The rhetorics and realities of community health care: the limits of countervailing powers to meet the health care needs of the twenty-first century.

As the paradox of medical success leaves behind more chronicity, policy makers around the world increasingly focus on community-based programs both to address chronic health problems and to prevent major disorders. This essay presents my comparative sociological framework of ideal-type models for understanding the countervailing powers that underlie and shape different kinds of heath care systems and their limitations in addressing the health care needs of the twenty-first century. In this context, I then analyze the revival of community health care rhetoric in the United States and compare it to the realities in which it operates. The realities of institutional power, fragmentation in funding, illness as a private condition and health care as a private good, the lack of societal commitment, competition, and the waning of community cohesion all suggest that communal democracy will be difficult to achieve. Current successes require further investigation. Examples from abroad suggest, ironically, that community health care develops best if the state and health professionals make a deep commitment to it, against their own immediate interests but for their enlightened self-interest.