US health care policy in 1990: looking back, looking ahead

Health policy in the United States is best understood as a policy of incrementalism with major interventions occurring only in response to crisis, as in the case of the Medicare legislation that profoundly altered our historic financing of health care. The characteristically minor, unplanned, adjustments that are made often have major unanticipated consequences, and these serve to explain the radical transformation of the nation's health system in the half-century since World War II. The main elements in this change--the evolution of employment-tied private insurance for the majority of the population, the predominance of specialism and superspecialism in medical practice, the expansion of the voluntary hospital system with capital liberally raised through tax-exempt bond issues, advancing technology and medical capability are reviewed. The major persistent policy issues--uncontrolled expenditures and the increasing numbers of uninsured--will ultimately precipitate change, perhaps by the end of the decade, very likely a minimum benefit, universal federal-state insurance system, supplemented by the private market--hardly radical systemic reform.