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Responses to current health care system changes are largely reactive and as fragmented as the changes themselves

Health care delivery is undergoing a profound restructuring as more Americans enroll in managed care organizations. Access to care—who gets which services and who decides—is a particularly complicated issue, especially because of the growing number of uninsured. Reactions to these changes in the health care system are as fragmented as the changes themselves, according to Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality's Center for Outcomes and Effectiveness Research. In a recent commentary, Dr. Clancy and her colleague Marion Danis, M.D., M.P.H., of the Department of Clinical Bioethics at the National Institutes of Health, note that 15 years of unsuccessful efforts to contain costs along with increased numbers of uninsured individuals culminated in a major effort to reform the entire U.S. health care system in 1993 and 1994. What emerged from that failure was a default consensus favoring market-based solutions.

Health care reform now refers to private sector innovations in health care delivery, with substantial discretion for priority setting delegated to negotiations between payers, providers, and health plans. This comes at a time when historic reliance on employer-based coverage is strained by shrinking rather than expanded coverage of workers. The authors note four challenges currently confronting our health care system. These are changing demographics to a more elderly population with chronic diseases; advances in technology (from organ transplantation and genetic diagnosis to breakthrough pharmaceuticals) that compete for limited resources; economic instability in world markets that make predictions about available resources for health care tenuous; and ethical dilemmas such as privacy of personal health information and equitable resource allocation for vulnerable groups.

Responses to these challenges have been largely reactive, according to the authors. They recommend that the health services and ethics research communities study these issues to help Americans make informed choices about health care priorities in the next century.

More details are in "Setting priorities American style," by Drs. Clancy and Danis, in Coulter, A., and Ham, C. (editors), The Global Challenge of Health Care Rationing. Philadelphia: Open University Press, February 7, 2000, pp. 52-59.

Reprints (AHRQ Publication No. 00-R020) are available from the AHRQ Publications Clearinghouse.

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