By Elwood, Thomas W
THE FEDERAL GOVERNMENT is involved in health care in various ways that include (1) providing services to veterans, (2) paying for care received by Medicare and Medicaid beneficiaries, (3) assuring quality through regulatory activity, (4) financing the discovery of medical breakthroughs, and (5) training members of the health workforce and assuring that the nation has an adequate supply of them. None of these functions would appear to be in any immediate danger of disappearing. Moreover, with the aging of the population, it is reasonable to assume that the role of the government in these endeavors will increase over time. The aim of this essay is to consider some ways in which the health care of tomorrow will be affected by the intermingling of several different kinds of factors such as demography, epidemiology, economics, technology, globalization, and individual health behavior.
As famous as he was for his exploits on the baseball diamond, New York Yankees catcher Yogi Berra may be remembered even more for his efforts to express his thoughts intelligibly. As he once noted, "Predicting is difficult, especially the future." At a more technical level, Philip Tetlock, a business professor at the University of California at Berkeley, verifies Berra's observation about the future. He is a pioneer in the relatively young interdisciplinary field of political psychology, and his studies provide an understanding of limitations in forecasting.
He asked 284 experts with advanced educational and professional training in international relations, political science, law, economics, business, public policy, and journalism to make thousands of predictions between 1998 and 2003. His data "plunk human forecasters into an unflattering spot along the performance continuum, distressingly closer to the chimp than to the formal statistical models. It is impossible to find any domain in which humans clearly outperformed crude extrapolation algorithms, less still sophisticated ones."1
Even long before Tetlock undertook his study, examples of other kinds of predictions that failed to materialize can be found in the health arena. Sir Macfarlane Burnet, a Nobel Prize winner in 1960, claimed that,
One can think of the middle of the 20th century as the end of one of the most important social revolutions in history, the virtual elimination of the infectious diseases as a significant factor in social life.
In 1963, physician and anthropologist T. Aidan Cockburn made this statement:
We can look forward with confidence to a considerable degree of freedom from infectious diseases at a time not too far in the future. Indeed . . . it seems reasonable to anticipate that within some measurable time . . . all major infections will have disappeared.2
In 1968, U.S. Surgeon General William Stewart indicated that it might be possible with interventions such as antimicrobials and vaccines to "close the book" on infectious diseases and shift public health resources to chronic diseases.3
Undoubtedly, this infectious sense of optimism was fueled by the presence of new vaccines and effective antibiotics, better nutrition, improved housing, and the spread of sanitation principles. Accompanying this positive outlook is the fact that beginning in the 1950s and continuing through the 1970s, medical schools in the United States began closing microbiology departments and terminating infectious disease training programs.
During a presentation at the National Institutes of Health on September 13, 2006, Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, stated that infectious diseases are the second leading cause of death worldwide, but for the age group from birth to age 49 yrs, they are the leading cause.
He makes a distinction among (1) newly emerging diseases, such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS) and severe acute respiratory syndrome (SARS), that never had been recognized previously; (2) reemerging diseases that have been around for decades or centuries but have returned in a different form or in different locations, such as West Nile Virus in the Western hemisphere, monkeypox in the United States, and influenza in various parts of the world; (3) deliberately emerging diseases that are agents of bioterrorism; and (4) a baseline matrix of infectious diseases that constitutes an ongoing threat. Now that the AIDS pandemic is 25 yrs old, he considers it to be a fundamental matrix disease.
As far as ever completely winning the battle against microbes, he does not share the optimism displayed by distinguished predecessors such as Burnet, Cockburn, and Stewart. Instead, he believes that unusual characteristics of microbes allow them to circumvent attempts to control them. Human generations occur approximately every two decades. Those of microbes occur in minutes, allowing them to replicate and mutate rapidly, giving them the advantage of selectively circumventing human interventions. Because humans never will wipe out all microbes, and they will never destroy us completely, the definition of success in his view is to maintain the balance.
