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In the United States, we are faced with steadily accelerating costs for health care, high medical fees, and the exclusion of significant segments of the population from access to care. Among most industrialized nations, only in the United States are millions uninsured or remain in employment positions solely to preserve coverage. In no other country must the elderly become impoverished to qualify for public assistance. While there are many contributing factors to the high cost of care, one element is the payment system, which fails to reward constraint. Patients frequently do not know the cost of services provided and, more significantly, those with insurance do not express concern for cost. Further, too many insurance policies are artfully constructed to avoid high-risk individuals.Although medical care costs have been steadily escalating at 20 percent annually, nearly one in every seven Americans lack insurance. Not only do lawmakers press for change, but so do taxpayers, insurance agencies, health providers, and patients. At present, almost 60 percent of health care is sponsored by employers. Private coverage accounts for 7 percent, Medicaid 6 percent, Medicare 8.6 percent, military 2 percent, combined benefits 3.7 percent. This leaves a dangerously under covered group of 13.1 percent of the population (1).

Who are those most at risk? For many, serious illness such as AIDS, cancer, or significant heart damage is grounds for exclusion. The rural poor, young workers without full-time jobs, the suddenly unemployed, the mentally ill, and the homeless are united in their exclusion from coverage (2). Thus, daily, millions of people fail to receive necessary medical care.

The public wants a health care system that will preserve freedom of choice for the patient but allows the physician to make medical decisions without fear of economic sanctions.Some observers are suggesting managed care, which ultimately creates a conflict of interest for physicians because they will be rewarded for deliberately limiting care. While we all stress the importance of quality care, the greater emphasis today has been one of concentration on cost containment and the elimination of abuse. Neither of these concerns, however, are likely to improve the overall provision of care. Some of the suggestions to be noted later may, in fact, help contain runaway costs, but considerable questions remain as to the implications for quality and responsive care. Prior to an understanding of health and the security provided by insurance, it may be wise to consider a definition of well-being. The three most generally used terms are life situation, morale, and happiness. Implicit within these constructs are concepts of life embracing purposeful progress toward goals, goodness of fit between the individual and the environment, as well as satisfaction with one's attributes (3). We now turn to a consideration of health within a social context.