ABSTRACT
Health reforms inevitably build on existing structures, professional groupings and preexisting forms of organization. Rationing technology results in queuing and establishment of priorities for treatment. By any kind of efficiency standard, American health care is highly wasteful and its enormous capacity encourages utilization in situations of marginal usefulness. Health care reform will inevitably increase the expenditures through enhanced insurance coverage and a variety of special programs in response to the need for increased access and earlier intervention. Although health interventions can be introduced in a variety of ways, curative efforts often come too late in the illness trajectory. Public health is a powerful point of intervention but in practice is caught between the interests of clinical medicine and those of economic, political and religious groups. Physicians have been trained to pursue what Fuchs has called the technologic imperative, an inclination to use interventions, however costly, that promise any possible benefit however small.