Another major concern is the threat of unknown, non-state- sponsored individuals or organizations acting without concern for any moral deterrents. The release of anthrax in Washington, DC, in 2001 provides one example. Whoever was responsible for that deadly attack has not yet been apprehended.
To cite another example, the Aum Shinrikyo Cult in Japan tried to aerosolize anthrax and botulinum toxin throughout Tokyo at least eight times between 1990 and 1995. The group also organized a team to go to Zaire in 1993 to obtain the Ebola virus. In 1995, the cult was responsible for releasing sarin gas in the Tokyo subway.
Lost in Transition
Advances in health care delivery continue to be made, but there always is room for improvement. When a patient is moved to a different unit or turned over to another doctor or nurse in a hospital, which can occur whenever work shifts change, communication failures may occur because important information often is lost in transition. Among hospitalized patients, adverse events can result even from relatively short-term transfers of care between physicians. Overnight residents are more likely to make preventable medical errors when caring for patients briefly transferred to them when caring for their own patients.4 Discontinuity of care also has been associated with medical errors and adverse outcomes in the outpatient setting.
Recognizing the existence of such problems is an important first step in doing something constructive about them. As a consequence, the Joint Commission on Accreditation of Healthcare Organizations has made "a standardized approach to 'handoff' communications" one of its new National Patient Safety Goals for 2006. Creating formal sign-out systems similar to those used in other industrial settings such as nuclear power and space shuttle mission control should lead to improvements in outcomes. Strange as it may seem, techniques developed by the Ferrari racing team pit crew have applicability in the clinical setting. Regulations developed in 2003 to limit resident duty hours are another step in the right direction.
Aging of the U.S. Population
In a speech by Federal Reserve Chairman Ben Bernanke, he stated that in coming decades, many forces will shape the U.S. economy and society, but in all likelihood no single factor will have as pervasive an effect as the aging of the population. In 2008, as the first members of the baby-boom generation reach the minimum age for receiving Social security benefits, there will be about five working- age persons (between the ages of 20 and 64 yrs) in this nation for each person aged 65 yrs and older. The 65 and older cohort will constitute about 12% of the U.S. population.
These statistics are set to change rapidly, at least relative to the speed with which one thinks of demographic changes as usually taking place. For example, according to the intermediate projections of the Social Security Trustees, by 2030-by which time most of the baby boomers will have retired-the ratio of those of working age to those 65 yrs and older will have fallen from five to about three. By that year, older Americans will constitute about 19% of the U.S. population.
He indicated that the coming demographic transition will have a major impact on the federal budget, beginning not so very far in the future and continuing for many decades. Although demographic change will affect many aspects of the government's budget, the most dramatic effects will be seen in the Social Security and Medicare programs, which provide income support and medical care for retirees and which have until now been funded largely on a pay-as-you-go basis. Under current law, spending on these two programs alone will increase from about 7% of the U.S. gross domestic product (GDP) today to almost 13% of the ODP by 2030 and to more than 15% of the nation's output by 2050.
The outlook for Medicare is particularly sobering because it reflects not only an increasing number of retirees, but also the expectation that Medicare expenditures per beneficiary will continue to rise faster than per capita GDP. For example, the Medicare Trustees' intermediate projections have Medicare spending growing from about 3% of the GDP today to about 9\% in 2050-a larger share of national output than is currently devoted to Social Security and Medicare together.
The fiscal consequences of these trends are large and unavoidable. As the population ages, the nation will have to choose among higher taxes, less nonentitlement spending, a reduction in outlays for entitlement programs, a sharply higher budget deficit, or some combination thereof. From a broader economic perspective, the question is how the burden of an aging population is to be shared between this generation and the generations that will follow. A failure to prepare for demographic change will have substantial adverse effects on the economic welfare of today's children and grandchildren and on the long-run productive potential of the U.S. economy.5
With the passage of time, the federal government may decide to launch new initiatives. A recent example is the outpatient drug benefit that became effective in January 2006 under the Medicare program. Projecting future costs never is an easy task, but if history is any guide, it is worth noting there is a tendency for advocates of new programs to underestimate what eventually will transpire. For example, in 1965 the projected cost for the Part A Medicare program in 1990 was $9 billion. The actual cost for that year blossomed to $67 billion. In 1988, home care costs under Medicare were projected to be $4 billion. Instead, they were $10 billion.
