A recent contributor to this blog wondered about the correctness of “health care” versus “healthcare.” I’d like to answer that question by channeling my inner William Safire (the late, great New York Times language maven). If you’ll stick with me, I’ll also disclose why the Centers for Medicare & Medicaid Services is not abbreviated as CMMS and reveal something you may not have known about God – linguistically, if not theologically.
The two-word rule for “health care” is followed by major news organizations (New York Times, Washington Post, Wall Street Journal) and medical journals (New England Journal of Medicine, JAMA, Annals of Internal Medicine). Their decision seems consistent with the way most references to the word “care” are handled.
Even the editorial writers of Modern Healthcare magazine do not inveigh against errors in medical care driving up costs in acutecare hospitals and nursinghomes. They write about “medical care,” “acute care” and “nursing homes,” separating the adjectives from the nouns they modify. Some in the general media go even farther, applying the traditional rule of hyphenating adjectival phrases; hence, “health-care reform,” just as you’d write “general-interest magazine” or “old-fashioned editor.”
Most importantly of all, the Associated Press decrees that the correct usage is, “health care.” That decision is not substantive – there is absolutely no definitional difference between “health care” and “healthcare,” despite what you might read elsewhere — but stylistic. As in The Associated Press Stylebook.
The AP is a cooperative formed back in 1846 by newspapers to share reporting via a wire service. Today, the AP calls itself the backbone of global news information, serving “thousands of daily newspaper, radio, television, and online customers….On any given day, more than half the world’s population sees news from the AP.” When that news arrives in text format, its spelling is determined by the AP stylebook. Which means a few billion people see the spelling, “health care.”
A stylebook? Isn’t spelling determined by dictionaries? Perhaps, but when you’re sharing content on deadline across the world, it helps if everyone agrees to refer to, say, the Midwest, not the Mid-West, and to use other common linguistic conventions.
Stylebooks differ. The AP would say that health care is two words; the Chicago Manual of Style, popular in academia, would write that as 2 words, but agree with the premise.
So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. A successful lobbying campaign on behalf of the lower-case form helped persuade the AP to adopt the new spelling in its 2010 stylebook update.
When Modern Hospitals changed its name to become Modern Healthcare back in 1976, it did so in part to seem, well, modern. It hadn’t been that many years, after all, since airplanes were flown by air lines, not airlines. Then, in the business-oriented 1980s, “healthcare system” became a convenient linguistic upgrade of the dowdy “hospital” that had gobbled up ownership of doctors’ offices providing outpatient (not out-patient) care.
At the same time, a growing number of companies decided to make this expansive new word part of their proper name or, at the very least, their style sheet. For instance, HCA, founded in 1968 as Hospital Corporation of America, today describes itself as “the nation’s leading provider of healthcare services.” The Reuters news service, heavily involved in business news, now uses “healthcare” in its stories.
The 2001 Institute of Medicine report Crossing the Quality Chasm provides a snapshot of the term’s transition. The report declares, “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.” The author of that ringing statement is the Committee on the Quality of Health Care in America.
However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999. AHRQ was a renamed and refocused version of the old Agency for Health Care Policy and Research, created in 1989. AHCPR, in turn, had almost been named the Agency for Health Care Research and Policy until an alert Senate staffer realized that the abbreviation would be pronounced, “ah, crap.”
Speaking of abbreviations, Tom Scully, the first administrator of the Center for Medicare & Medicaid Services, once explained to me why it is known as CMS, not CMMS. It seems that Health and Human Services Secretary Tommy Thompson wanted an agency name with a catchy three-letter abbreviation, like FTC or CIA, to replace the old HCFA (Health Care Financing Administration). So a legal opinion was obtained from the HHS counsel that employing an ampersand to separate the words “Medicare” and “Medicaid” permitted the use of the CMS designation. Some might suspect this Solomonic ruling of caving in to a bit of pressure from above.
Which brings us to God. Some years back, the AP decided that while “God” would remain capitalized (the pope was not similarly blessed), the second reference would be “his,” not “His.” As influential as the AP might be in this world, those concerned with a Higher Authority still write about God as if He were something more than an ordinary man.
I keep waiting for the AP editor who made that decision to be struck down with lightning by the Deity. But, on the other hand, She may have a sense of humor.
Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.
