What should be government's role in promoting the kinds of personal behavior that lead to long life and good health! Mild measures of education and exhortation may be ineffective; imposition of stronger coercive actions may be unacceptable. Philosophical and social principles involved are complex, and threats to freedom can be averted through an understanding of moral justification for any intrusion.
Despite significant differences in ideology, values, and social organization, most Western developed countries-and probably most countries in the world-face common problems of financing, organizing, and providing health care services. As populations increasingly demand medical care, there is growing concern among the governments of most nations to provide a minimal level of service to all and to decrease obvious inequalities in care. To use available technology and knowledge efficiently and effectively, certain organizational options are most desirable. Thus, there is a general tendency throughout the world to link existing services to defined population groups, to develop new and more economic ways to provide primary services to the population without too great an emphasis on technological efforts, to integrate services increasingly fragmented by specialization or a more elaborate division of labor, and to seek ways to improve the output of the delivery system with fixed inputs. Although all of these concerns to some extent characterize national planning in underdeveloped countries, they particularly describe tendencies among developed countries as they attempt to control the enormous costs of available technologies. Throughout the world there is increasing movement away from medicine as a solitary entrepreneurial activity and more emphasis on the effective development of health delivery systems. Having discussed these trends elsewhere in detail (Mechanic, 1974, 1976), what I will do here is examine how changing technology and organization affect not only the provision of medical care, but also the underlying assumptions of practitioners and patients. My thesis is that medical care constitutes a complex
A questionnaire survey shows that physicians in four medical specialties evaluate chronically and terminally ill patients not only in terms of the physiological aspects of illness but also in terms of the extent to which they are capable of interacting with others. A patient's potential capacity to perform his social roles depends upon his "salvageability," i;e., the likelihood that he will be able to resume his roles and the degree of irreversible physical or mental damage which indicates his capacity for resuming them. The priorities in terms of treatment are the following: (1) salvageable patients with physical damage; (2) salvageable patients with mental damage and unsalvageable patients with physical damage; (3) unsalvageable patients with mental damage. Within these catagories variables such as patient attitude, family attitude, age, and social class, which define the social environment of the patient, also influence the physician's decision to treat him. Studies of hospital records of cases in two of the specialties were consistent with they survey findings. The findings suggest that there is a disparity between the traditional ethic concerning the treatment of such patients and the actual behavior of many physicians. As a solution to the inconsistencies between ideal and actual behavior, the development of medical guidelines for the withdrawal of treatment with respect ot certain specifically defined conditions is recommended.
"Financing Medical Education: An Analysis of Alternative Policies and Mechanisms." The Journal of Higher Education, 42(7), pp. 627–628
This paper addresses some of the issues related to health care in the United States. In so doing, I give primary emphasis to questions involving access to health care. Even so, I limit the discussion of any particular topic to its most important facets. The principle of selection involves various criteria: insofar as possible, I discuss those issues that are important at a system level (particularly as they impinge on the allocation of resources), that involve economic arrangements influencing behavior and performance, and that can be illuminated by the economist's perspective. I attempt to give primary emphasis to those variables whose influence is far ranging. In so doing, of course, we cannot examine every network of interrelations. Although this simplifies the discussion, we pay a price for incompleteness. There is little choice, however. One of the difficulties with the health field stems from the fact that everything is interrelated: that intervention on one front has “side effects” on other fronts; that intervention designed to accomplish one purpose sometimes fails to do so because other factors that appear unrelated are not changed. To discuss everything is impossible. On the other hand, to say nothing because we cannot discuss everything is irresponsible. Finally, we will have to reach judgments even in spite of the relative weakness of the data available for analysis. We know far less, for example, about the availability of services (particularly if corrected for quality differentials) than we would like to. So, too, with the impact of differences in utilization on levels of health. The current refrain often seems to be, “But we have no output measures.” That, regrettably, is frequently the case. Nevertheless, just as we cannot be silent because of the complexity of intertwined relations, neither can we be silent because of insufficiency of data. We can use experience and judgment to arrive at (tentative) conclusions. Not knowing everything does not mean we know nothing. The first question we address is, “Why is so much attention devoted to the health sector; why all the fuss about equity?” This issue is often raised by those who regard health as important, but who believe the relation is very weak between medical care expenditures and services (inputs) and health (outputs). They argue that monies that might go to the health sector to achieve equity might be better spent in other areas—e.g., housing, nutrition, education—even if the goal that is being sought is better health. All of us have heard the analysts who question the value of increasing the availability of health resources or services. We have heard distinguished leaders of medicine note that most disease is self limiting and that in a high proportion of cases physicians cannot intervene effectively.1 Some remarks are in order on the question of the importance of medical services. I do not intend to review the evidence on whether medical services make a difference (and to what degree) to the health of a population. Rather, I propose to consider the significance of the fact that the public believes the services to be important and, therefore, desires a greater equity in their distribution. In the case of health and medical care, we are dealing with a sector in which, because of customs and folkways, image may be even more important than reality. Because some (even if relatively little) medical care deals with matters of life and death, because of fear, because of infatuation