The Changing Ethnic and Cultural Face of the U.S. Population
The population of the United States will continue to grow. As long as this country remains a magnet that attracts immigrants, growth will occur even if there is a dip in the birthrate. As of October 17, 2006, the population had reached 300,000,000. The Census Bureau projects that by 2030, there will be 363,584,000 inhabitants of the United States, by 2040 there will be 391,946,000, and by 2050 there will be 419,854,000 persons in this country; of this amount, 50% of the population will be non-Hispanic white compared with being 69% nonHispanic white in the year 2000.6
Presently, many kinds of health disparities exist among minorities in the population. The reason why this is true is a function of many interrelated variables. In addition to poverty, substandard housing, poor nutrition, low levels of education, an unhealthy environment, and a host of other pertinent concerns, members of various groups also may be distinguished by the ability to communicate using the English language, their respective beliefs about medical care, care-seeking behaviors, disparities in patient preferences for treatment, and willingness of patients to adopt behavior recommended by health personnel such as the use of medications.
Much of the gap between recommended and actual levels of chronic disease care is attributable to medication nonadherence, which costs an estimated $100 billion a year in the United States and leads to thousands of serious adverse events or deaths each month. Yet, medication nonadherence often may be a rational response to the information patients are given and many factors that drive nonadherence are beyond the control of patients.7
Nonadherence can result when physicians omit critical information when starting treatments with new medications such as the name of the medication, its purpose, duration of treatment, dosing schedule, and expected adverse effects. The use of electronic medical records or automated pharmacy databases represents ways of correcting treatment deficiencies of this nature. The production of polypills for the management of multiple disease conditions is another future development that has the potential to offset the nonadherence problem.
The Health Literacy of America's Adults is the first release of the National Assessment of Adult Literacy. The findings are based on assessment tasks designed specifically to measure the health literacy of adults living in the United States. Health literacy was reported using four performance levels: below basic, basic, intermediate, and proficient. The majority of adults (53%) had intermediate health literacy. About 22% had basic and 14% had below basic health literacy.
Relationships between health literacy and background variables (such as educational attainment, age, race/ethnicity, where adults obtain information about health issues, and health insurance coverage) were also examined and reported. For example, adults with below basic or basic health literacy were less likely than adults with higher health literacy to obtain information about health issues from written sources (newspapers, magazines, books, brochures, or the Internet) and more likely than adults with higher health literacy to receive much information about health issues from radio and television.8
Being health literate offers no firm guarantee that individuals will make correct decisions. Approximately half (48%) of all American adults report taking some type of nonprescription vitamin, dietary, or mineral supplements regularly. One in six (16%-18%) report using dietary supplements like Echinacea, ginseng, amino acids, or over-the-counter hormones regularly.9
Women are more likely than men to use complementary and alternative medicine, including prayer for health reasons, natural products (e.g., nonvitamins and nonminerals such as herbs or herbal medicine), and deep-breathing exercises. When asked what they would do if a government agency said that the supplement they use most often was ineffective, 71% of regular users reported that they would continue to use it.10
Allied Health Workforce
Acute workforce shortages already exist in the United States, as exemplified by the professions of medical technology/clinical laboratory science and respiratory therapy. Even when students are attracted to a career in a health profession, the cost of obtaining an education is becoming a formidable barrier. Although state and local funding per student increased 3.5% in 2005, constant dollar funding for college and university students was at its lowest in 25 yrs, according to the annual study of state higher education finance recently released by the Association of State Higher Education Executive Officers.11
Support per student decreased dramatically from 2001 to 2005 because enrollment grew by 14.3% and inflation grew by 14-2% without corresponding increases in public funding. While support for higher education remains a priority for most states, total tax revenues have decreased as a percentage of state wealth, thus decreasing overall support. Moreover, huge federal deficits are a factor that may produce strong resistance to expanding federal aid for higher education.
