Book Review

Growing Old Gracefully

Power and Illness: The Failure and Future of American Health Policy

N Engl J Med 1994; 331:486-487August 18, 1994

Article

Power and Illness: The Failure and Future of American Health Policy
By Daniel M. Fox. 183 pp., illustrated. Berkeley, University of California Press, 1993. $20. ISBN: 0-520-08409-8

Daniel Fox has written a brave and important book. Combining his expertise as a historian and a policy analyst, he reveals the soft underbelly of the debate over health care reform -- its problematic assumptions and its fundamental limitations. We are still doing what Fox shows has been done for decades: trying to shoehorn the special needs of people with chronic diseases into a system designed to treat acute illnesses. Power and Illness provides considerable insight into why we have done that in the past, why it is so difficult to stop doing it now, and why we simply must stop doing it in the future.

Fox teaches us to look at the American health care system in a novel way. He views it as the response to a particular understanding of the nature of health, the goals of medicine, and the burden of disease in society. He convincingly demonstrates that during the first half of the 20th century, a remarkably stable coalition of leaders in medicine, business, philanthropy, and government enjoyed sufficient public trust and political power to build a system of medical care based on their vision of scientific possibility and social need.

Fox tells the story of that coalition crisply. Rooted in medicine's struggle against infection and acute life-threatening diseases, the coalition promoted biomedical research, specialized medical training and practice, and a vast infrastructure of hospital-based services. One of the most important aspects of the politics of health care reform in the 1990s is that this coalition, particularly the alliance between organized medicine and business, has broken down.

Almost from the very beginning, the architects of American health care failed to allow for growth in the prevalence of chronic degenerative conditions, notably cancer, heart disease, stroke, and diabetes, in the increasingly long-lived American population. Fox makes the point that the problem was not so much a failure to recognize the growing presence of chronic illness as a failure to accommodate and respond effectively to the demands of long-term care. Treatment of chronic diseases was grafted onto the specialized, hospital-based system of care, and priority was given to managing the acute phases or crises of these conditions.

Fox argues that a more adequate and appropriate response to chronic illness would have required a fundamental rethinking of the assumptions governing the acute care model. Building on the work of Anselm Strauss and others, Fox presents a thorough and provocative analysis of the implications of taking chronic illness seriously in health policy. They include greater emphasis on prevention and behavior modification, more attention to long-term and community-based services, and health care financing based on large and inclusive, community-rated risk pools. These implications challenge the deeply entrenched institutions of medical education and specialty practice. They also challenge the financial and intellectual interests of most physicians -- even today, careers in long-term care have little prestige and low rewards.

In the end, Fox is cautious and ambivalent about the prospects for meeting the challenge of chronic illness in an aging society. He argues that simply adding the costs of better long-term care to the existing system -- the predominant policy strategy of the past -- is no longer feasible. His message is that we must redistribute resources from short- to long-term services, and he sides with those who believe that we can readily do so without adverse effects on the public's health.

Where will we find the political and moral will to meet the challenges of chronic illness? Fox appeals to the need for a greater sense of mutual responsibility in American society as a moral foundation for health policy, but he does not tell us where we will find that moral sense. Tomorrow, when chronic illness may be a part of life for all of us, perhaps society will forge a new contract with medicine that is based on community needs, even as a new medical social contract seems to be emerging today on the basis of greed.

Bruce Jennings
The Hastings Center, Briarcliff Manor, NY 10510