PARADIGMS LOST - THE PERSISTING SEARCH FOR COMMUNITY IN US HEALTH-POLICY

Local communities have long played an important role in health and soc ial policy in the United States. But the concept of community was stra ngely absent from the federal debate on health care reform in 1993 and 1994. I attribute this absence to the paradoxical nature of community as a frame for guiding policy making. The concept of community has br oad appeal across the ideological spectrum, but this breadth masks a s et of long-standing and powerful tensions that determine when communit ies are seen as appropriately given responsibility for addressing soci etal problems. This article reviews the historical evolution of the ro le of community in health policy, highlighting the ways in which vario us tensions emerged. It applies these perspectives to an analysis of t he attitudes of the U.S. public and congressional staff in 1995. Data from two surveys demonstrate that support for community-based reforms is much lower for medical care than for other social needs, including some health-related concerns such as long-term care and the treatment of substance abuse. Statistical analyses suggest several possible expl anations for the lower support for community-based medical care. The a rticle concludes with a discussion of the implications for future comm unitarian strategies designed to improve U.S. medicine or social polic y.