Currently, it is not possible to quantify the allied health workforce with any degree of accuracy on a national basis. Two separate initiatives are in motion that have the potential to produce valuable information. First, under the auspices of the Association of Schools of Allied Health Professions, the board of directors of that organization in October 2006 approved a proposal to work with accrediting agencies to obtain data on the number of graduates of allied health programs each year and the extent of faculty vacancies.
The second initiative is an element of the Allied Health Reinvestment Act, S.473, a bill that the Association of Schools of Allied Health Professions was responsible for producing in the 109th Congress. If that legislation is enacted, the Health Resources and Services Administration in the U.S. Public Health Service would be assigned the task of synthesizing allied health workforce data collected by federal agencies, private organizations, and other related producers of relevant information.
Migration is playing a larger role in population redistribution within the United States. With birth and death rates currently low and largely similar across the country, natural increase (the excess of births over deaths) exerts less influence than it used to in explaining why some regions, states, or counties have faster population growth than others. Population changes both in actual numbers and in percentages by age cohort exert a significant effect on the kinds and amounts of health services required. The educational system also is affected by these same factors from the perspective of producing health professionals to fill available positions.
Developments in Technology
President Bush vetoed H.R. 810 on July 19, 2006. The legislation was aimed at making more human embryonic stem cell lines available to federally funded researchers. It was his first veto in the nearly six years that he has served as the nation's chief executive. Despite the failure to have this measure enacted, efforts will continue by private entities and state governments to move forward in this branch of medical research. Scientists who wish to study human embryonic stem cells can follow one of two routes. They can accept federal funds but be restricted to having access only to a small number of cell lines created before August 9, 2001, or they can seek other kinds of funding from the states or from private sources to gain access to a larger number of cell lines that have been created since then.
What eventually materializes from these studies to improve health status is yet to be demonstrated. Exaggerated claims have been made thus far, and it can be expected that more will continue to be made. Advising paralyzed patients that they will walk again is at present a stretch of the imagination, yet individuals afflicted with serious conditions have every reason to maintain hope that a cure is close at hand. Their hopes are addressed when they visit Web sites such as the Preventive Medicine Center in Rotterdam, which lists the kinds of conditions amenable to improvement and possibly even cures through stem cell treatment. As the deputy editor of the New England Journal of Medicine noted:
We really don't know what will ultimately come out of research on embryoni\c stem cells. It is important to play down promises to the public that the work will produce anything of clinical value in the foreseeable future. We simply don't know how an embryonic stem cell will behave in a human, and we don't know whether human marrow contains a pluripotent stem cell that can transdifferentiate. . . . Research on stem cells will encounter many twists and turns, but it is an endeavor that is eminently worth pursuing.12
Polls suggest that most Americans do not share the views of President Bush. In a survey in July 2006 by the Pew Research Center for the People and the Press, 56% of respondents said it was more important to conduct stem cell research that might lead to cures than to avoid destroying human embryos. Only 32% said that preserving the potential life of embryos should be the priority.13 As evidenced in the election of 2006, control shifted from Republicans to Democrats in Congress. As new members are elected to that institution and the presidency changes hands over time, it is conceivable that federal policy regarding stem cell research policy may be modified.
Related considerations have to do with the adoption of innovations. Even when new ideas are sound and result in the creation of beneficial practices that save lives and reduce costs, many years can elapse before they experience widespread use. The flip side is that some new forms of technology essentially may be worthless, but a medical center will implement them to avoid losing market share to a neighboring facility. Pressures arising from patients who demand the latest innovations, combined with the persuasive powers of prestigious members of a medical center's board of trustees, almost guarantee that such purchases will be made.
As of October 2006, there are genetic tests for more than 1,000 diseases and the number is increasing rapidly. Amazingly, there is no mechanism in place in the United States to check that such tests are accurate and reliable. An expectation in government circles is that the Center for Medicare & Medicaid Services, an agency responsible for the quality of clinical laboratories, would provide a similar proficiency testing function for laboratories involved in this line of work. Unfortunately, there is no routine evaluation of the competence of genetic testing facilities.
