A critique of the present and proposed strategies for redistributing resources in the health sector and a discussion of alternatives

This paper is divided into three parts. The first contains a brief description of the past and present distribution of physicians in the United States 1) by levels of care in the four United States census regions, 2) by community size in the nation, 3) by areas, according to the median income of the population in areas within an Eastern state, and 4) by the four main sections of a metropolitan region in that Eastern state, i.e., the business district, the inner city, the middle city, and the suburbs. Past and present distribution of physicians is analyzed, and it is shown that there is an increase in secondary and tertiary care physicians and a decline in primary care ones, with a growing concentration of physicians in the larger communities, in the wealthier areas, and in the suburbs. In part two, it is postulated that the present strategies for change based on the “market” ideology implicit in most types of health legislation (CHP, RMP, PSRO, HMO, COLC, HCRC, and others) will not correct, but may strengthen, the maldistribution. Indeed, these pieces of legislation respond to different constituencies that make up the main loci of economic and political power in the health sector. It is postulated that it is precisely these loci of power that arc the cause (rather than merely a symptom) of the maldistribution of resources. In part three, alternative strategics for change are presented, with recommendations for 1) shifting the planning and regulatory powers over the health sector from the private to the public sector, and 2) democratization of health institutions, with control of these institutions by elected representatives of both those who work in them and those in the communities who are served by them. The possibilities of adopting these strategies in this country are discussed in the light of some international experience, and with consideration of the present economic and political realities of the United States.