Back to the original topic, thanks for a fascinating article! As a grammar geek who recently took a job as a marketing manager for a company involved in the care of others’ health, I’m trying to establish my own internal style guide and have been wrestling with “healthcare” vs. “health care.” Personally, I prefer the two words, though I can’t quite say why; I suppose I think that the one-word version looks a bit lazy.
Then again, I still haven’t gotten over AP’s decision to accept “website” as one word without a capital “W” or, worse, “email” instead of what I think is the much more proper “e-mail.” (Washington Post copy editor Bill Walsh’s book has a great section on that, arguing that “email” is begging to be pronounced “uh-mail.”)
On that note, I intend to keep using “health care” whenever possible!
I decided to take a more practical look at the 2 spellings. So, I pulled up this graph of whether Healthcare or Health Care is more searched on Google: http://www.google.com/insights/search/#q=healthcare%2Chealth%20care&cmpt=q
Surprisingly, the 2 terms are almost exactly equal, but with healthcare barely edging out health care. Although, there was a big spike in Health Care searches at the end of 2009.
I loved this! I have another reason to spell it healthcare – saves me a spot on twitter. Next step: hcare.
Such a good read.
And here I just thought it was a difference in American vs. English like gray vs. grey.
I had no idea so many people had so many ideas about this word structure. I always thought health care or healthcare followed the loss of wellness and or healthy. I never thought about this until now. Could I throw in healthy care and add to the debate? No just joking.
I was worried for a second there!
If they decide to redefine Electronic Health Records as Electronic Health Care Records and not Electronic Healthcare Records I would have to rename myself as the EHCR Guy.
This would not be cool!
“I keep waiting for the AP editor who made that decision to be struck down with lightning by the Deity. But, on the other hand, She may have a sense of humor.”
Whether half in jest or not, this statement shows the hatred embedded in religious thinking, and the source of so much misery worldwide.
Thanks, not everyone cares about what to say and not everyone cares about what to write either. Nice comparison.
Nice article! I prefer “Healthcare”. The is no reason why and I don’t have any explanatory statement for that. I just like it spelled in this way…:-)
Isn’t “health” a noun, rather than an adjective? I assume we’re not talking about “healthy care”.
And is “care” used in this context a noun, or could it actually be a verb? I suppose the latter is doubtful.
If both are nouns, would “doorknob” or door knob” be more appropriate?
I saw the reference to Don Berwick (“What’s he hiding”) in the comments and I recalled a discussion I had with the brilliant quality guru shortly after he created the Institute for Healthcare Improvement”s acronymn IHI in the ’90s. Similar to the desire to avoid the AHCPR nickname of “ah crap,” our current CMS head used the combined word healthcare soley so folks wouldn’t call his budding institution “IHCI” or as a five year old would pronounce it: “ikkey.”
Fun post Michael.
Thanks for an entertaining and informative post, Michael. I’d appreciate it if you could also help us to sort out the relative merits of “ehealth” “HIT” and “health IT”. And then of course we have “RHIOs” “HIOs” and “HIEs”….
Although, I agree with your discussion. I still feel that as professionals instead of focusing on the ‘business’ aspect of healthcare, we should direct our efforts in making our clinical skills more sound. Below is a nice website, where you can start.
1. Central searchable repository of a pharmacists ‘curb-side’ notes.
2. Transition between hospital and retail settings, your notes can transition with you, not your job!
3. For access from anywhere, when I do not have direct access to my references/websites.
4. For the Pharmacist, BY the Pharmacist.
Our local “non profit” hospital netted just over $41 million last year. That was net. The CEO make a little over $6 million in total compensation.
They did this by incorporating most affiliated group practices and then took a %9 vig for doing the billing and then began raising the rents since the Hospital network owned all, and I mean all, local office space. This was right after they put all the salaried hospitalists in charge to guarantee charges were run up around the clock. For a non-profit they have become a local corporate monster.
Been waiting for the rank and file docs to notice what the heck is going on but they remain seemingly sedated and uninterested. Pretty much supports my theory that the only people making money in health care now are HMO, Pharma and hospital execs. It’s sad what the docs have given away by simply not paying attention.
check out today’s http://www.baltimoresun.com and read how many CEOs of alleged nonprofit hospitals are making Million dollar a year incomes and lots of perks.
This is what defines “non profit”? Anyone who supports this kind of thinking, readers and listeners should step back and reassess who and what you are dealing with. Face it folks, there is no place for profit mongering in health care.
Listen to these people with their personal and questionable agendas, and put your faith that they will make a difference hereon? Or, are you all lemmings just rushing the edge?