A 2006 survey by the Genetics and Public Policy Center found that in the United States, at least one third of these laboratories fail to perform proficiency assessments for some or all of their tests and that analytic errors increase in direct proportion to the failure to conduct proficiency testing. Errors in genetic testing can produce disastrous consequences, even having the potential to result in fatalities. Regulations are needed. The prediction is that eventually a system of proficiency testing will be established by the federal government.14
Nanomaterials (a nanometer is one billionth of a meter) for commercial use, such as sunscreens, clothing, computer chips, and cosmetics, already have been produced. Disposable imaging capsules that can be swallowed may soon be coursing through human blood vessels to produce detailed images noninvasively. Nanometers and other tiny microscopic-size devices built from DNA molecules that travel through the body in search of pathogens to eliminate may become as common as IV bottles.
As noted by the National Research Council, however, nanomaterials have unusual and useful properties, but their unique attributes make them a doubleedged sword. They can be tailored to yield specific benefits, but also can have unknown and possibly negative impacts such as unexpected toxicological and environmental effects. The environmental, health, and safety implications of nanotechnology are of significant concern to and a topic of serious discussion by government agencies and commissions, nongovernmental organizations, the research community, industry, insurers, the media, and the public.15
Gold and other substances that are inactive in bulk form become highly reactive at the nanoscale level. As particle size decreases, more atoms are found on the surface compared with those in the interior. Increased relative surface area can lead to a change in chemical properties, raising the possibility that nanoparticles can pose a threat as a new form of pollution. Health concerns revolve around dangers in the workplace, waste streams from industry and laboratories, skin surface contact with cosmetics, ingestion of food and beverages containing nanoparticles, injection of medicinal products, and excretion of medical particles that are not biodegraded.
In recognition of the importance of confronting such potential hazards, the U.S. Food and Drug Administration formed an internal nanotechnology task force in 2006 to oversee regulations pertaining to the development of innovative, safe, and effective Food and Drug Administration-regulated products that use nanotechnology materials.16
The question of what health care in the United States will look like in the future leads to the following predictions. Medical technology will continue to advance and pharmaceutical breakthroughs will lead to the successful treatment of conditions that currently offer much more resistance to any interventions, such as certain forms of cancer. Meanwhile, it is likely that the poor always will be among us and that rural, isolated regions of the nation will be afflicted by inequities in the distribution of resources such as human capital in the form of the health workforce.
The use of electronic medical records is viewed as a way to improve patient care and reduce health care costs. Information technology is not as essential a part of health care as it could be. Small family-owned restaurants and dry cleaning establishments use computers in ways that are missing in the health sector of the economy. Trucking companies are able to monitor vehicles, optimize routing, and communicate with drivers. Meanwhile, in some parts of the nation it can take anywhere from weeks to months for a reportable dis ease to be communicated to public health officials.
In key areas such as hospitals and physicians' offices, patient information still is being recorded by paper and pen. Even worse, patient information is not transferred and shared by providers. What is needed is the ability to develop a system that will enable providers to share information with one another while also protecting the personal data of patients.
The best available evidence suggests that about one fourth of physicians were using an electronic health record (EHR) as of 2005, but fewer than one in 10 physicians were using EHRs with functionalities such as electronic prescribing. Data on hospitals' use of information technology are more limited, but best estimates suggest that 5%-10% of hospitals had electronic prescribing-or computerized physician order entry (CPOE) EHR-systems in 2005. Whether hospitals had stand-alone CPOE systems or comprehensive EHR systems with a CPOE component is unknown.17
Viewed from a demographic perspective, the past is prologue. Approximately 77 million so-called baby boomers are approaching retirement age, and someday they all will die. Between now and that fateful occasion when each person heaves a final breath and passes through the door of oblivion, it can be stated with certitude that their presence will have a considerable impact on the financing of programs such as Medicare, Medicaid, and Social security. Money spent on those entities may have to result in the reduction of expenditures for other necessities such as education.
