The Regionalization of Personal Health Services

While politicians have known for years that the essence ofleadership is embodied in a keen awareness of what the followers want, that news hasn't yet percolated sufficiently deeply into the medical care field. This is an excellent book-a model of thoughtful, academic analysis and insights, with a dash of historical relevance to give it the appearance of utility. Regionali7ation is good, necessary, useful, cost sparing, efficient, etc. Yet, no matter how meticulously elucidated the elements are, one is left with the question: after 50 years, why no progress? It is substantially the same question we have to ask ourselves about the absence of national health insurance. Surely the time has come! But ... The book is a worthwhile compendium ofknowledge of regionalization. Hidden in the discussions, in Pearson's historical disquisition; in Bice and Kerwin's essay on governance; in the comments during the discussion periods, the answer emerges. The United States is a federal system. What the states haven't tried, the federal government can only rarely accomplish. Regions are not political entities, and they have no constituencies. In some they even arouse a kind of fear, a wariness of the dictatorial potential of an administrative body with no political base. Others jealously guard the prerogatives of specific political entities. So, despite the example of Rochester here and Puerto Rico nearby, and the Soviet and Eastern European models, medical care regionalization is only a wistful dream. To those whose eyes see only federal control, like Greenlick and Yordy, and who are contemptuous ofefforts on any smaller political scale, the lack ofeffective regionalization programs is a small loss. They wait for the federal prograuns. I think they will have to wait until the state programs have been tried, tested and proven. GEORGE A. SILVER Dept. ofEpidemiology and Public Health Yale University School of Medicine