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The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security

BMJ 1997; 315 doi: (Published 29 November 1997) Cite this as: BMJ 1997;315:1476
  1. Donald Light, professor of comparative health care systems
  1. University of Medicine&Dentistry of New Jersey, USA, and Glaxo Wellcome visiting professor, University of Manchester

    Jacob S Hacker: Princeton University Press, £29.95, pp 248 ISBN 0 691 04423 6

    Given the many ways that Margaret Thatcher's transformation of the NHS into a competitive marketplace increased costs and created dislocations, “The Road to Nowhere” might aptly title a book about NHS policies in the 1990s. But, instead, Jacob Hacker examines how managed competition came to be so uncritically embraced in the United States, why universal health insurance seemed so certain to pass, and why President Clinton's reform proposal went nowhere—”One of the most dramatic reversals of political fortune since President Woodrow Wilson's ill-fated campaign on behalf of the League of Nations.”

    Since then, the number of uninsured has been rising at about 100 000 a month to one sixth of the population, and those with illnesses or high risks are increasingly deselected. Coverage of the insured has steadily thinned, charges and fees have risen sharply, and the “savings” are credited to competition. The original vision of equitable, responsible managed competition rewarding efficiency, it seems, has become an excuse for reducing coverage and discriminating against the sick.

    The strength of this brief, readable book lies in the way it pulls together threads of history …

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