The First Quarter-Century: Looking Back, Looking Ahead

Abstract

From the Editor-In-Chief Health AffairsVol. 26, No. 6: 25 Years In The Health Sphere The First Quarter-Century: Looking Back, Looking AheadJames C. RobinsonPUBLISHED:November/December 2007Free Accesshttps://doi.org/10.1377/hlthaff.26.6.1523AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSHealth servicesQuality of careMedicare T his issue marks the twenty-fifth anniversary of the founding of Health Affairs and challenges us to reflect on where we have been and where we are going. It is also a moment to celebrate the contributions of John Iglehart, who as founding editor has led the journal’s evolution from a slim volume to a broad portfolio of interrelated activities, including the peer-reviewed print and Web-based journal and the interactive blog. For me, this issue creates the moment to start walking the walk as incoming editor-in-chief, with a fiduciary responsibility to maintain the journal’s scholarly integrity and brand reputation while extending into global health and biomedical innovation. To stimulate our collective reflections, we have solicited Perspectives from a selective list of policy analysts and activists, allowing them full freedom to choose their topics and comment on historical trends, contemporary politics, intellectual debates, the role of the journal, and the larger health services research enterprise. Many of these authors are veterans of battles past, of efforts to create universal health insurance or to promote coordinated care or to mainstream mental health. The tone of some contributions is circumspect with respect to what can be expected. One senses a fatigue from so many high hopes unfulfilled, projects not adopted, initiatives never given a fair chance to succeed. Instead of emphasizing what we have not achieved over the past quarter-century, however, I believe that it is important to note some of the deep and positive trends that have developed and from which there is no going back.We have forever left the domain of “third-party reimbursement” in favor of using public and private insurers as active purchasers of services on behalf of their enrollees. No longer do physicians enjoy unquestioned authority to define what is medically necessary and how it must be delivered, by whom, in which context, and for what price. We can dispute the virtue of contemporary initiatives in “pay-for-performance,” but no one suggests a return to “pay-for-nonperformance.” We have moved from the framework of professional dominance to one of measurement and accountability, with quality defined as processes done in accord with the best available evidence and with good risk-adjusted outcomes. We have moved from professional dominance toward a new ideal of shared decision making, after a short detour through consumer-driven health care. Americans can be counted on to do the right thing, after all, once they have tried every alternative. Conservative political objections notwithstanding, the populace continues to shift into governmental insurance programs, as private employers restrict coverage, Medicaid and State Children’s Health Insurance Program (SCHIP) programs expand, and the baby boomers age into Medicare. Liberal political objections notwithstanding, those public programs rely ever more extensively on private plans to contract with providers, structure benefits for individuals, manage care for chronic illnesses, and identify patterns of over- and underuse.We have made major advances against heart disease and other major scourges of modern epidemiology, greatly reduced tobacco use, and developed a breathtaking array of biopharmaceuticals and medical devices.Last but not least, we continue to develop the infrastructure of health services research, policy analysis, and management training. The universe of peer-reviewed journals, philanthropic foundations, university programs, and conferences has expanded these past decades beyond the imagination of anyone in 1982.We will continue to debate strategies for market and social change, torn between the desire for deep change and caution born of past defeats. Many of our authors suggest incremental changes to elide the three obstacles to change: vested interests, rival visions of the good, and the advantages of incumbency. The twin papers by Jack Wennberg and his colleagues take the contrary position, advocating that we use pay-for-performance principles as the thin edge of a wedge to shift Medicare toward supporting informed patient choice for high-cost surgical procedures and the channeling of services to providers that practice in an evidence-based and efficient manner.Lest we despair at what we have not achieved, let us measure our shortcomings against our ambitions. We want to expand insurance coverage, reduce administrative expenses, foster clinical innovation, improve quality and efficiency, reduce errors, encourage prevention, induce cost-conscious and informed consumer demand, limit fraud and excess profits, coordinate the continuum of clinical services, and, speaking for my fellow Californians, feel good, look good, and live forever. Not a bad list. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 November 2007 InformationCopyright 2007 by Project HOPE - The People-to-People Health Foundation, Inc.PDF download