American Health Care: Paradigm Structures and the Parameters of Change

Recent commentary on the health care scene in the U.S. has moved increasingly toward explanations of why little or no change has occurred despite many declarations of crisis. From Alford\u27s (1975) elitist analysis in Health Care Politics to Navarro\u27s (1976) marxist analysis in Medicine Under Capitalism, critics in and out of the social sciences have tried to make sense of the array of current problems and the apparent lack of response to or change in them. These analyses are in striking contrast to earlier commentaries (e.g., Schwartz, 1971; Garfield, 1970; Anderson, 1972; Citizens Board, 1972) which, while highly critical of then current health care arrangements, foresaw the potential for change within the system and often made recommendations for potential solutions. If these earlier analyses might be said to have been characterized by an unwarranted optimism regarding the potential for change, the more recent analyses have more than counter-balanced that orientation with an overwhelming skepticism regarding any significant change, short of major societal restructuring. Health care arrangements are seen in these analyses as rooted in the more basic distribution of power and control in the U.S. (from an elitist perspective), or in the fundamental economic structure of the society itself (from a marxist perspective). Thus no significant change should have been, nor can be expected

Professionalism and the Control of Knowledge

Madness becomes mental illness through the joint project of psychiatry and the community of consensus lent to it. The psychiatrist, like the shaman (to paraphrase Leve\u27-Strauss), acts through the cultural plasma of his times. And the psychiatrist provides a definition for events, making mental illness of madness, while occupying a unique position within the scheme of society. Psychiatry has been attacked from many directions in recent years. Despite these varied challenges, however, its power appears to have abated little if at all. How can we account for this fact? On the surface one might assume that the scientific basis or the treatment success of psychiatric practice provides the buttress to repel the ongoing attacks. But we suggest here that the continuing power and the prestige of psychiatry can be understood more clearly by examining its relation to society at large rather than the relation to its patients. There appear to be two analytically separate but empirically interrelated factors at work. First, and of main importance, is the absence of an acceptable alternative to psychiatric practice in American society and Western culture in general. The stress must clearly be placed upon the condition of acceptability. Second, and growing out of the first, is the professional and organizational status psychiatry enjoys and the benefits implied therein. The ensuing discussion will elaborate these points and attempt a critical examination of the relationship between psychiatry and society

The Impact of Consumerism on Health Care Change: Alternatives for the Future?

The quest for consumer participation in the management of health care delivery may have experienced its first signs of success, but the implications of that success are as yet unclear. The establishment of consumer majorities on the newly developed health systems agency (HSA) boards was seen as an important milestone in the development of the consumer movement in America over the last ten years. The initial wave of optimism over the Great Society programs that in part gave birth to the consumer movement has long since vanished, but some of the organizational results of those attempts at innovation have become routinely established, as the requirements for consumer participation specified in wave after wave of health related amendments clearly indicates. But what are the results of this participation, and what can we reasonably expect in the future