'80sö(Hastings, 1997).
It is perhaps sufficient to note that the term "managed care" had not entered the popular lexicon in 1970 to see how dramatically the institutional character of health care has shifted since that time. However, some changes in care delivery have been made as a matter of public policy. In this regard, the U.S. Veterans Administration, which historically provided $17 billion in publicly funded health care to armed services veterans every year, in 1996 began to decentralize the management structure of hundreds of hospitals, outpatient clinics, nursing homes, and other facilities while also initiating efficiency and consolidation of facilities, programs, and services, ôborrowing ideasö from private industry, such as shifting from costly inpatient care to less costly outpatient care, managed care practices, and preventive medicine: ôVA is trying to reengineer its system, while maintaining its core missionö (GAO, 1999).
The focus on getting the patient out and not in the hospital has characterized health-care delivery in general, to the degree it was possible for patient and caregivers to realize good patient outcomes with less inpatient time. On the other hand, this focus has shifted responsibility for patient welfare out of the institutional setting and into the private setting of the patient and family. Whether all patients are well positioned to engage in responsible self-care that in former decades might have been administered in a hospital has been the subject of ongoing debate. The present point, however, is that there has been systemic change, not simply changes in policy of one hospital or indeed one $17-billion care agency.
In general, of course, health care in institutional settings has become much more expensive for receivers of care, even as the health-care system--decentralized on one hand, consolidating via mergers and acquisitions on the other hand--has become more elusive, less accessible ...