The Present Illness

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Why is the American health care system so challenging to reform? Efforts have historically faltered due to their limited scope. In this exploration, Martin F. Shapiro, MD, PhD, MPH, combines history, sociology, research, and personal experience to examine the extensive issues plaguing US health care. He argues that meaningful change requires significant societal shifts. With keen insight and humor, Shapiro analyzes how various stakeholders—clinicians, medical schools, hospitals, scientists, insurers, governments, and patients—contribute to and perpetuate a dysfunctional system. He identifies three primary barriers to reform: the commodification of care, the values and limitations of participants, and toxic relationships among these groups. Shapiro proposes a comprehensive agenda of concrete actions to tackle the numerous factors behind the system's failures. He emphasizes the interconnectedness of problems and solutions, cautioning that piecemeal reforms will be undermined by those benefiting from the current system. Despite the daunting task of overhauling health care, Shapiro advocates for a more extensive effort across all health care sectors and society to create a humane, effective, and just system.