In this era when for many of us restful sleep is often disturbed by nightmares of asteroids plowing into the earth in the near future, or by fears that the zit on our posterior is the inevitable first hint of an attack by flesh-eating cocci, a rational paranoiac would be wiser, I think, to concentrate his fears more on our health-care system. Aside from our tell-em-what-they-wanna-hear politicians, everyone seems to agree that our health-care system is in deep trouble. There are many reasons for this concern, but the most important is that we demanding and self-involved baby boomers are quickly blobbing our way into old age, and we will undoubtedly inundate our health-care system with demands it cannot meet. Sadly, however, the experts disagree sharply about how to fix the system, so it should come as no surprise that the solutions offered in A Design for the Future of Health Care by Larry Bryan, and the Fraser Institute’s Health Incentives, Canadian Health Reform in an International Context are nearly diametrically opposed.

Bryan is a physician and former hospital administrator, so he brings both an under- and overview to the problem. “Under” in that he has worked within the system as a dispenser of health care (we used to call them doctors), “over” in that he has also administered the way health-care services are dispensed.

In his solution to our health-care problems, however, it’s clearly the administrator in Bryan who wins out, because I find it hard to imagine a more top-heavy bureaucratic system than the one Bryan suggests. Nearly every aspect of health-care delivery under Bryan’s proposals would be watched over by a committee or administrator, and although many of the important decisions would be decentralized, or to use a current bureaucratic buzz phrase, they would be “delivered closer to home,” in the end, Bryan’s overhaul of the system would result in more and more committees and bureaucrats making more and more of the decisions.

I was left with a nagging feeling that this overhaul of the system would be a very hard sell to health-care workers because under Bryan’s system, physicians, nurses, and non-professional health staff would all have their roles drastically altered. Surprisingly, the easiest sell might be to health-care consumers (we used to call them patients) who, if recent polls are to be believed, seem to be quite willing to accept the idea of rostering, in which a person is assigned to one physician and can only leave that practice by giving several months notice. The reason these polls surprise me is that if I have learned one thing in my medical life, it’s that even more than their belief in their right to poke fun at Toronto and Ottawa, Canadians believe in their inalienable right to doctor-shop to obtain second, third, even fourth and fifth opinions.

Nevertheless, this book contains many excellent ideas, especially Bryan’s point that to use health-care dollars more effectively we must begin to put much more emphasis on the outcomes of our decisions in health care. I may be drummed out of my doctors’ associations for saying this, but for far too long, we have been doing things in health care just because that’s the way we have always done them. We must begin to get a better measure of health-care outcomes, and when we do, I believe a significant percentage of current medical practice will be turfed out the window. Kudos to Bryan for emphasizing this point.

I doubt if anyone will be surprised to learn that the solution the Fraser Institute’s editors offer in Health Incentives is simply to open the health-care system to “the market,” a term this book uses so often I was left with dreams of open-air stalls with competing doctors squawking about the best price they could give you for a facelift or hemorrhoidectomy.

What is particularly subversive about Health Incentives is that it is an excellent read, and it will no doubt quickly make many readers into free-market converts. The reason I say this is subversive is that economics and medicine (and this book is a combined effort of doctors and economists, a most unholy alliance) are both disciplines in which practitioners often select only those statistics that are most useful to their point of view, although a contrarian can often select another set of statistics and make an equally valid case for the other side. There are valid arguments to be made against an unfettered free-market approach to health care, but you won’t find them in this book. That aside, Healthy Incentives is very interesting and contains many useful ideas and much to ponder.

A criticism I would lob at both these books, however, is that they do not really discuss the growing body of evidence that one’s health is to a large extent a factor of determinants such as one’s income and education level; that is, the more one earns, the more healthy one is likely to be, so perhaps the answer to the long-term health of the nation is not to fiddle with the health-care system so much as to put more money into education and housing and other social determinants of health.

Finally, Prescription for the Future is really a magazine article posing as an hour-long tape. I cannot imagine many people, aside from CEOs of health-care organizations (the kind of people who endorse the tape on its jacket), who will take the time to listen to this entire tape because for experts in the field, I am sure this is mostly old hat, and for everyone else, there is little here of interest, especially since the narrator has the kind of voice you hear when the dentist is bending over to reassure you that the root canal you are about to have won’t hurt a bit.