Nit picking these words is for computer geeks who design code and devices with rigidity that is lifethreatening to patients.
I would like to know who gives money to Berwick’s “non-profit”.
After all, his policies at CMS or CM&MS will have been influenced by the largesse of his supporters.
He undoubtedly will further reduce what doctors get paid for being at the bedside all night of an elderly infaction case, while redistibuting the health care dollar to the industries that supported his non-profit, eg HIT companies.
That is how it works. The kickback system is sick. OPatients suffer. If Berwick were any good and above this, he would be transparent about his greenbacks.
I don’t know about the Blog being Shaghied. However the topic has no practical Purpose but to talk about Non sense.
There are much greater issues of importance than discussing Proper English!Further, I think it is important that Health Care Blogs provide opportunities of differing perspectives and views. Simply, not from the consortium of Health Care Professionals alone!
The profession has taken on the persona of a private Club Med that excludes and in some instances demeans the concerns of Patients. The result of this is a industry friendly enviroment(on All Levels) that places the patient dead last in policies and rights.
Michael, I am sorry your discussion got shanghaied. It was fun for a while.
Corpuscle Connie, MD, and propensity, I’ll await an actually balanced report on the question of Berwick’s finances. Your sources are one-sided and looking for blood.
HITechxpence [sic] your “accurate description” of what you called “Hellthcare” is a childish spew of reactionary non-sense. Perhaps you should find a post that’s actually discussing this topic that’s so close to your…uh, heart. And, for cryin’ out loud, child, pick a nick we can at least pronounce.
Leaving the Politics of right wing Con servatives on the Doubious and fictious title of “ObamaCare”. Who really Cares? Although the majority of Health Professionals live in the Illusion of Caring for ones Health. It all comes with a Price Tag.Failing to meet the pre-requsites will end in certain dismemberment and Death.
As amusing as it seems to split Hairs on the Meaning of Healthcare or Health care.It is eronious to believe that this profession would except anthing other than payment for services.Rather, holding patients monitarly Hostage for services is such a low bar for caring.
As previously mentioned; it is Sick Care that is most appropiate message.Those who can afford to pay their way is given Care and when the money is gone. Who really Cares?
I was interested to learn that Berwick will not disclose his non-profit’s source of funds (for his multimillion $ compensation package)and for the “favors” of industry (rather than patients)who will benefit by his policies. Thank you propensity for posting. What do the Berwick zealots think of his avoidance of transparency?
As someone who had to memorize the AP Stylebook back when it was a 24-page booklet and who has spent the last 10 years in health care communication, “healthcare” has never been “right.”
I didn’t realize there was an & in CMS’ official name. Learn something new every day!
Thanks for posting something I felt qualified to comment on 😉
Great post but you neglected the more accurate description of Hellthcare as reported here: http://www.roadtohellth.com/index.php?option=com_content&view=article&id=148:need-to-sell-a-lemon-concoct-a-story-that-makes-it-qpersonalq&catid=43:showcase-rnp-3&Itemid=175
Speaking of CMS, what is Berwick hiding, exactly? http://finance.senate.gov/newsroom/ranking/release/?id=e428ec83-7413-499c-8844-ecf629cb6ea8
I have a quibble with your reasoning with respect to eschewing use of healthcare as a single word. You say,
Health is not an adjective. It’s a noun. In the pair health care, health is a noun adjunct. You are correct that the English language doesn’t usually allow for combining nouns with their adjectives (acutecare), but we form compounds of nouns and their adjuncts all the time: airplane, firetruck, headcheese, football.
That explanation of CMMS is both believable and ludicrous. CM&MS or CMMS makes more sense.
As for the argument one way or the other, I can accept either usage, but try to be consistent. If you use healthcare in your title, don’t use health care in your article. It makes you look inattentive.
The real trouble is, we do not have a health care or a healthcare system in this country, although we may get there if some of the healthcarereforms move forward. We largely have a Sickcare nonsystem, into which most healthypeople do not enter until they lose some or most of their health.
@Rob- Dude, you look like a total dork in your pic. You’re just not as funny as you think you are. Sorry, but it’s true.
The korporatization of kare and caring about folks health is as much a sad evolution of modern life, as it is testament to ignorance about preventive care.
If we can capitalize on health science knowledge and capitolize a preventivecare enterprize, healthcare will again become healthy (and affordable) care.
