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____________________________________________________________309 Presentation HEALTH CARE TODAY: PRAGMATIC REFORM OR UTOPIA? DAVID H. MULLIGAN Commissioner Massachusetts Department of Public Health 150 Tremont Street, Tenth floor Boston, MA 02111 OUR HEALTH care system is in disarray. While it is the most costly system in the world, it is not accessible to over 35 million Americans. Health care services are irrationally and inequitably spread over our landscape. Unfortunately , while both primary and preventive care are denied to many, costly and as yet unproven high technology services are purchased and provided to others. The health care system today is so often driven notby the necessary medical procedure, but by the reimbursable one. While most would agree that increased access to primary care is our most urgent need, our medical school graduates are choosing specialties with increasing frequency. This at a time when the problems of AIDS, substance abuse, sexually transmitted disease, tuberculosis, and the lack of primary and preventive care go unattended in so many of our older urban communities, and in the poorer rural areas, hospitals pursue the latest offerings of expensive "high tech" machine at the expense of primary care. Therefore, with respect to health care reform, I recommend that we borrow a slogan from the environmental protection movement: "Think Globally, Act Locally." There are many calls for substantial change in the system of health care delivery both here and abroad .Catch phrases such as "Canadian style," "single payer," "play or pay," "socialized medicine," and "health care rationing" have become familiar vernacular. All such concepts certainly merit attention. It is possible that several plans already proposed or perhaps even an existing system could achieve exactly the type of health care reform that we need. However, whether idea, plan, or system, each must be evaluated pragmatically for merit within the context of three key components in any successful reform of the health care delivery system—provisions for: 1) health care coverage for all; 2) dramatically improved access to both prevention and treatment services; and 3) high-quality, affordable services. Journal of Health Care for the Poor and Underserved · Vol. 4, No. 3 · 1993 310 Reform or Utopia? While it is important to consider global reform and to deliberate thoughtfully the merits of each proposal under consideration, we cannot permit our fascination with the debate to delay action on the pressing health-related problems of our time. No one of us alone has the power to change the entire system. And yet, within our own spheres of influence, it is quite possible for us to address issues surrounding access, affordability, quality assurance, and efficiency on an almost daily basis. Too often people think that nothing can be achieved in the absence of sweeping reform. This kind of thinking can lead easily to passivity—people waiting to be saved—in contrast to empowerment which motivates individuals to challenge, issue by issue, each component of the current system. Many vested interests protect the status of the system as it is, both the good and the bad. As a consequence, we could have major health care reform next year—or not until the new millennium. While it is likely that we all can agree that major system change is necessary, and in some form desirable, none of us can afford to wait for others to figure it out, make the key decisions, and implement the reform before acting locally on issues ourselves. Therefore, with global reform in mind, it is important to choose, quite pragmatically, to plan and implement programs now which promote and ensure increased access, more affordability, and improved quality of services on the state, regional, and local levels during our lifetimes. In Massachusetts, several current public health initiatives serve as examples of this type of proactive stance: "Linkage" programs. As part of its "determination of need" approval process, the Department of Public Health now requires hospitals planning to invest in large capital expansion to develop and implement (as part of the plan and in cooperation with the surrounding community) services and programs which specifically address local health needs. Access to community-based cardiology services. In an effort to prevent illness and death from undiagnosed and untreated cardiac disease among African-American males, the Department of...

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