Challenges for the public in negotiating the health system in the 21st century

This paper addresses the challenges and opportunities that face the public in negotiating the health care system (both medicine and public health) in the 21st century. It addresses three issues: how consumers exercise choice, with special attention to the choice of health care coverage; how patients and communities interact with clinicians and public health professionals; and whether and how the public's "voice" is heard as health policy decision s, at the societal and institutional levels, are made. With respect to each of these issues, the paper describes the current status of public influenc e and articulates a vision for the future. These three related visions are (1) that empowered, informed, supported consumers make decisions about heal th plans, clinicians, treatments, and their own behavior; (2) that clinicia ns and public health professionals, working as partners with patients and c ommunities, are in a position to "standardize the customization of care" so that all aspects of care are tailored to the needs of the individual, fami ly, or community in question and social, economic, and cultural factors are taken into account in the day-to-day practice of medicine and public healt h; and (3) that the ability and willingness of the public to negotiate and shape the health care environment is supported by an independent infrastruc ture that permits enhanced public involvement in health policy making and g overnance. The paper identifies key elements of this vision, discusses chal lenges to pursuing and achieving each vision, and identifies opportunities that may support the pursuit of the vision.