Tension, compression, and shear: directions, stresses, and outcomes of health care cost control

"Control" of health care costs is often portrayed as a struggle between external, "natural" forces pushing costs up and individuals, groups, and societies trying to resist the inevitable. This picture is false. Control includes strenuous efforts by some to raise costs, and by others to resist those increases, and/or to transfer costs to someone else. But all such forces originate in the purposes and interests of individuals and groups. Health care cost control is a struggle among conflicting interests over the priorities of a society, and claims of "inevitability" are simply part of the political rhetoric of that struggle. International experience supports certain conclusions. First, there is no basis for the claim that limits on expenditure growth must threaten the health of (some members of) a society. Second, there is a substantial variety of experience with cost control. Failure in the United States is often presented as evidence of the impossibility of control, but most other countries have succeeded. Finally, control requires the direct confrontation of interests, with substantial build-up of stress. Advocates of expansion are more successful if they can transform compressive forces into efforts to shift the burden onto someone else. Pressures from providers in every country for "privatization" and/or payment by users reflect this recognition of economic interest.     

The metropolitan character of urbanization in Mexico, 1900-1988

The author analyzes trends in urbanization in Mexico during the twentieth century, with a focus on the impact of rapid industrialization since 1982. Sections are included on the interrelations among economic development, industrialization, and urbanization; stages, levels, and measures of urbanization; the development of the city system in Mexico; and stages in the growth of Mexico City. (SUMMARY IN ENG)     

Book reviews

Russland als Vielvolkerreich. Entstehung, Geschichte, Zerfall. Andreas Kappeler. München, Germany: C. H. Beck, 1992, 395 pp, bibliography, index.

A Traveller's Companion to Central Asia. Kathleen Hopkirk. London: John Murray, 1993, 292 pp, £16.

Samarkand and Bukhara. John Lawton. Photographs by Francesco Venturi. London: Tauris Parke Books, 1992, 128 pp, £16.95. Mirror of the Orient. Roland and Sabrina Michaud. London: Thames and Hudson, 1992, 96 pp, £12.95, paperback.

The Continuing Conflict in Kashmir. Regional Conflict in Jeopardy. Iftikhar H. Malik. London: Research Institute for the Study of Conflict and Terrorism, 1993, 25 pp, £10.     

Are you ready for the cure?

The Clinton health-care plan will soon be unveiled. Here is an inside look at what it contains so far.