INTRODUCTION
The perfect health care system is like perfect health—a noble aspiration but one that is impossible to attain. In the preceding chapters, we have discussed many fundamental issues and principles involved in formulating health care policy. A recurrent theme has been the notion that “magic bullets” are hard to come by. As stated in Chapter 2, policies tend to evolve in a cyclic process of finding solutions that create new problems that require new solutions. Policy changes may offer a degree of relief for a pressing problem, such as inadequate access to care, but frequently also give rise to various side effects, such as stimulating health care cost inflation.
All health care systems face the same challenges: Improving health, controlling costs, prioritizing allocation of resources, enhancing the quality of care, and distributing services fairly. These challenges require the management of various tensions that pull at the health care system (O’Neil & Seifer, 1995). The goal of health policy is to find the points of equilibrium that produce the optimal system of health care (Table 17-1).
| Health of the individual patient | Health of the population |
| Tertiary care | Primary care |
| Acute care | Chronic and preventive care |
| Cost unawareness in medical practice | Cost awareness |
| Unlimited expectations for care | Affordability of care |
| Individual physician | Organized health care team |
| Professional management | Corporate management |
| Market competition | Government regulation |
| Inequity in distribution | Fair distribution |
Dr. Madeleine Longview is chief resident in critical care medicine and supervises the intensive care unit of a large municipal hospital. It’s 5:30 AM, and the intensive care unit team has finally stabilized the condition of a 15-year-old admitted the previous evening with gunshot wounds to the abdomen and chest. Dr. Longview sits by the nursing desk and surveys the other patients in the unit: a 91-year-old woman admitted from a nursing home with sepsis from a urinary tract infection, a 50-year-old man with shock lung caused by drugs ingested in a suicide attempt, and a 32-year-old woman with lupus erythematosus who is rejecting her second kidney transplant. Dr. Longview feels personally responsible for the care of every one of these patients. She tells herself that she will do her best to help each of them survive.
As Dr. Longview gazes out of the windows of the intensive care unit, the apartment houses surrounding the hospital take shape in the breaking dawn. She wonders: Which block will be the scene of the next drive-by shooting or episode of spouse abuse? Which window shade hides a homebound elder lying on the floor dehydrated and unable to move, waiting for someone to find him and bring him to the emergency department? Which one of the unvaccinated kids in the neighborhood will one day be rushed into the unit limp with meningitis? In which room is someone lighting up the first cigarette of the day? Dr. Longview somehow feels responsible for all those patients-to-be, as well as for the patients lying in the hospital beds around her. After these sleepless nights on duty, the doubts about the value of all the work she does in the intensive care unit creep into her thoughts. She has visions of shutting down the unit and putting all the money to work hiring public health nurses in the community, or maybe just paying for a better grammar school in the neighborhood. But then what would happen to the patients needing her care right now?
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