The American Healthcare "System" in 2005 -- Part 2: Who Is in Charge?

Editor's Note:
American Health System Reform has returned to the front burner for 2007-2008. MedGenMed ran a sequence of Webcast Video Editorials in 2005 that tried to tell the whole story -- past, present, and proposed future -- in 7 easy lessons. It was well received then with high readership but the politics was cold. The situation in American healthcare has not changed fundamentally since 2005, except that conditions have worsened and a new presidential campaign is upon us. Ergo, the politics of health "system" problems is now hot. So, we are republishing all 7, in order, on sequential Thursdays. Read, enjoy, or get angry, but let us know what you think. Send us your reactions, proposals, serious health policy articles, letters, brickbats, essays, whatever. Help us boil the pot to inform the profession and the populace.

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Who is in charge of the US healthcare system? No one and everyone. Anarchy and chaos stand side by side. There is nothing remotely akin to a "US healthcare czar." "The marketplace" determines how much money is spent on what and how many people of what types work in healthcare. Yet, it is by no means a "free market." It is constantly reshaped by numerous forces, none truly predominant, although government of all kinds, including Medicare, Medicaid, the Veterans Administration, the Public Health Service, and the 50 states and many local health departments -- plus the military, government in aggregate constituting nearly 50% of all US healthcare expenditures. Who can "order" that patient safety measures be put into effect? No one. Who can require compatible computerized medical records in the home, the doctor's office, the pharmacy, the emergency room, and the hospital? No one can, even if such an implementation would provably save lives and money. Who can ensure that the quality of care provided in the physician's office, where the most care is given, is above a certain standard? No one. Who can even require that it be measured? No one can. You may ask why we spend so much and get so little. Actually, we get a lot, not a little, of testing, technology, medications, surgeries, hospitalizations, and all the rest -- often a lot of what we need...only a little.[1] That's my opinion. I'm Dr. George Lundberg, Editor of MedGenMed (to be continued).

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