2 - Health—A Community Affair

Summary

Just as all politics is local, so, too, are patient needs.

—James Block, MD, president, Rochester Area Hospitals Corporation (1978–84)

What does the experience of one community tell us about the role of communities in organizing and financing health care? To set the stage for that discussion, the concept of community in America will be considered from several perspectives, as well as the diversity of community health systems. The chapter concludes with a description of a project of the Robert Wood Johnson Foundation (RWJF) in the 1980s aimed at involving local community coalitions in containing the growth of health care costs.

Community: Concept and Characteristics

What is a community? The concept of community is elusive. It has “a privileged place in the romantic symbolic lexicon of America, as significant as mother, apple pie and democracy… [and] as much in the domain of poets and politicians as urban researchers and city planners.” In this book, we consider community in spatial terms; that is, as a local or substate unit. Boundaries around neighborhoods, cities, counties, or even regions—whether or not legally delineated—determine the geographic location of a community. Values demarcate how members identify either as individuals or collectively with the community. Self-interest as well as common interest (however defined and by whom) motivate engagement in community affairs. The result is that each community can and does vary along the dimensions of place, values, and interest. Diversity, not similarity, characterizes American communities. “No city,” political scientist Robert Dahl observed, “can claim to represent cities in general … and none can claim to display the full range of characteristics found in a national political system.”

Community in the American Context

What constitutes and what perpetuates a community? One perspective—evident from the founding of the Republic to the present day—poses community as a counterpoint to individualism. A second view, primarily within the domain of political science, focuses on the dynamics of representation and decision making within communities. A third, within the sphere of influence of economists, is concerned with the function of markets at the community level. Each perspective, as elaborated below, is relevant for understanding communities and health care.