Tension, compression, and shear: directions, stresses, and outcomes of health care cost control


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Publication Topics

Tension, compression, and shear: directions, stresses, and outcomes of health care cost control

Publication TypeJournal Article
Year of Publication1990
AuthorsEvans RG
JournalJournal of health politics, policy and lawJ.Health Polit.Policy Law
Pages101 - 128
Date Published1990
KeywordsCanada, Cost Control, Fees and Charges, Health Expenditures/trends, Health Policy, Health Priorities/economics, Health Services/utilization, Humans, Insurance, Health/economics, Reimbursement Mechanisms, Stress, Physiological, United States
Abstract"Control" of health care costs is often portrayed as a struggle between external, "natural" forces pushing costs up and individuals, groups, and societies trying to resist the inevitable. This picture is false. Control includes strenuous efforts by some to raise costs, and by others to resist those increases, and/or to transfer costs to someone else. But all such forces originate in the purposes and interests of individuals and groups. Health care cost control is a struggle among conflicting interests over the priorities of a society, and claims of "inevitability" are simply part of the political rhetoric of that struggle. International experience supports certain conclusions. First, there is no basis for the claim that limits on expenditure growth must threaten the health of (some members of) a society. Second, there is a substantial variety of experience with cost control. Failure in the United States is often presented as evidence of the impossibility of control, but most other countries have succeeded. Finally, control requires the direct confrontation of interests, with substantial build-up of stress. Advocates of expansion are more successful if they can transform compressive forces into efforts to shift the burden onto someone else. Pressures from providers in every country for "privatization" and/or payment by users reflect this recognition of economic interest.
Citation Key334