I was left with a grave sense of hopelessness—the problems are not just plentiful, but they also run deep into the soul of American history and culture, consumerism, expectations, and independence. Dr. Howe bravely offers potential solutions, but they seem feeble in contrast to the weight of the problem. Even his concluding great new hope—a market-based system that is able to control costs and deliver quality health care—requires “such a complex set of numerous and interrelated actions” that we are left paralyzed under the weight of despair.