The New England Journal of Medicine
December 12, 2002
Homeostasis without Reserve – The Risk of Health System Collapse
By Lewis G. Sandy, M.D.
Although most observers of the health care system view the 1990s as a period of extensive instability and change, in reality the health care system, taken as a whole, exhibited remarkable homeostasis.
Now, in 2002, after a tumultuous decade in health care and in health policy, today’s health care system looks remarkably similar.
Yet the turbulence of the 1990s did profoundly affect our health care system. Maintenance of homeostasis requires effort and consumes energy. The cumulative effect of the public-policy and marketplace changes of the 1990s has been the near-elimination of the system’s reserve capacity and the exhaustion of available compensatory mechanisms.
A high-quality, cost-effective, and just health care system can be developed in the United States. It would require the public will to spend substantial resources on expanding coverage, willingness on the part of providers to restructure the delivery of care so as to improve quality and access, a general recognition of the limits to medicine and to spending on health services, and a social consensus on the nature and degree of inequality in our health care system. We will need to do these things sooner or later. As in the case of a patient facing a physiological assault with diminished homeostatic reserve, it would be far preferable to treat the U.S. health system as an outpatient than to wait until it is in the intensive care unit, dependent on a ventilator and on pressor therapy.
http://content.nejm.org/cgi/content/full/347/24/1971
(Available to NEJM subscribers only)