Whether they want to do so or not, elected officials are going to be forced to make structural changes involving these programs and the choices are not all that attractive. Raising taxes on younger workers could result in a considerable amount of generational conflict. Older persons will have great power at the ballot box and may be able to exert their will in ways that antagonize the rest of the population that is left paying the bills. The other principal alternative is to change the programs themselves by increasing the age for eligibility, imposing more cost sharing, or reducing benefits.
The proportion of white persons in the United States descended from European countries will continue to decline. The percentages of minorities in the population will grow, and the point may be reached where the term "minority" itself loses all meaning and significance because of intermarriage among members of different groups. For the immediate future, the health care provided for many persons will be compromised because they lack the ability to communicate in English, in addition to the fact that they also may possess cultural beliefs about the origins and treatment of disease that run counter to what Western allopathic medicine has to offer.
On the other side of the ledger, many individuals with reduced literacy and language skills will occupy low-end jobs in the health field in venues such as nursing homes and home health services. Turnover rates among them will continue to be high. An inability to communicate properly with older patients of a different cultural heritage may help to reduce the quality of care delivered.
Higher education shows no signs of becoming any less expensive, nor is there much likelihood that either the states or the federal government will be able to provide sufficient resources to individuals to match increases in tuition. Within the realm of higher education, a real challenge will be to attract enough students who are willing to enroll in mathematics and science courses necessary to undertake careers in the health field.
That kind of matriculation has been in a downward direction, and American students tend to fare poorly in comparison with their counterparts in other countries on the basis of standardized tests in science and mathematics. St\rangely enough, while American students achieve the lowest scores in these subjects, they have the highest scores when self-esteem is measured. Fortunately, students from other lands come to the United States to attend school and some of them stay here upon completion of their studies.
Gaps between persons who are fortunate enough to obtain a sufficient amount of education and those who cannot do so may help to exacerbate a digital divide that already exists within the population. It is likely that health care providers will rely more on the Internet to communicate with patients as part of follow-up care. Computer literacy and access to the Internet differ by ethnic group and socioeconomic status. Those kinds of differences may contribute to further disparities in the health of certain population subgroups.
It can be expected that pundits on either side of the political divide will continue to debate whether the individual or society is responsible for poor health. Heated discussions along such lines have been occurring for more than a century.
According to the Centers for Disease Control and Prevention, in 2000 the leading causes of death in the United States were heart disease, cancer, stroke, chronic respiratory disease, unintentional injuries, and diabetes. The most common actual causes, however, were tobacco, poor diet and physical inactivity, alcohol consumption, microbial agents (e.g., influenza), toxic agents (e.g., pollutants), motor vehicle accidents, firearms, sexual behavior, and illicit use of drugs. Each of these actual causes has a behavioral component.
Competition in the Health Workplace
The health industry consists of many professions, and it is not uncommon to find some of them in direct competition with one another. Some of the more controversial issues entail direct access by patients to nonmedical practitioners without having to obtain prior approval by a physician, scope of practice, and recognition for reimbursement purposes by agencies that pay for health care services.
Typically, the state level is where many battles occur, but the federal government also plays a role. One question is whether certain health providers will have their services covered under Medicare as part of the "incident to" policy, which allows a physician to be reimbursed for services provided by another health care provider working under the physician's direct supervision. The other employee must be an employee of the physician's practice, and the physician must be present in the office suite when this other practitioner furnishes services.
Currently, under the Medicare program, only physical therapists, occupational therapists, and speech-language pathologists can provide physical medicine and rehabilitation services "incident to" a physician. Other professionals such as athletic trainers and lymphedema therapists are pursuing the same privileges through legislation in Congress. In related arenas, dentists and dental hygienists or anesthesiologists and nurse anesthetists are engaged in similar activities in opposition to one another.
