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November 1, 2000

Deficiencies in US Medical Care

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(17):2184-2185. doi:10.1001/jama.284.17.2184

To the Editor: In asking whether US health care is the best in the world, Dr Starfield1 overlooks a much more fundamental issue: the absence of nationally agreed-on goals and directions for promoting the good health of our citizens and the absence of a nationwide system for implementing health goals.

Without clear health policy goals and clearly developed ways of directing the health care effort in a goal-directed manner, US health care will be determined by "the invisible hand" of a relatively unregulated health care market that values efficiency, economy, cost-saving, and the most diluted, adulterated product that the public will tolerate. These de facto health care goals tend to promote the financial interests of an industry (health care financing) in preference to the public's health interest. The false assumption behind the current adulation of market forces is that an informed "consumer" will make "rational" decisions and choices about health care coverage and that bad service will be competitively driven out by good service. However, for the most part "consumers" do not directly purchase health care for themselves. It is bought for them by their employers, whose managers are seeking the best deal, not necessarily the best or most comprehensive coverage.

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