PREFACE TO THE SECOND EDITION

The chapters to follow have been written as a textbook in health care management and policy. The book may serve as an introduction to problems and issues in U.S. health care for people entering related professional fields. It is also intended for use by people already experienced in a specialized area of management, policy, or patient care for attaining perspective on the system as a whole.

Every day, millions of Americans encounter challenges in locating and paying for services and obtaining care of the highest quality for themselves or their loved ones. Many are led to wonder how health care operates “behind the scenes,” why an essential service should involve such difficulties, and what steps might be taken toward the system’s improvement. This book is intended primarily for students. But it is also a factual resource for citizens, clinicians, and officials seeking to better understand and improve health care in the United States.

For no reader will the material presented here be entirely new. Without exception, everyone reading these pages will have experienced health care as a consumer. It is hoped that this book will help readers of any background see their experience as part of a large, complex, and ever-changing system. An improved view of where the reader’s experience fits within this firmament will enable her or him to better render direct service, manage human and material resources, influence policy, and utilize health care for his or her own needs.

The second edition of Health Care in the United States: Organization, Management, and Policy places long-recognized issues in the context of the twenty-first century’s first decades. The COVID-19 pandemic ranks as a historic challenge; yet much has been learned from this episode for future encounters with emergent health threats. The Affordable Care Act (ACA), widely controversial after its enactment, has shown clear signs of achieving its objectives and attaining public acceptance. Heightened public attention to diversity, equity, and inclusion (DEI) promises commitment to new policies and interventions to reduce health and survival disparities among Americans.

Although pundits and policymakers have predicted revolutionary change, many basic features of health care in the United States have remained remarkably stable in the 2000s. Innovations hailed as system-changing—prospective payment, managed care, the ACA itself—have had limited overall impact. The U.S. health care system has long been and remains predominantly private, decentralized, and employer-financed. For this reason, the challenges addressed in the chapters to follow appear likely to remain well into the future. It is important to understand that challenges visible in the U.S. health care system are not unique to this country. Throughout the world, health care is highly personal in nature, depended on for survival by many, widely viewed as a “right,” and steadily increasing in cost. These basic features of health care ensure continuing controversy perhaps everywhere over access to care, quality of services, responsibility for payment, and reliability of outcomes.

Many countries share health care challenges with the United States. The wealthy democracies of Western Europe, which all have national health plans of some kind, for example, experience socioeconomic disparities in health and life expectancy akin to those observed in the United States. Sweden, a country as strongly committed to the welfare state as any on the globe, still reports overcrowding and delays in its hospital emergency facilities and widespread dissatisfaction with health care. The health care system in Canada, to which Americans have looked for generations as a model for the United States, today faces severe challenges due to increasing costs and uncertainties about how delivery of care should be organized.

This book is intended to help readers see their own specialized area of the health care system in the perspective of the whole. It covers a broad spectrum of health care–related subject matter, including such diverse areas as epidemiology, health behavior, the health care labor force, hospitals and ambulatory care organizations, and health care finance. The chapters to follow may not necessarily provide information that is new to specialists in the relevant area. But even for experts in a particular dimension of health care, the book will contribute to a comprehensive understanding of the system and its issues.

Within practical limits, this book attempts to be definitive and comprehensive—and to be definitive in this case requires a highly factual approach to each area addressed. Many unsupported assertions characterize management thinking and policy debate. The field of health services research, however, has produced a tremendous volume of relevant, high-quality studies. This book makes extensive use of such research.

The text attempts to adequately address the essential tasks of the health care system, the features of each system component, and issues relevant to the future. Truly comprehensive treatment of the U.S. health care system, however, would require many more pages than those in this volume. The more closely one examines any dimension of health care, the more complex and multifaceted it reveals itself to be.

Rather than attempting to be exhaustive, the book concentrates on matters with the broadest implications for the delivery of health services. Consistent with this approach, hospitals receive more attention than long-term care organizations or public health departments. The social and economic issues arising in long-term care are by no means unimportant. But services delivered in hospitals predominate as drivers of health care costs. Similarly, the labor supply and contributions of physicians and nurses receive more attention than other health professionals. None would dispute the importance of persons outside these fields. Physicians, however, exercise more control over the delivery process, and their decisions crucially affect health care utilization and costs. Nurses comprise the largest single component of the health care labor force and provide the most visible and immediate care in many places. In addition, adequate supply of these professionals has at times been highly problematical.

This book is divided into three parts. Part One, “The System and Its Tasks,” provides an overview of the U.S. health care system’s components and challenges. Chapter 1 addresses the characteristics and dilemmas of health care as experienced by human beings everywhere and across historical eras. The chapter points out that although health care in the United States may be poorly integrated and decentralized, it is indeed a system, each of whose components is interdependent with several others. Chapter 2 identifies characteristics of the U.S. health care system that distinguish it from those of other countries, explains why these features exist, and raises questions about the type and degree of change acceptable to U.S. citizens. Chapter 3 presents a brief summary of the field of epidemiology and the health issues that lead Americans to utilize health services. Chapter 4 identifies patterns of human behavior, including individual acceptance of risks to health, that help determine both need for and utilization of health care.

Part Two, “Means of Delivery,” addresses actual operations of the system. Chapter 5 highlights the importance of formal organizations—such as ambulatory care practices, hospitals, and managed care firms—as the system’s actual operating components. Chapter 6 addresses the supply, demand, distribution, and management of health professionals, placing special emphasis on physicians, nurses, and health care administrators. Chapter 7 covers the ways in which Americans pay for their health care and the implications of insurance for consumer behavior and costs. Chapter 8 treats research as a sector of the health care industry, with special implications for the future of health care. This chapter covers basic questions regarding the validity, usefulness, and potential misuse of research in the health field. It highlights the challenge of making decisions that are crucial for health care efficacy and cost on the basis of research findings.

Part Three, “Paths Forward,” examines approaches Americans have taken to improving the system, its output, and the means that will be required to put innovations into effect. Chapter 9 covers the effects of key innovations in U.S. health care delivery over the past generation and assesses the impact of these measures. Chapter 10 addresses the contributions that prevention can make to the well-being of Americans and the control of health care costs. Chapter 11 concentrates on government and the political process as potential agents of progress or, alternatively, causes of stagnation and backsliding.

Finally, Chapter 12 examines alternative routes that Americans have considered toward an improved health care system. This chapter pays special attention to non-U.S. health care systems as potential models for improvement in the United States. The chapter concludes by highlighting controversies that are likely to continue into the future and identifying reforms that are feasible in view of American public opinion and potential industry opposition.

Each chapter ends with a series of discussion questions. These questions focus not on review of principles or facts appearing in the chapters, but are a means of encouraging the reader to develop her or his own synthesis of the facts and...