Thirty-seven years ago, Stanford economist Victor Fuchs, PhD, penned Who Shall Live?, a book that took basic ideas in economic theory and applied them to health and medical care in a way that hadn’t been done before. His now-classic publication, which was embraced by fellow academics and placed on the required-reading lists of countless college courses, has been credited with kick-starting the field of health economics.
The second expanded edition of Who Shall Live? was recently released (a second edition was published in 1998), and I had the chance to sit down with Fuchs – now in his 80s and as active, articulate and affable as ever - and chat about it. He told me he never thought the original publication, written as a trade book, would make such an impression, but he now recognizes that “its lasting influence will be through students” who are assigned it in the classroom.
Fuchs said he wasn’t interested in “pushing policy” in his first edition – he just wanted to get people thinking about the issues. In the book, he presented the challenges in trying to allocate health resources efficiently and equitably, and he identified the three major problems with U.S. health care: high cost, gaps in access, and inadequate health levels.
Indeed, as Fuchs points out in the introduction to the new edition, there have been major changes in health, medical care and health policy since 1974 – yet much remains the same:
On the one hand, medical practice has been inundated by a torrent of new technology in recent decades. Also, thousands of studies in health economics and health services research have enlarged our understanding of the behavior of patients, physicians, hospitals, drug companies, and other participants in the health sector. On the other hand, the problems that seemed so troubling when I wrote Who Shall Live? — high cost, gaps in access, inadequate health outcomes — are still with us.
Fuchs told me he believes the recently enacted federal health plan does only a little to solve the problems he wrote about almost four decades ago. “It’s basically a redistribution plan – it helps poor and sick people but at a cost to the rest of the population,” he explained. He’s been vocal about the potential benefits of his own, voucher-based plan to achieve universal coverage, control costs and improve health, but he recognizes the country’s current political climate wouldn’t allow for the adoption of such sweeping change.
“If what I’m saying makes sense, it will break through someday,” he said of his idea.
So does Fuchs think that our country's health-care woes will someday be solved? Is there any reason to be hopeful that a more efficient, more equitable health care system will be achieved? Yes, he told me - after all, other countries have done it. “I’m an optimist by nature, but it’s going to be difficult as long as we have this political situation,” he said.
We'll see what the next 37 years bring!