Painful Choices

Book excerpt: More than ever, society faces painful choices in the allocation of resources for health care. How it makes these choices, and how wise they are, will determine the quality and character of health care for years to come. David Mechanic examines existing and impending dilemmas the American health care system must manage as it confronts these choices. He explores conceptual approaches to health and health care, showing how these translate into research, and defines a strategy for informed choice. The result is a masterful volume by one of our leading medical sociologists at the peak of his career. Mechanic looks at the continuing emphasis on biomedical technology in the context of growing economic, constraints, as medical care becomes more expensive and demands become greater. He examines the discrepancy between public expectations and how health care is actually provided, and points out increasing discordance between demographic trends and disease patterns and the medical system's emphasis on acute care. Of particular concern is the enormous gap between entitlements for medical care and the increasing need for long-term care. This gap is of particular concern because of the United States's enormous investment in health care, which now consumes 11 percent of the Gross National Product, Although there is no particular consensus on what is an appropriate level of investment in health, policymakers are impatient with the medical system's apparent inability to control costs, and are concerned as well about the competition for resources between health and other sectors. Mechanic examines new trends, such as managed care, and transformation of the role of those who provide health care from patient advocates to allocators of services-a crucial distinction. The choices that will have to be made in the next decades are difficult They will also be painful, but they are inevitable. The key challenge will be to respond to the anxieties of the 37 million uninsured children and adults, the growing numbers of frail elderly, and the needs of patients with serious mental illness and other chronic disabilities. All of this must be accomplished while maintaining a high level of service for the rest of the population, and without breaking the bank. To achieve this, Mechanic argues, health services must be shaped to enhance function and quality of life, and not simply in response to technological imperatives. In its profound understanding of the social and political context, in which competitive initiative, the growth of regulation, new health care systems, and approaches for making research sensitive to patients are all evident, "Painful Choices "provides a framework for responsive and meaningful policy analysis.