Health care policy: lessons from the past and issues of the future

Liberal distributional values, the increasingly powerful capacity of medicine to provide more and better care, and concern about the health hazards of an industrial society fueled the vast expansion of the health care sector during the last 20 years. That growth was facilitated by a growing economy. The current health policy debate at one level reexamines the distributional bases of entitlement programs, and at another seeks alternative resource allocation mechanisms to reduce the cost of health care. This article has two themes. First, distributional and allocational policies are shown to be intrinsically related, so that the health policy debate is fundamentally a clash between liberal and libertarian values. Second, the inexorable social forces driving the health care system are shown to be the aging of the population and the rapid expansion of technology. The resulting dynamics imply the further growth of the health sector, now in the environment of a sluggish economy. Future policies will have to struggle with how to ration scarce health resources and how to reorient the health care sector to the problems of the aged.     

Industrial rationalization of a cottage industry: multi-institutional hospital systems

The environment facing hospitals, generally supportive until the 1970s, may now be characterized as complex, turbulent, and constrained. In response to such environmental conditions, hospitals have adopted new strategies and structures. The strategies, described as corporate rationalization, have led away from the traditional structure of freestanding, autonomous hospitals and toward the formation of multi-institutional systems. These systems are designed to provide sufficient strength to cope with the environment, to acquire scarce and valued resources, to allow organizational stability, to achieve organizational purpose, to enable growth and/or survival, and to enhance market position. The impact of multi-hospital systems is viewed in two major areas: acquisition, retention, and utilization of economic and human resources, and organizational, political, and social factors.     

Two Decades of Change: A Ranking of Key Issues Affecting Intergovernmental Relations

This article describes the results of a 1981 survey of 1,000randomly selected scholars of American government and politicswho were asked to rank the most significant intergovernmentalevents and trends of the past twenty years. Responses were receivedfrom almost 40 percent of these scholars; no significant returnbiases were detected. These scholars ranked civil rights andvoting rights acts as the most significant events of these decades.General Revenue Sharing and the reapportionment cases were rankedsecond and third in importance. The increased flow of federaldollars to states and local governments was ranked the mostimportant trend affecting intergovernmental relations, followedby the increased public disaffection with government and thegrowing dependence of local governments on state and federalaid. The Vietnam War and the inflationary spiral it initiatedwas ranked as the most significant social event affecting thecourse of intergovernmental relations, followed closely by theenergy crisis and the beginnings of the "Great Society." Thearticle also examines the effects of party identification, age,year of degree, government experience, region, and city sizeon scholarly attitudes toward these events and trends. Whilethe overall rankings were not dramatically altered, partisanship,region, and city size all were factors found to be noticeablyrelated to scholarly rankings of these important events andtrends.     

B. Reviews: general

A HISTORY OF THE ARAB PEOPLES. By ALBERT HOURANI. London, Faber and Faber, 1991. xviii, 551pp. £25 (hb).

STUDIES IN ARAB HISTORY. Edited by DEREK HOPWOOD. (St.Antony's/Macmillan series.) London, Macmillan, 1990. 189pp. 5 plates and 3 figures.

A HISTORY OF THE SELJUKS: ?BRAHIM KAFESOGLU'S INTERPRETATION AND THE RESULTING CONTROVERSY. Translated and edited By GARY LEISER. Carbondale and Edwardsville, Southern Illinois University Press, 1988. 208pp. Genealogical charts, maps in end covers. $29.95.

THE HISTORY OF THE JEWS IN THE LATIN KINGDOM OF JERUSALEM. By JOSHUA PRAWER. Oxford, Clarendon Press, 1988. xv, 310pp. 5 maps.

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THE END OF EMPIRE IN THE MIDDLE EAST: BRITAIN'S RELINQUISHMENT OF POWER IN HER LAST THREE ARAB DEPENDENCIES. By GLEN BALFOUR‐PAUL. Cambridge, Cambridge University Press, 1991. xxiv, 278pp. £30.00.

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Slim just left town: decisionmaking on an intensive care unit

The title of this paper comes from an incident that occurred while I was participating in morning rounds on the pediatric and surgical intensive care unit of a large, midwest tertiary care center. The patient under discussion was an eight-week-old girl who had been born without kidneys, and who had been cared for on the unit for seven weeks. In the previous week, the baby's condition had gone steadily downhill, as she experienced on medical catastrophe after another. One of the nurses asked the staff doctor who was leading rounds that morning, "What are the baby's chances?" The physician replied, "Her chances are slim." To which one of the young residents immediately answered, "Slim just left town."