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18. This is not a new idea; it is an extension of the strategy for appraising
governmental records advocated by Theodore R. Schellenberg in Modern
Archives: Principles and Techniques (Chicago: University of Chicago Press,
1956), 52.


19. Milton I. Roemer, Ambulatory Health Services in America: Past, Present, and Future
(Rockville, Md.: Aspen Publishers, 1981), 30.

20. For a more detailed explanation of functional analysis and its value, see Helen
Willa Samuels, "Rationale for the Functional Approach," in Varsity Letters:
Documenting Modern Colleges and Universities (Metuchen, N.J.: Scarecrow Press,
1992), 1-18.

21. For more specific information on impending health care reforms, see Chap-
ter 2.





Overview of the U.S.
Health Care System


The U.S. health care system is complex and constantly changing. Since
World War II, it has grown to become one of the two largest American
industries. In 1992 the nation spent $838.5 billion, or 14 percent of the
gross national product, on health care — a higher proportion than that
spent by any other country. Compared to other nations' systems, health
care in the United States is decentralized and competitive, characterized
by a mix of public and private health care institutions and organizations.^
In fact, the United States is one of only two developed countries (the other
is the Republic of South Africa) that does not have a health care system
run by its government.

If a health care system is defined as "a group of curative and preventa-
tive service components — organized, coordinated, and controlled to
achieve certain goals,"^ then the U.S. health care system may be more
accurately described as a nonsystem, largely because of the predominance
of free enterprise and the absence of nationalized health care.' It is,
nevertheless, stable and resilient, both because it is decentralized and
diverse and because the medical profession itself exercises tremendous
power through organizations such as the American Medical Association.
The government's role is also powerful and is primarily exercised through
governmental regulation, especially regarding third-party payment mech-
anisms and health care standards.

Broadly viewed, the health care system has six major functions:

• patient care (diagnosis and treatment)

• health promotion (activities aimed at encouraging good health, such
as fitness programs and informational campaigns)


• biomedical research

• education (of health care professionals)

• regulation and formulation of policy (regulation establishes standards
for institutions and practitioners; formulation of policy involves
coordinating health care services within a specified region or
jurisdiction on a suprainstitutional level)

• provision of goods and services (such as pharmaceuticals,
wheelchairs, diagnostic and therapeutic equipment, and malpractice
and health insurance)

These functions are carried out by diverse institutions and organiza-
tions that interact and overlap with one another, each institution encom-
passing one or more functions in its mission (sometimes along with other
functions that are not related to health care). The institutions may be
classified as:

• health care delivery facilities (e.g., hospitals, nursing homes,

• health agencies and foundations (e.g., U.S. Department of Health and
Human Services, Robert Wood Johnson Foundation),

• biomedical research facilities (e.g., Boston Biomedical Research
Institute; Acupuncture histitute, Monterey, California),

• educational institutions for the health professions (e.g., Massachusetts
College of Pharmacy and Allied Health Sciences, Forsyth Dental
Center School for Dental Hygienists, Bowman Gray School of

• professional and voluntary associations (e.g., American Nurses
Association, American College of Healthcare Executives, American
Cancer Society), and

• health industries (e.g., Merck, Codman and Shurtleff, Johnson &
Johnson, Blue Cross/Blue Shield).'^

These institutions are funded by governments, voluntary contributions,
investors, philanthropic foundations (notably the W. K. Kellogg, Robert
Wood Johnson, and Rockefeller foundations), or by a combination of
these methods. 5

The matrix depicted in Table 1-1 is a visual representation of the
conjunction of the health care system's functions and organizations.
Although the matrix is artificial and contrived, it provides archivists with
an overview of an extremely complex system in terms that are meaningful
to their work.

Brief descriptions of the six categories of health care institutions and
organizations follow. In-depth studies of each category are provided in
Chapters 2 through 7.

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