CURING, CARING, AND ECONOMICS: DILEMMAS OF PROGRESS DAVID MECHANIC* In the past 25 years, advances in science and technology have fundamentally altered the approach to medical care, the mix of health personnel , and the degree of public and private investment. In 1955, national health expenditures totaled $17.7 billion, 4.4 percent of the gross national product and slightly over $100 per capita. Twenty-five years later we are spending approximately $250 billion, approximately a tenth of our gross national product, and almost $1,000 per capita [I]. The increase in intensity of medical care is reflected in the fact that in 1960 community hospitals had 2.3 employees for every patient, but the ratio increased to 3.7 by 1977 [2, p. 226]. While the enormous growth of the health industries is apparent, their contribution to life and health and to the welfare of the nation, relative to magnitude of investment, is more commonly disputed [3]. With the impressive growth of medical research in the post-World War II period, and advances in biomedical knowledge, medical care became both more scientific and more capable of making a difference in particular instances. But with the exception of the control of mortality from infectious disease, which had a large impact, most of medical discovery affected outcomes at the margin and had only a modest impact on longevity. Whatever its self-conceptions, medicine was still as concerned with caring as with curing, and the chronic conditions that produce a heavy burden of illness and mortality still largely remain outside its control. It is now generally accepted that the health of populations depends more on their demography, their social structure, and how they choose to live than on medical care. Since 1955, economic advances, improved education, better access to medical care, and increased sophistication of care all contributed to significant reductions in infant mortality, and some advances in longevity as *University Professor and Dean, Faculty of Arts and Sciences, Rutgers University, New Brunswick, New Jersey 08903.© 1982 by The University of Chicago. AU rights reserved. 003 1-5982/82/2504-0305$01 .00 722 I David Mechanic · Curing, Caring, and Economics well [2, pp. 1 14-1 19]. The gap in length of life between men and women increased, however, reflecting the effects of differential life-styles and behavior. Much of the differential can be explained by greater exposure to violent death among men, or by differences in smoking, drinking, and other behaviors. The effects of behavior on health and longevity in turn affect demography, creating new social problems. The female advantage in longevity of almost 8 years results in a large imbalance by sex among the aged and in part explains the predominance of women in nursing homes. New technologies and changing attitudes similarly affect demographic trends. The introduction of a sophisticated technology that could be conveniently used—the birth control pill—allowed families and individuals substantially to achieve desired fertility, and resulted in a dramatic drop in the birth rate. The liberalization of attitudes toward abortion, and its legalization, allowed further "fine tuning" of individuals ' objectives. Demography, technology, and values all help determine the social policy agenda. Federal Programs in Health The past 25 years have also witnessed a massive involvement of government in medical care financing and regulation, and one dramatically altering organizational relationships in health care. The introduction of Medicare and Medicaid in 1966, and its impact on professionals, medical care institutions, and medical care costs, fundamentally changed the relationships between public authorities and private providers. While physicians and institutions benefited immeasurably from the increased financing made available by these programs, they also became quasipublic providers, ceding some of their operating flexibility to external authority. While massive federal programs spurred inflation, the use of sophisticated but not always necessary technology, and a strong profit orientation in the response of the private sector, they touched the lives of many people in need by providing sophisticated medical care not previously available. Medicare and Medicaid significantly improved access to medical care for elderly persons and for the medically indigent [4]. The traditionally observed relationship between low socioeconomic status and little use of physician services was reversed, and rates of admission to hospitals...
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Nov 1, 1990
Mary M Mitchell + 1
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