Paradigms lost: the persisting search for community in U.S. health policy

Local communities have long played an important role in health and social policy in the United States. But the concept of community was strangely absent from the federal debate on health care reform in 1993 and 1994. I attribute this absence to the paradoxical nature of community as a frame for guiding policy making. The concept of community has broad appeal across the ideological spectrum, but this breadth masks a set of long-standing and powerful tensions that determine when communities are seen as appropriately given responsibility for addressing societal problems. This article reviews the historical evolution of the role of community in health policy, highlighting the ways in which various tensions emerged. It applies these perspectives to an analysis of the attitudes of the U.S. public and congressional staff in 1995. Data from two surveys demonstrate that support for community-based reforms is much lower for medical care than for other social needs, including some health-related concerns such as long-term care and the treatment of substance abuse. Statistical analyses suggest several possible explanations for the lower support for community-based medical care. The article concludes with a discussion of the implications for future communitarian strategies designed to improve U.S. medicine or social policy.