Such battles show no signs of undergoing a reduction in either frequency or intensity in the immediate future. Well-organized interest groups devote ample resources to pursuing the attainment of objectives in legislative and regulatory spheres. Lobbyists working on their behalf in Washington and in state capitals should have no fear of becoming a species that will either diminish in size or disappear soon.
Improving Personal Health Status
All too often, the assertion is made that high-quality health care is a basic human right that should be enjoyed by all. Implicit in this statement is the assumption that good health care equates with improved health status. Handing a health insurance card to every resident of this country will not be an all-embracing panacea. Factors involving the ability to access care revolve around considerations such as suitable transportation facilities, time and economic constraints, social support, availability of child care, the shift from fee-for-service to managed care, growth of telemedicine and evidence-based care, discrimination, and the ability of health professionals to provide care effectively to members who differ from the standpoint of age, race, ethnicity, and social class.
At any given time in the United States, there is never a shortage of proposals regarding how to improve the health status of the inhabitants of this country. The following represent the kinds of action that often are recommended: establish more parks and recreational facilities, curtail food advertising directed at children, develop alternate transportation systems to reduce injuries and fatalities that stem from motor vehicle use, restrict gun ownership, prevent unemployment and job insecurity, restore persons to lost jobs, provide insurance discounts for the healthy, impose mandatory immunization schedules for children, have the government subsidize healthy foods, eliminate "for profit" insurers/ hospitals/clinics, and furnish living wages.
Any one of these proposals immediately becomes enmeshed in a political thicket involving basic questions such as who will pay and who will benefit from such a change? Given that resources are limited, in what other areas should spending cuts occur in order to pay for the new service or facility? How much authority should the government have when it comes to infringing on personal freedom?
To cite a common example of a controversial issue, women who have to walk on dark streets at night or who live alone are among the major purchasers of handguns. Should they be denied the right to take action that they see as crucial in relation to personal safety?
The leading cause of injury-related deaths among 65- to 74-yr- old persons is motor vehicle accidents. It is the second leading cause for the 75- to 84yr-old group. Older drivers have a higher fatality rate per mile driven than any age group except male drivers younger than 25 yrs. The American Medical Association estimates that as the population of the United States ages, drivers aged 65 yrs and older eventually will account for 25% of all fatal crashes.18
Proposed ways of dealing with this problem include continuing education for older drivers, licensing recertification, and mandatory road testing for all drivers aged 65 yrs and older. Advocacy groups for the aged undoubtedly will deem such measures discriminatory and will oppose them vigorously.
Many health and social problems do not admit of easy solutions. Among the many interest groups seeking enhancement of benefit packages is the community of mental health providers. For decades, there has been a steady plea for creating parity so that mental health benefits are provided to the same degree that services are covered for physical health conditions.
Advocates of benefit expansion often cite problems stemming from addiction to drugs and alcohol. Many occupants of jails and prisons were under the influence of an addictive substance at the time of arrest. Generally, incarceration facilities around the United States lack the resources to offer treatment and counseling services for inmates so affected by alcohol and drug abuse. Even when these services exist, they are terminated when prisoners return to the streets.
Much crime sterns from perpetrators needing money for their next fix as the severe effects of withdrawal begin to manifest themselves. Thus, the cost to society as measured by the financial damage and physical/emotional harm affecting crime victims, the costs of incarceration, and the revolving-door nature of criminals being discharged from and reentering the criminal justice system suggest that providing adequate health care for addicts has the potential to reap savings.
This example alone suggests the complicated and convoluted nature of meeting a society's health care needs, especially from the standpoint of financing. Among individuals who spend much of their adult lives in and out of jails, it is unlikely they are paying into the Social security system, and if they live long enough, they won't be eligible for Medicare. The burden then falls on Medicaid, which differs from state to state and in its own way is financially unsustainable.
The war in Iraq undoubtedly will play a role in adding to the ranks of those who already are suffering from addiction while serving in the military or who will acquire a drug or alcohol problem (or both) after being discharged and returning home to civilian life. They also will enter that murky area where different kinds of benefit programs with varying eligibility requirements meet or fail to meet a person's health and health-related social needs.
