Public Health in the Market: Facing Managed Care, Lean Government, and Health Disparities

Nancy Milio is an American authority on community health, and her field-based experience comes through in the pages of this articulate book. Though always tactful and helpful, she cannot help but describe the shambles to which public health has been reduced by the decision of employers and government to turn health care over to for-profit corporations. When stockholders are the prime constituency, ``it can confuse the aims of community prevention with those of public relations
and marketing, and impair accuracy of and access to data that are vital to public health assessmenty''(p. 267). Decisions on how goods, services and information are allocated ``place Americans' interests and opportunities as consumers above their rights, responsibilities and actions as citizens'' (p. 272). The situation is so fragmented and primitive (though she would never be so blunt) that she has to recommend that ``public health councils could more effectively guide public health agencies than the many hundreds of tiny boards of health, each with its own limited capacity to carry out even a few of the essential public health services'' (p. 280), and she has to remind her American readers that ``Healthy communities are first healthy places'' (p. 276). How embarrassing to have readers in Scotland, or Costa Rica or India learn how far behind public health organization is in the richest nation that is ready to spend billions on upgrading its military.

Public Health in the Market is divided into four parts and fourteen chapters. Part 1 provides a well-researched overview of the new world which market-based policies have created, in which public monies are privatized. Part 2 assesses the consequent policies. Part 3 lays out Milio's template for policy practice that informs the whole book and her work, and Part 4 provides two in-depth analyses, based on original research, of two contrasting states, as well as the concludingchapters.

Milio's template or model centers on one of those figures with 15-20 factors, combined into general boxes, with arrows going in all directions, that could be critiqued if one wanted to get down to specifics. The accompanyingtext is a mixture of observations about US public health policy since the 1960s and general observations. For example, each policy issue has its own web of participant groups; knowledge of the territory is prerequisite for any serious strategy; changing the beliefs of policymakers is almost impossible. Yet these and other truisms are often ignored by those who try to affect public policy.

The case studies of Arizona and West Virginia are eye-openers. We learn that the richest fifth earn about 13 times more than the poorest fifth, an amazingdeg ree of relative poverty, and that about one-quarter of the children live below the poverty line, an income set low as an emergency household budget. We learn that during World War I, public health officials in Arizona had to go from town to town, trying to persuade residents that they needed to pay for sewer connections. Some refused. By the 1960s, Milio reports, the Arizona State Department of Health had reached a budget of 12 cents per capita. Ironically, the credo of individual rights and unfettered growth have resulted in high rates of violent crime, poverty, unemployment, overcrowded classrooms and communities that are unhealthy places-a fistful of public health problems that cannot be solved with private medical care. Even in the 1990s, the state still lacked the ability even ``to estimate its
investment in the ten essential public health services'' (p. 180). This pair of chapters is full of complex detail about efforts to develop public health programs in the two states.

Milio sees clearly and documents well the effects of competition policy and markets on public health and health care. Cost containment programs have actually worsened access of vulnerable groups to health care. Managed care organizations have no responsibility for or interest in upstream public health causes of patient problems. Any given community is divided into each company's market share, thus carvingup any responsibility for the whole. Vital information for public health programs, once gathered routinely, becomes proprietary. The services and patients that are more profitable get siphoned off, leaving public health centers and programs in budgetary crisis. Large-scale fraud and bankruptcy are not uncommon and throw care into
turmoil, especially for thousands with serious problems.

In any market, there are a few winners and many losers. Overall, this book provides tellingdetail and timehonored insights into a tragedy of our times, enhanced by a wonderful collection of quotations that frame the issues in historical perspective. The book is well edited, indexed and printed by the Press.