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With health care reform at the top of the domestic agenda, this volume assesses the Clinton administration's proposals and several alternative plans by discussing how six other countries have organized health care finance and delivery to achieve universal access to comparable quality care at much lower costs. The six countries examined-Australia, Canada, France, Germany, Great Britain, and Japan-reveal both the variety and fundamental similarities of medical care systems in the rest of the industrialized world. Joseph White uses foreign experience to indicate the proper direction for American reform and to identify interesting alternatives that suggest compromises for what are usually presented in the U.S. as "either-or" choices. Examples include the role allowed for private insurance within all national systems; exceptions to fee schedules in Australia, France, and Germany; and the complaint mechanism for malpractice in New South Wales. White begins by describing each country's system and then follows with chapters disucssing three classes of problems. "Quality and Access" uses the experience of other countries to establish a reasonable baseline for what the U.S. should aim to achieve. "Collecting the Money" discusses who pays and how. "Controlling Costs" explains how other countries have moderated their cost increases. The final chapter assesses American reform proposals in light of the foreign evidence. White argues that a synthesis of "competition" and "regulation" is possible and that such a synthesis is approached by the Clinton proposals. But he also identifies areas where those proposals fall short or risk collapsing of their own weight. He concludes by comparing the administration's proposals to the major alternatives. "This book is serious scholarship at its best. Comprehensive in scope, insightful in character, and compelling in its

This Perspective explains why implementation analysis of the cost control provisions within the Patient Protection and Affordable Care Act is not particularly useful. These provisions are either relatively straightforward or, more commonly, so flawed that successful implementation is highly unlikely. The analysis shows that effective and equitable cost control will require coordinating payers to create all‐payer fee setting. This poses significant challenges but has been implemented relatively successfully in many countries. The balance of the article uses experience with all‐payer systems in other countries and fee setting within Medicare to identify key choices within any all‐payer system. It highlights the importance of simplifying considerations and focusing on outcomes—the incomes of providers and total spending—rather than engaging in a hopeless search for technocratic payment "accuracy."

The extensive literature about the George W. Bush administration's Program Assessment Rating Tool (PART) has not emphasized an issue that appears quite clearly in interviews with senior Office of Management and Budget (OMB) and congressional staff. Budget analysis can pursue efficiency in two ways. One, the object of traditional analysis, involves assessing programs to understand the ratio of inputs to outputs within an agency, and thus the effects of more or less funding. Another approach, termed "budgeting for results," measures program performance so as to allocate funding among programs in a way that increases total welfare. The second approach is much more difficult because it necessitates comparison of measures of unlike phenomena, requires expertise that often does not exist, and is more easily contested as invoking values rather than facts. Both congressional and OMB sources report concerns that PART weakened budget analysis by diverting resources from traditional analysis. If one goal of reformers is for the OMB to provide analysis that will influence Congress, the focus should be on strengthening the capacity to do traditional budget analysis.

Budget reform requires goals that are both good public policy and achievable. The core purpose of budgeting is to consider and relate details and totals. Common demands for reform are dubious because they slight consideration of details. For this reason, too strict a definition of "balance" would be bad policy; the demand for balance over many decades is neither good policy nor realistic; and multiyear discretionary spending caps can be both bad policy and impractical. Concern about passing annual budget resolutions ignores the fact that the major reason for annual totals is no longer endorsed by policy makers and economists. Scorekeeping should be honest and accurate and often can be improved, but possible achievements are limited. Budget reforms will not make government accountable if the governing coalition is united in seeking to avoid that, and if neither the public nor elites demand it.