Victor R. Fuchs, whose comprehensive grasp of the challenges facing the United States health care system, and eloquence in explaining those challenges to policymakers and the general public, made him what many called the “dean” of American health care economists, died on Saturday at his home on the campus of Stanford University in Palo Alto, Calif. He was 99.
His son Fred confirmed the death.
Dr. Fuchs was best known for a slim, erudite book published in 1975 with the attention-grabbing title “Who Shall Live? Health, Economics and Social Choice.” He was among the first to articulate in clear, layman’s prose why the United States was in the midst of rapidly rising health care costs, while costs in other countries stayed manageable.
The book has become required reading among physicians, health economists and anyone interested in the knotty issue of American health care, and it has never been out of print.
Dr. Fuchs showed that the real problem facing the country was not health care coverage but health care costs; America, he wrote, was spending more and more without achieving better health outcomes.
Moreover, he argued, reforming that system would not come without costs of its own. If America wanted better care, it would have to pay for it, either through taxes or higher insurance premiums. Difficult choices would have to be made about who got what care, and how, especially if one goal was health equity.
“We cannot have all the health or all the medical care we would like to have,” he wrote. “We have to choose.”
Some considered the book unseemly. There was something distasteful, his critics said, about applying economic analysis to a field concerned with life and death.
But Dr. Fuchs, at the time an economist with the National Bureau of Economic Research, made a compelling case for realism.
It turned out, he found, that health and health care did not, in fact, move in tandem, and that the differences in national outcomes had more to do with culture, environment, social policy and individual choice than with the cost or level of health care. Fancy specialized care, which the U.S. excels at, was no guarantee of better health overall, he contended.
“The access problem involves mostly basic care and emergency care,” he wrote, “and could frequently be met with physicians’ assistants, nurse clinicians and other types of health professionals.”
In 2005 he joined with Ezekiel J. Emanuel, an oncologist and bioethicist, to propose a plan to provide universal health coverage through vouchers, which people would use to purchase basic health insurance. Buying additional coverage would be up to them.
Dr. Fuchs did not hold out hope that their plan would come to fruition. The biggest problem facing the U.S. health care system, he argued, was the unwillingness of politicians and the public to make the hard choices necessary for real change.
He was a strong critic of the Clinton administration’s health care reform efforts in the early 1990s — not because he disagreed with the goal or even some of the proposals, but because he thought the White House was naïve about what actual reform would take.
“The Clinton plan was a combination of ignorance and arrogance, and it turned out to be a disaster,” he told The New York Times in 2000. “But I never believed for a minute that they could get major health care reform. Health care reform requires a substantial political investment.”
He was equally negative about President Barack Obama’s health care changes a generation later. He said they did nothing to address the underlying causes of high costs and instead simply just shifted those costs around.
“Cost shifting doesn’t do anything about the real cost of health care,” he said in an interview with KFF Health News. “The name of the game in Washington is to try to hide who is bearing the cost.”
Victor Robert Fuchs was born in the Bronx on Jan. 31, 1924, the son of Jewish immigrants from Austria. His father, Al, sold furs, and his mother, Frances (Scheiber) Fuchs, was a homemaker.
Victor served in the Army during World War II, then returned to New York to attend New York University. After graduating with a degree in business administration in 1947, he went to work for his father.
He married Beverly Beck in 1948. She died in 2007. Along with his son Fred, he is survived by another son, Ken; his daughters, Nancy Fuchs Kreimer and Paula Fuchs; 10 grandchildren; and six great-grandchildren. His brother, Lawrence Fuchs, a noted professor of American studies at Brandeis University, died in 2013.
After a few years in the family trade, Dr. Fuchs decided on a new career and enrolled in the doctoral economics program at Columbia University. He received his Ph.D. in 1954 with a dissertation on the fur business.
He taught at Columbia and New York University before moving to the National Bureau of Economic Research, a nonprofit organization based in Cambridge, Mass. In the early 1970s the bureau sent him to Palo Alto to open its West Coast office. He received a joint appointment at Stanford, and in 1978 he moved to the university full time.
He wrote more than 200 research papers and 16 more books after “Who Shall Live?,” including a follow-up of sorts, “How We Live: An Economic Perspective on Americans From Birth to Death” (1984). The Times economics writer Peter Passell called that book “an economist’s-eye view on everything from why some women smoke during pregnancy, to whether it makes sense to send Junior to Harvard, to why Junior’s widowed mom won’t move back in with the kids.”
Dr. Fuchs retired in 1995 but continued to write papers and books; he finished his latest, a new edition of “How We Live,” not long before his death. It is scheduled for publication next month.
Clay Risen
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