I have been teaching a survey course on the American healthcare system in MBA and MPH programs for more than 30 years. During this time, students have constantly expressed frustration at the system's incredible complexity, leading to inefficiencies and wastefulness. In fact, calling it a system is really a misnomer—it is more like a cluster of variably interrelated subsystems. One needs only to look at the financing systems for proof of this fragmentation: Medicare, Medicaid, the Children's Health Insurance Program (CHIP), employer-based health insurance, Health Insurance Exchange–based coverage, Veterans Administration care, and TRICARE for families of active military. These mechanisms are just the major ways healthcare is paid in our country. Add to this disarray the complexities of different types of provider organizations, technology companies, and other healthcare entities and a person is likely to offer one of three solutions to our problems: throw up one's hands and walk away, offer incremental changes, or blow up the system and start over by, for example, instituting a single payer system.

In order to make sense of the complexity of these problems and solutions, this textbook takes a very different approach from others textbooks on this subject. For each topic, I present a detailed, relevant history as background for understanding its current status. I take this approach for two reasons. First, before we can make plans for improvements, we need to fully understand where we are now. To understand where we are now, we must understand how we got here. Second, with the exception of innovative technologies, nothing in healthcare is new. For example, Western society has tried many types of financing, organizational structures, and regulations. Each of these attempts has created its own set of problems. Since the problems are also not new, it is necessary to understand what was tried in the past to fix them, the contexts in which the solutions were attempted, and why these attempts succeeded or failed.

With this approach, it also becomes easier to deliver three overarching goals for this book.

First, provide frameworks for understanding problems. When one is faced with a difficulty in the healthcare system, it is useful to understand the type of problem it is. For examples: Is it a quality issue? Is it an issue of a trade-off between quality and access? Is it a pricing issue? Once the problem is properly framed, it can be placed in the context of the entire system, and rational solutions can begin to form. Consider a medical analogy. A patient presents with symptoms. If a physician can identify them as belonging to problems in a particular organ system, investigation is then much easier and can lead to a more rapid diagnosis and treatment plan.

Second, provide facts. A working knowledge of the subject is always necessary to begin framing a problem. For example, understanding the structure and funding streams of Medicare is essential to identifying key issues and solutions.

Third, healthcare is changing so rapidly that it is difficult to keep up with regulations, organizational changes, and technological innovations, to name a few. I have, therefore, provided extensive resources so that one can get updates more easily. This last item would seem easy in the internet age. However, in writing this book, I have been struck by the fragmentation of information and, occasionally, the errors in what has been accepted as “common knowledge.” For example, I found it interesting that HIPAA issues (the federal program that deals with patient privacy and security) are handled by the Office of Civil Rights.

As you read this book, I hope you will gain an appreciation not only of the complexities and problems of our healthcare system but also of the opportunities to implement truly effective and meaningful changes.

While this work is a single-author text, the professional career encouragement and support I have received have been invaluable to its conceptualization and execution. Unfortunately, the three mentors I wish to thank are no longer with us: Professor Morton Kamien, Dean Emeritus Donald Jacobs, and my father, Mervin Shalowitz, MD, to whom this book is dedicated.

The personal encouragement and patience of my wife, Madeleine Shalowitz, MD, MBA, has been priceless. My children also deserve a note of appreciation for their gentle nudges: “So how's the book going, Dad?” Thanks to David Shalowitz, MD, MS, Kira Spivack, and Ilana Shalowitz. Finally, a special acknowledgment to the late Murphy Shalowitz, who was my constant companion throughout the writing of this book.