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Amy Gutmann argues that a just society could not, pace Michael Walzer, distribute social goods in accordance with the standards of complex equality. To support this view, Gutmann points to conflicts between multiple meanings of goods, which require adjudication in accordance with moral considerations that cut across distributive spheres. Drawing on the several meanings of productive employment and medical care in contemporary USA, she concludes that justice is complex, but not specific to distinct spheres.

This chapter examines the emergence of market ideology and how it has reshaped understanding of the nature and import of inequality within the American health-care system. It describes four changes that have dramatically altered the politics of inequality in medical care. First, the introduction of markets to medical care exacerbates unequal health outcomes. Long-standing differences in health-care utilization and health outcomes are likely to grow under market reforms. Second, market arrangements promoted the growth of large health-care corporations. Their political power may circumscribe government policy making that could limit health inequalities. Third, market frames are associated with different standards of fairness for assessing the performance of the health-care system. This changes the outcomes seen as inequitable, and hence suitable, for government intervention. Fourth, market schemas have transformed prevailing discourse around important perspectives on health policy, including the rights of citizens and the responsibilities of local communities.

This chapter focuses on racial disparities in health care. It shows how certain principles of political organization in culture in the United States perpetuate racial disparities. The chapter suggests that market ideology is the biggest obstacle to health-care equity. The U.S. health-care system is designed to produce disparities, since it allocates medical care primarily by market criteria rather than by medical need. Market principles generate racial and ethnic disparities, and allow racism to continue under cover of economic justifications. The chapter argues that the nation will not be able to ameliorate racial and ethnic disparities until political leaders are willing to face up to the consequences of their devotion to the pluralistic ideals in medicine.

The basic premise of this chapter is that we have at our disposal a wealth of evidence-based knowledge of critical health care delivery strategies that would, if implemented on a large scale, yield both a social right to health care for all citizens and favorable population health care outcomes at lower cost. This chapter provides a synthesis of this knowledge, and then identifies a limited set of very specific health care system delivery reforms that meet three evaluative criteria: equity, sustainability, and political feasibility. Equity refers to the extent to which any particular health care system delivery reform achieves a fair balance between the competing interests of different segments of the patient population and society at large. Sustainability refers to the extent to which a health care system delivery reform initiative yields favorable impacts on population health while realizing large reductions in immediate and future health care costs. Finally, political feasibility refers to the likelihood of a given health care system delivery reform in view of the competing interests of different stakeholder groups affected. This chapter offers a principled and empirically justified blueprint for the most promising health care system delivery reforms towards the fulfillment of these three ends.

This introductory chapter provides a background of Forest Grove Elder Services and its nurse practitioners (NPs). It advances the notion of clinic work to illustrate the ways in which the Grove's NPs brought care work into the medical encounter. The term “clinic work” reflects the reality that the NPs' work was different in both form and content from the medical work of their physician colleagues. It also underlines the ways in which the NPs' work invoked a different form of relationality—it was in deep relationship with the organization or clinic in which it was located. Forest Grove Elder Services is not an ordinary outpatient clinic. It is a federally backed policy experiment to evaluate whether a comprehensive care model could ameliorate the state's economic burdens for long-term care. In some ways, the Grove's experimental objective was to figure out how to deliver care work under the aegis of medical care. Thus, the Grove's NPs were not simply performing an expansive form of work on behalf of their patients; they were also providing an expansive form of organizational care work for their employer. The chapter then considers the utility of NPs under state retrenchment.

This introductory chapter explains why evidence-based medicine is important. The sluggish incorporation of medical evidence into clinical practice is a concern for three key reasons: safety, quality, and the efficiency of resource allocation. First, the delivery of unproven care can expose patients to serious risks. Second, the slow integration of evidence can lead to suboptimal outcomes for patients who receive treatments that work less well for their conditions than alternatives. Third, the failure to implement evidence-based practices encourages wasteful spending, causing the health care system to underperform relative to its level of investment. This book assesses whether the delivery of medical care in the United States is evidence based. It argues that by systematically ignoring scientific evidence (or the lack thereof), the United States is substantially out of balance.

This chapter focuses on the evidence-based medicine (EBM) reform project. Ultimately, if the EBM project is to realize its aspirational goal to improve the quality and efficiency of U.S. medical care, it is necessary but insufficient for research agencies like Patient-Centered Outcomes Research Institute (PCORI) to endure. In the long run, patterns of medical governance must change. PCORI (or whatever entity succeeds it) must develop a reputation among key stakeholders for competence, relevance, and impact that causes policy makers to conclude that supporting EBM is in their own political interest. The chapter then draws on lessons from the literature on U.S. state building to develop strategies to increase the durability of medical governance reform in contemporary American politics. It also briefly reviews the challenges of political sustainability that face any new agency or policy.