Opinion surveys conducted in 2006 reveal that health care is an important but second-tier issue for government action. Americans' top health care concerns are mostly related to economic insecurity, rising costs, and the problems of the uninsured. The biggest perceived health threats are cancer, HIV/AIDS, and avian flu. Although most Americans do not think that the health system is in crisis, the public remains dissatisfied with both this country's health care and public health systems.19
As is often the case, the clarion call for health system reform is in the air and the topic remains a good campaign issue for persons wishing to be elected to public office. As important as health care is, however, it usually must compete with other issues such as moral values, the economy, terrorism, and military intervention abroad.
A good place to begin thinking about the health care system in the United States is to recognize that one does not exist here. Instead, there are several systems. Examples are Medicare for the aged, the disabled, and patients with kidney disease; the federal- state Medicaid program for the indigent; the Indian Health Service; the program administered for veterans; the program offered for military emplo\yees and their dependents; the various health insurance programs for federal employees; the state children's health insurance program; and the various kinds of insurance coverage financed by employers through mechanisms such as health maintenance organizations and preferred provider organizations for the civilian workforce.
Any one-size-fits-all approach that is recommended also is likely to engender opposition from any or all of the aforementioned sectors because some beneficiaries are satisfied with the existing arrangement and would be reluctant to relinquish it for something new and untried. Apart from any structural defects that characterize the present way of providing health care, the major complaint usually revolves around the problem of those who lack insurance coverage.
Another development worth noting is that seriously ill Americans for financial reasons are seeking treatment in advanced private hospitals in countries such as Mexico, India, Thailand, Lebanon, and Pakistan. Many hospitals in these countries have passed muster with one or both of two international quality assessment organizations: the International Organization for Standardization and the Joint Commission on Accreditation of Healthcare Organizations.
The trend of receiving health care beyond U.S. borders can be expected to increase as long as out-of-pocket spending for health care and insurance premiums escalates beyond the grasp of low- and middle-income Americans. Presently, in some low-wage industries, more than 75% of workers who are eligible for benefits reject employer-provided health insurance because it is viewed as being unaffordable.20
The Role of Government
Depending on an individual's political beliefs, governmental action in the public health arena can be viewed as representing a commitment to social justice by providing for the most vulnerable in society who lack regular access to health care or as a negative force that is overly paternalistic and which supersedes individual judgment. The creation of smoke-free places such as bars and the imposition of requirements for motorcycle riders to wear crash helmets are examples of roles that the government can play, which are not necessarily greeted with enthusiasm by all segments of the population.
If New York City comes to serve as a model, public health surveillance in the United States will take on a radical new form, entailing a reconfiguration of the relation between public health and medicine. Recent events raise questions about the relations between privacy and public health and the obligations and limits of the state in clinical disease management.21 The issue involves a proposal to combat the worsening problem of diabetes by having electronic laboratory-based reporting of hemoglobin A^sub 1C^ tests for all city residents. Critics are opposed because of the incursion on privacy and the fact that diabetes is not a communicable disease that is a threat to that city's public health.
Developments stemming from genomics and advances in nanotechnology will make their way into medical practice, but consumption patterns undoubtedly will prove to be uneven. Some forms of genetic testing are highly expensive. How will the costs be covered if such tests and subsequent treatment interventions are applied to all who might benefit from them?
Finally, this essay began with some comments about the accuracy of making predictions and will close in a similar vein. Based on his personal experience as ambassador, governor, and army lieutenant general, the great Italian historian Francesco Guicciardini wrote his reflections over a period of 18 yrs during the 16th century. One of his maxims is as follows.
The Future is so deceptive and subject to so many accidents, that very often even the wisest of men is fooled when he tries to predict it. If you look very closely at his prognostications, especially when they concern details-for often the general outcome is easier to guess-you will see little difference between them and the guesses of those who are considered less wise.22
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THOMAS W. ELWOOD, DrPH
Association of Schook of Allied Health
Copyright Association of Schools of Allied Health Professions Spring 2007
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