Preface

Since its first edition in 1998, Understanding Health Policy: A Clinical Approach has illuminated the workings of the US health care system. For this ninth edition, we are happy to welcome a third author, Rachel Willard-Grace, a health services researcher focused on building better teams to improve health care delivery. As a former medical assistant, pharmacy tech, and health care administrator, Rachel brings a new perspective on how health care is organized and delivered.

This is a book about health policy as well as individual patients and caregivers and how they interact with each other and with the overall health system. We, the authors, have taken care of patients and are also health care analysts. In one sense, these two sides of our lives seem quite separate. When treating a patient's illness, health expenditures as a percentage of gross domestic product or variations in surgical rates between one city and another seem remote if not irrelevant—but they are neither remote nor irrelevant. Health policy affects the patients we see on a daily basis. Managed care referral rules determine which specialist will see a patient; coverage gaps in the Medicare benefit package affects access to care for older adults. Understanding Health Policy hopes to bridge the gap separating the microworld of individual patient care and the macrouniverse of health policy.

The book is primarily written for health professions students and practitioners—physicians, nurses, nurse practitioners, physician assistants, pharmacists, social workers, community health workers, public health experts, and others—who will benefit from understanding the complex environment in which they work. Physicians feature prominently in the text, but in the actual world of clinical medicine, patients’ encounters with other health care providers are an essential part of their health care experience. Physicians would be unable to function without the many other members of the health care team. Patients seldom appreciate the contributions made to their well-being by public health personnel, research scientists, educators, and many other health-related professionals. We hope that the many nonphysician members of the clinical care, public health, and health professions education teams as well as students aspiring to join these teams will find the book useful. Nothing can be accomplished without the combined efforts of everyone working in the health care field.

Understanding Health Policy attempts to explain how the health care system works. We focus on basic principles of health policy in hopes that the reader will come away with a clearer, more systematic way of thinking about health care in the United States, its problems, and the alternatives for managing these problems.

Given the public's intense concerns about health care in the United States, we call out the failings as well as the successes of the US approach to financing and organizing care. Only by recognizing the difficulties of the system can we begin to fix its problems. The goal of this book, then, is to help all of us understand the health care system so that we can better work in the system and change what needs to be changed.

In our attempt to unify the overlapping spheres of health policy and individual health care encounters, we use clinical vignettes as a central feature of the book. These short descriptions of patients, physicians, and other caregivers interacting with the health care system are based on our own experiences, the experiences of colleagues, or cases reported in the medical literature or popular press. Most of the people and institutions presented in the vignettes have been given fictitious names to protect privacy. Some names used are emblematic of the occupations, health problems, or attitudes portrayed in the vignettes; most do not have special significance.

In exploring controversial issues of health policy, our own opinions inevitably color and shade the words we use and the conclusions we reach. We present several of our most fundamental values and perspectives here.

We believe that health care should be a right enjoyed equally by everyone. Certain things in life are considered essential. Society is not outraged if someone is turned away from a movie or concert because he or she cannot afford a ticket. But sick people who are turned away from a medical practice can make headlines, and rightly so. All people should have equal access to a reasonable level of appropriate, high-quality health services, regardless of ability to pay.

In 2009, the United States entered into a fierce debate over whether health care should be a right. The debate focused on President Barack Obama's campaign to enact universal health insurance. Following a year of public ferment, Congress passed the Affordable Care Act, which moves in the direction of guaranteeing health care as a right. Yet, at the time of writing this edition of Understanding Health Policy, the controversy continues.

We recognize the serious, persistent inequities in the health and health care of the US population. Study after study find that socially marginalized groups suffer poorer health than groups with greater social privilege and power. These disparities are shaped by deeply rooted forces such as racism, sexism, poverty, and rural isolation. Improving the health care system requires eliminating these inequities.

We believe that limits must be placed on the costs of health care. Rising costs make health services and health insurance unaffordable. Many companies are shifting more health care costs onto their employees. As government health budgets balloon, cutbacks are inevitable, generally hurting older adults and people in low-income brackets. Individuals with no health insurance or inadequate coverage have a far harder time paying for care as costs go up. As a general rule, when costs go up, access goes down.

We believe that cost controls can be imposed in a manner that does relatively little harm to the health of the public. Scientific advances that spawn new, expensive technologies may benefit some patients but are often inappropriately used for patients whom they do not benefit. The accelerating cost of administering the health care system wastes money that could be reinvested in clinical and public health programs that promote health. Eliminating medical services that produce no benefit and cutting administrative waste are examples of a path to “painless” cost control.

Most physicians, nurses, and other health professionals are trained to provide clinical care to individuals. Yet clinical care is not the only determinant of health status; standard of living and public health measures have an even greater influence on the health of a population. Health care, then, should have another dimension: concern for the population as a whole. Individual clinicians may be first-rate in caring for their patients’ heart attacks, but may not worry enough about the prevalence of smoking, uncontrolled diabetes, and substance use, or about nieghborhoods that are “food deserts” or lack safe spaces for exercise, affecting the health of the group of patients enrolled in their practices and the broader community. The COVID-19 pandemic starkly revealed the need for greater integration of public health and clinical medicine. We believe that health care providers should be trained to add a population orientation to their current role of caring for individuals.

We could not have written this book by ourselves. The circumstances encountered by hundreds of our patients and dozens of our colleagues provided the insights we needed to understand and describe the health care system. Any inaccuracies in the book are entirely our responsibility. Our warmest thanks go to our families, who have provided both encouragement and patience.

Earlier versions of Chapters 2, 4, 7, 11, 12, and 17 were published serially as articles in the Journal of the American Medical Association (1994;272:634–639, 1994;272:971–977, 1994;272:1458–1464, 1995;273:160–167, 1995;274:85–90, and 1996;276:1025–1031) and are published here with permission (copyright, 1994, 1995, and 1996, American Medical Association).

This is a book about health policy. As such, we will cite technical studies and will make cross-national generalizations. As health care practitioners, however, we are daily reminded of the human realities of health policy. Understanding Health Policy: A Clinical Approach is fundamentally about the people we care for: the underinsured janitor with high-deductible insurance enduring the pain of recurrent gallstone attacks because surgery might be unaffordable, or the retired university professor who sustains a stroke and whose life savings are disappearing in nursing home bills uncovered by her Medicare or private insurance plans.

Almost every person, whether a parent struggling to pay rent, a young college graduate navigating a first job, a well-to-do physician, or a millionaire insurance executive, will someday become ill, and all of us will die. Everyone stands to benefit from a system in which health care for all people is accessible, affordable, equitable, appropriate in its use of resources, and of high quality.