The U.S. Health Care System
Several years ago, Ivan Illich ( 1976) made a remarkable and radical claim regarding health care. Illich suggested that it is often the process of being drawn into the medical establishment with its host of iatrogenic maladies that renders individuals sick or unhealthy. Indeed, Illich, writing in his well-known text, Medical Nemesis, noted, "That society which can reduce professional intervention to the minimum will provide the best conditions for health" (p. 1). If Illich was right, then one might well argue that the United States has developed the very poorest conditions for health. In the early 1990s, spending on health care had reached an all-time high, there was an explosion in medical technology, and "professional intervention" seemed to abound. In fact, there were many who came to the conclusion that the U.S. health care system itself was sick--that it was too costly and that it left far too many individuals without the protection of health insurance. This was a different type of systemic illness than Illich had articulated, but it did become the focal point of a heated political debate, and it helped to establish an overall context for investigation of that controversy. The specific structural context for the 1994 health care reform debate can best be explored by examining the nature of the health care system in the United States.
The term "system" suggests notions of various parts, interrelated in many ways, working to produce a larger whole that is somehow more than the mere sum of those parts. Railroad systems have multiple tracks and destinations. A health care system may be somewhat similar to the latter. It runs along several tracks, has many stops and starting points, and--in the case of the United States--the occasional derailment along the way.
Although the railroad analogy conjures up several initial thoughts about the status of the U.S. health care system, some additional context and framework for understanding are necessary. In fact, some comparative context helps to better place the status of the U.S. health care system in its rightful place on a global scale. A great many United Nations task forces, governmental reports, and scholarly authorities have generated volumes of information regarding comparative health care systems. One