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There are 123 academic health centers in the United States, and they are markedly diverse in organization and function. Some have large research programs, others emphasize the education of nurses and allied health professionals, but all have one characteristic in common--namely, the dominant role of the medical school-teaching hospital combination. Their evolution has been shaped to a great degree by four federal initiatives: funding of research and research training by the National Institutes of Health, legislation that permitted close relations between Veterans Administration hospitals and medical schools, health-manpower legislation, and Medicare and Medicaid. Although academic health centers were created to foster the integration of structure and function, federal funding has always been categorical in support of research, teaching, or patient care. No federal funding was ever intended to stabilize the overall academic health center as an institution. This mattered little during a period of expansion, but the future of academic health centers is now uncertain in a period of federal cutbacks, rising health-care costs, and worry about an oversupply of physicians. Academic health centers must enter a new phase of institutional planning for which they are ill equipped. Special interests must be submerged for the good of the whole, diversity must be encouraged, and each center should exploit its own special strengths.
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