Precious story about lawyer opinion on CMS, we are doomed with these dimbulb attys running DC. IF health care reform was only willing to care about malpractice we could fund a real healthycaringsystem.
Hey, let’s spend time debating the difference between moron and idiot! We’ve exhausted the pronounications of “to-may-to” versus “to-Mah-to”, so let’s move to higher ground!
No, the debate is between health care, and health careless.
What the hell is this site becoming? Is anyone else reading some of these posts and just shaking their heads wondering that this is why we have this disgusting health care deform garbage coming out of DC?
What’s next? Are stethoscopes outdated instruments!?!?!?
I did not realize my picture is so tedious. It is! It just sits there and doesn’t change! Wow.
JLeck, here is my source on the Chicago Manual of Style. The sentence was written the way I did it to indicate that they prefer using numerals in places where the AP uses words.
And thanks to others for interesting, erudite and just plain nice comments.
Very interesting post- I myself have always wondered about the “correct” usage. I find myself agreeing with Margalit’s reasoning above: “So health care, in my mind, is the process by which some people take care of others in need, and healthcare is an industry”. Can’t say why but that’s how I’ve always looked at it as well.
Wonderful as always Michael – and a very welcome distraction from some of the discussion here of late.
I find that I write “health care” for non health care audiences, and healthcare when I am writing for healthcare audiences. Not sure why and can’t say that I’ll change.
CMOS does *not* recommend “2 words.” Where did you get that idea? Ick.
So would it be “mental healthcare”? That sounds like some people’s view of reform…
Great post! I’ve had this debate with many people. I personally prefer ‘healthcare’.
The linguist in me loved this article, and thank you for the intense history of the words (I myself had wondered at the “CMS” abbreviation). I normally used the term “health care” simply because that’s how Merriam-Webster defines the term and I’ve found it to be the common usage (which is explained by the style guides you’ve cited).
As anyone who’s looked at linguistic history knows, languages are living breathing organisms, changing as much as the people who speak it (unless, like Latin, it’s dead). English as we speak it today bears little resemblance to the language that “Beowulf” is written in; Chaucer is a step up, but still quite difficult to read. After all, the language we speak today is made up of original Germanic languages, Latin from Roman expansion, Danish/Nordic from the Viking raiders, and French from the Norman conquest. Each time there’s a new influence the language adapts to the circumstances; after all, where Saxon herders said “Cow,” Normans at the table said “beef,” and so we have different words depending on whether an animal is at pasture or for dinner.
No one says “electronic mail,” and the constraints of technology and human memory will continually shorten phrases and words for communication. Whether “healthcare” or “health care” ultimately reigns will be one for the dictionaries and style guides to ultimately recognize, after the majority has already decided through usage. I’d wonder, though, if the uses of “healthcare” cited in this article would be interpreted as the usage of a single word as an adjective as opposed to a noun: “healthcare services” (“healthcare” describes what kind of services), “Healthcare Research” (what kind of research? “healthcare” research). Style guides, after all, don’t always adapt the way people wish them to, nor as quickly as some might like.
I was happily using “healthcare”, even named my blog On Healthcare Technology, but I am now making a conscious effort to use health care everywhere I write. Why? Healthcare reminds me of Obamacare and I don’t like that term, and more important, it somehow diminishes the weight of “care” and I usually don’t want that part overlooked.
So health care, in my mind, is the process by which some people take care of others in need, and healthcare is an industry.
Well, I certainly feel vindicated, thanks:
Rob, in terms of Matthew changing his blog title, the Brits, as you know, have this odd proprietary feeling about the English language. Over here, “health care vs. “healthcare” is a choice. Over there, the latter is still an abomination. Heck, even “stylebook” is still two words.
Very good post! I started writing “healthcare” and now it just rolls off my fingers when I write, and putting the space would force me to have to think – something that I rarely do while writing. Medicine is full of these kinds of words: gall bladder vs. gallbladder, blood stream vs. bloodstream, and breast feeding vs. breastfeeding. The bottom line (bottomline?) is that docs hate to document things and they will inevitably become shortened.
Thanks for writing this. Maybe you can get Matthew to follow Tommy Thompson’s lead and change it from THCB to THB. It is far more catchy, IMO.
I think twitter and search dictate #healthcare over #health #care 🙂
Thank you for this nice article. Reading this is better than reading anything Dr Rob Lambert writes. Better than looking at his tedious picture too.