THOSE INVOLVED IN THE DELIVERY OF HEALTH care
in the United States face a dilemma. The balance among health care quality, access, and cost is becoming increasinglyprecarious. For those who have access, the quality of health care in the United States is recognized as equal to that in any other country, and much better than that in most. However, access is a major problem. An estimated 35 million persons in this country have no health care coverage and are essentially disenfranchised from the health care system. At least an equal number are grossly underinsured, and any severe illness would drive them into poverty.
Another major issue facing the country is the cost of health care. These costs currently exceed 12% of the gross national product (GNP) and will surpass 15% by the year 2000 if the current rate of increase continues. Front-end cost constraints such as health systems agencies and technology utilization review committees have had little impact on the rate of increase in health care costs over the past 2 decades; nor have back-end mechanisms such as diagnosis-related groups (DRGs) and health maintenance organizations (HMOs) that attempt to control the payment and reimbursement process for health care services. It is becoming increasingly clear that the dilemma of health care quality, access, and cost in this country is unresolvable without major reformation of the delivery of health care. However, a reformation approached as a confrontation and without a clear direction for change is a revolution, and a revolution is an effort to overthrow the existing order without necessarily offering something better in its place. That is why the dilemma of health care in the United States today is characterized as The Health Care Crisis.
Many factors have contributed to the present dilemma. Among them are these:
Inflation, especially salaries and wages in a labor-inten-
Population growth, particularly in those population
Population aging, because older people require more sive process such as health care delivery.
subgroups that can least afford health care.
health care.