Constraining costs at the community level: A critique

Although long-term health system reform likely will involve elements of government regulation, competition, and voluntarism, Americans historically have preferred the latter in seeking solutions to society's problems. Private foundations form a key part of the voluntaristic community effort, providing funding and leadership in areas where governments lack effectiveness. In 1984, The Robert Wood Johnson Foundation embarked on a $15.2 million, four-year initiative, known as the Community Programs for Affordable Health Care (CPAHC), which intended ''to demonstrate that community-based groups could work cooperatively and effectively to contain health care costs at the local level,'' according to a foundation spokesman. As part of its ongoing commitment to evaluation, matched by few other foundations, the foundation gave $436,000 to Lawrence Brown and Catherine McLaughlin to evaluate CPAHC. In this essay, they summarize their evaluation findings, which constitute a direct assault on this community coalition model that, for many people involved, held much promise in containing rising health care costs. Brown, of Columbia University, is one of the few American political scientists who has engaged the intersections between politics and health policy during an era when economists dominate the scene of analysis and commentary. Brown received a doctoral degree in government from Harvard University and has spent a distinguished career in various academic settings. He served as editor of the Journal of Health Politics, Policy and Law and has written numerous books and articles. McLaughlin, who received a doctoral degree in economics from the University of Wisconsin, is an associate professor in the Department of Health Services Management and Policy at the University of Michigan School of Public Health. She has published extensively on health maintenance organizations and price competition.