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From the Editor

U.S. Health Care: Taking The Long View

Leading this issue of the journal is a paper that revisits a subject of continuing fascination to longtime analysts of American health care: How do we spend the vast sums that make up the annual trillion-dollar-plus budget? Marc Berk and Alan Monheit report that while 5 percent of the population accounts for the majority of the nation’s health spending, managed care has had little impact on the aggregate distribution of resources among patients who use the most services. James Lubitz and colleagues examine long-term Medicare spending trends (1965–1998), noting that the ratio of per capita spending for people age sixty-five and older compared with those under age sixty-five increased from 2.87 in 1966 to 4.60 in 1995. Following are papers by Bob Blendon and John Benson giving a fifty-year perspective on American views on health policy; by Jon Gabel and colleagues on trends in out-of-pocket spending by insured workers; and by Amy Bernstein and colleagues on trends in medical care encounters.

The nation’s most profitable business sector has long been that of pharmaceutical manufacturing. While these enterprises are widely admired by Wall Street, Washington (beyond the Food and Drug Administration) has never paid much attention to the industry, at least since the days of Estes Kefauver. That "benign neglect," as author Ernst Berndt characterizes it (p. 113), is rapidly changing because of the likelihood that Congress will add an outpatient drug benefit to Medicare, making this program the world’s largest purchaser of pharmaceutical products almost overnight. Complicating this legislative challenge, as John Poisal and Lauren Murray report, is the fact that 73 percent of Medicare beneficiaries who live in the community already had some form of drug coverage in 1998. But, as Bruce Stuart and colleagues found, fewer than half of beneficiaries had continuous drug coverage over a two-year period (1995–1996). Next, Ernst Berndt pursues the question, Why has drug spending soared during an era of successful health cost containment? Richard Frank discusses the differential pricing of prescription drugs, and Tom Croghan examines a particular therapeutic category—antidepressants—and the controversy surrounding their increased use.

This issue also includes a call by Joe New house and Gail Wilensky for a new federal policy on graduate medical education (followed by three perspectives) and Health Tracking material that probes whether consumers know how their health plan works, profiles major risk-bearing intermediaries, examines the relationship between patients and profits, and surveys patients’ attitudes toward cost containment bonuses for managed care physicians. We also include the latest analysis of national health spending by Stephen Heffler and colleagues, as well as trends in the use of and spending for mental health services in an era of managed care. Finally, several essays in Narrative Matters examine the personal impact of medical errors, on both patients and their physicians.

John K. Iglehart

Founding Editor

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