People want health care that maximizes their health potential and satisfies their individual needs and values. They also want access to a wide range of health services in an efficient manner at reasonable cost. In addition, they are concerned about rising costs and unexplained variations in the use of health services by seemingly similar patients. They are further confused by the fact that the effectiveness of component health services is uncertain.
These conflicting desires give rise to the tensions and controversies that characterize the health care system in the United States and many other countries. To help resolve these conflicts, we need to understand what people value about health care and how different values lead to diverse goals and outcomes.
The American system offers a wide variety of choices: private insurance through employment, private insurance purchased on the marketplace under the Affordable Care Act, single-payer Medicare for most people 65 and older, and state-managed Medicaid programs for the poor. There are 28 million people without any insurance at all. The health care system is complex and fragmented, with a myriad of players—doctors, nurses, technicians, therapists, pharmacists, laboratories, hospitals, and others.
Some people believe that market principles and competition should be applied to the health care system to enhance patient choice, improve quality, and reduce cost. These ideas are rooted in the belief that the economic principles of an ideal market—perfect information, homogeneous products, large numbers of suppliers and customers (here, doctors and patients), and free entry of new competitors—apply to health care. The facts do not support these assumptions, however. For example, there is often no way for patients to find complete information about providers quickly and easily, the product—health care—is not a commodity, and competition is constrained by the presence of regulatory mechanisms (Weisbrod, 1983; Lohr, 1986).
Still others argue that a person-centered approach is more important than efficiency. The emphasis on a holistic view of the patient and the importance of addressing the patient’s emotional and spiritual as well as physical needs are seen as a crucial way to deliver high-quality, person-centered health care.
Others suggest that healthcare resources should be allocated according to a cost-benefit analysis, in which alternatives are compared with respect to their financial costs and benefits. This approach is not without its critics, however, particularly when it is taken to extremes.
Finally, some people believe that allocations should take into account the needs of future generations. The idea is that the current generation owes it to future people to make enough investments in research and prevention so that they can receive adequate health care when needed, rather than bankrupting the system for no good reason in order to provide immediate benefits to the present generation. This is known as “intergenerational justice.” However, there are many questions about this approach, including whether it is feasible or even desirable to allocate resources in this way. As we learn more about the health care systems of other nations, we may be able to adopt practices and policies that can bring us closer to our goal of a health care system that provides optimal health for all its people at a price the nation can afford.