br New and changing medical relationships As

New and changing medical relationships As we have noted, most discussions about medical relationships have focused on the important relationship between doctors and patients. In the past, these discussions tended to center on modes of communication. In the 1950s, for example, Szasz and Hollender (1956) discussed the potential for the emergence of new models of doctor–patient communication that could be effective depending on the type of illness and model of care. An acute illness such as an infection or injury could be treated primarily, if somewhat mechanically, with medical expertise and limited input from patients. Here, the biomedical model, driven by standardized assessments and best-practice guidelines, emphasizes a fixed logic or structure of patient care that limited the amount of patient involvement in the medical relationship. Chronic illnesses, however, require the cultivation of new relationships that transcend those of the biomedical model. Chronic medical care is often dynamic and long-term (Wagner et al., 2001). Patients, therefore, must be consulted and work collaboratively with providers to establish a plan of care that is both rooted in evidence as well as in line with patient preference, that is, guided by the goals patients set for themselves. Developed out of a chronic illness model, the tradition of patient-centered care thereby creates opportunities for patient-provider collaborations, fortified by a strong commitment to open and bidirectional communication (Berwick, 2009; Pelzang, 2010). Some scholars have argued that the traditional biomedical model is insufficient for the treatment of chronic illness, especially because it does not foster the kind of relationships that are required to both prevent and manage these conditions (Longino & Murphy, 1995; Mirzaei et al., 2013). Discussions recently have focused on alternative approaches that rely on care coordination among providers and settings, such as primary and specialty practices, ambulatory care, and long-term facilities (Burns & Pauly, 2002). The proliferation of particular roles within health care systems is not only a ion channels of complexity; these roles produce qualitatively different modes of interaction formalized in new relationships. In many ways, however, the focus on chronic illness merely expanded – instead of rethought – the biomedical model. For example, including patients in each phase of treatment does not guarantee that their input will be taken seriously, just as open communication does not necessarily change power dynamics. Ultimately, the treatment of chronic illness focuses on treating individual patients after the onset of illness and according to a traditional medical model (Halfon et al., 2014). Although the prevention of chronic disease has become popular through practices such as health promotion and expanding access to primary care, these practices often assume a biomedical paradigm that emphasizes individual-level behavior and outcomes rather than population-level concepts, such as community well-being. For this reason, the move to population health in medicine increasingly requires a substantive adjustment in relationships as well as systems that are responsive to and reflect these new relationships.
Pre-ACA policy developments Although the ACA facilitates the formation of new relationships for purposes of promoting population health, several aspects of the law have the potential, as well, to facilitate a rethinking of how doctors, patients, and communities interact in relation to these structural changes. Before turning to the ACA in detail, however, it is important to note that the current wave of health care reform was preceded by several important policy developments. During the 1960s. There is a space here that should be deleted.s, for example, as part of President Johnson\'s “War on Poverty,” community health centers were envisioned as a viable modality of treatment. The Economic Opportunity Act of 1964 provided the initial impetus for this strategy (Lefkowitz, 2007). Later legislation consolidated and focused these programs (Bailey & Duquette, 2014). Local resources were combined with Federal dollars to combat poverty by providing primary health services to underserved areas. Neighborhood clinics were thus established in low income urban and rural communities (Geiger, 2005). The general idea was that these centers would have impact on multiple levels. For example, jobs would be created, along with training local persons, while the health of poor communities was improved (Geiger, 2003). Moreover, the services offered would be low-cost and sustainable, due to local involvement in planning and implementing these interventions. Key to this approach is that health should be viewed holistically. Familial, environmental, and employment factors, for example, were introduced as important determinants of health. Additionally, patients should participate actively in their treatment. Community health centers, in this sense, should be governed by local boards that include patients. As a result of these changes, services would be culturally appropriate and situationally relevant, thereby improving community life. Prevention and education, likewise, would be elevated in importance. This shift in orientation can be viewed as part of the social movements that emerged during the 1960s. The hope was that average persons would participate more fully in vital institutions, including health care, and as a result would agitate for further equity (Geiger, 1993). Although funding waned for health care care operating on the community level in the 1980s, the fundamental goal was that social and health disparities would be reduced, as institutions become more democratic.