This community comprises only a small percentage of the population and, with respect to health care, it is particularly vulnerable. When we consider the number of risk factors that can lead to injury among artists, we note that, in contrast to the armies of specialists who attend sports professionals, similar services for artists are much more limited. This paucity can easily put an end to promising careers.

As a retired physical therapist and Ph.D. in political science with a focus on health and housing policy, I am a keen observer of the health care debates currently taking place in the United States.

One useful way to examine policy development is to consider what has been termed the neo-institutional approach to policy analysis. When this investigative framework is used, policies are studied from the standpoint of the ideas, the interests, and the institutions that have been involved in their creation, the way in which those elements are affected by those policies, and the methods by which they tend to influence the outcome of those policies.

The following are a few of the ideas that have played a fundamental part in policy formulation and have made health policy a contentious matter in America:

• Going back to the Colonial period, the populace has had a deep aversion to taxation and excessive control by government.
• America has a profound commitment to capitalism, with investment for profit rather than for public good as a basic tenet.
• The question of choice has long been a growing issue in the marketing of policies as well as products.
• The defense by health insurance companies of their right to insure whom and what they will is now being challenged by the public.

The interests in this debate are the groups in society which are affected by policy change. They encompass students and professionals in music, dance, visual arts, theater, literature, and media, and include teachers, designers, administrative and production personnel, as well as investors, patrons, and other stakeholders.

The institutions are the organizations that attempt to affect and are affected by policy change. These include government bodies, unions, guilds, and professional associations, as well as health care and insurance companies.

Thus we see why health policy is such a complex issue.

As Maestro Stelluto states, “the satisfied do not want change, the disgruntled call for reform, and some have no voice at all.” It is a sad truth that, with respect to health insurance, many in the arts community fall into the latter group. If Maestro Stelluto is to be commended for outlining the nature of the problem, then Juilliard is to be commended for the steps it has taken within its purview to meet the challenges that beset so many in this underrepresented segment of society.

Dr. Ruth J. E. Glickman
Toronto