with science and technology—as well as because medicine oftentimes does help some individuals and, therefore, each individual can hope that it will help him—persons have come to believe that medical care services and intervention by the physician make significant contributions to health. This view is not likely to change. It is quite likely that public policies will reflect what the public believes to be the case even if analysts find little evidence to support the public view. Part of the reason that policy will respond to public belief relates to the attitudes that surround questions of health and of life and death. Part of the reason relates to the different perspectives of the public and the analyst. This difference in perspective, and in criteria used in decision making, lies at the heart of some of the major difficulties in allocating resources to the health sector. The analyst is likely to examine issues—e.g., the impact of medical care on health—in terms of group phenomena. He is interested in a rate of return, in what happens on the average. The citizen—importantly, the provider as well as the consumer—is far more interested in the individual case. His behavior is responsive to the fact that intervention can make a difference in one case rather than to the fact that it makes a difference in only one per cent of the cases. If each individual believes or hopes that he may be the one who will benefit and if we do not know who the one will be and, therefore, require that the service be available to all who might benefit, we have a situation made for conflict. The analyst may say that only one per cent of the cases will benefit. The physician (trained to think in terms of the individual patient) and the patient (for obvious reasons) will focus on the fact that in one per cent of the cases there will be a benefit. Neither will want to be denied the resources needed for the particular case at hand. That case, after all, may be the one in a hundred. This, I believe, is one of the basic difficulties in formulating and administering public policy in the field of health care. We reject market mechanisms that might allocate resources to and within the health sector, in part, because market results are at variance with our values. We say “medical care is a right” because we do not believe medical care should be rationed in terms of income. As a consequence, we need to develop other allocative and rationing mechanisms. Often these alternative processes will involve government regulation and program development. Government, however, will find it difficult to limit the resources allocated to the health sector and thus, in effect, to ration services.2 In making public policy, provider and consumer attitudes (concern about the individual) weigh against the analyst's benefit-cost ratios (reflecting concern about populations).3 Furthermore, when the consumer hears the analyst say that, in the light of the rate of return, we need not devote additional resources to the health sector (or to particular parts of it) he recognizes that the constraint on resources implies rationing. Existing American health care financing mechanisms provide little assurance that the rationing mechanism will not be income related. Medical care, of course, is rationed in other economies and under other health care financing mechanisms: when central government allocates a given amount of resources to the health sector and when this amount is less than either consumer or provider could or would like to utilize, some “rationing” will take place. The issue, therefore, is not rationing itself, but the nature of the rationing process. Are the rationing decisions related to income or to medical needs or priorities?4 Thus, groups who today receive less than what they consider their fair share of services are hardly likely to be impressed by an argument that they translate: “Some people do get more of certain services, but after all the services don't—on the average—yield high benefits (relative to their costs). Therefore, though the rich may ‘waste’ their money in purchasing the services, we shall not invest government funds to increase the availability of the services. The poor should not be distressed—they are not being denied things of considerable value.” In recent years, much of what has been said about medical services could have been so translated. This, however, means maintaining the status quo. It is not surprising that the translation is not likely to find favor among those whom the status quo has not served relatively well. For these (and other) reasons, arguments that equity is not that important will not find favor among the general public. Most consumers will remain more concerned about distributional equity in the provision of health services than about equity considerations in the provision of most other goods and services. They will behave as if medical services do count for more and public policy will respond to their concerns.5 The issues raised in the above discussion are important in considering public policy. Should government allocate resources as the public might prefer, even if those resources will not accomplish that which the public desires? What, for example, is the proper mix for an antipoverty program, that which the analyst feels will eliminate poverty or that which the poor value highly? The two are not always the same. We avoid these important issues by suggesting that if government cannot “educate” the consumer or beneficiary it will have to respond to his images, tastes, values and beliefs. What is the present situation in regard to equity in access to care? There are two parts to this question: the financial constraints and the delivery system performance. We shall need to examine both for we cannot assume that solving the problem associated with financing care would make services available, nor can we assume that increasing the supply of services would enable persons to purchase them. Let us begin with the easier part: the financial barrier. I use the term “easier” because restructuring the financing of health care is, in many ways, easier to achieve than is a restructuring of the delivery system. The fact that we are debating national health insurance (NHI) rather than a national health service (NHS) is not a coincidence. Surely we need not belabor the point that financial barriers to health care exist in the United States. Little would be gained by once again citing the data that all of us already know. Prepayment and voluntary health insurance, largely the result of labor-management agreements, have reduced the financial barrier for many, but not for all Americans. Medicare, Medicaid and a variety of categorical programs addressed to particular population groups or to particular diseases have also helped. Yet, even so, financial problems remain. These are of two kinds: (1) the ability to pay for care, (2) the impact of payment on family income and assets. In this connection, it is useful to remind ourselves of some of the history of the Medicare debate. That legislation was justified on the basis of two arguments. The first derived from the fact that many persons, ages 65 and over, were unable to obtain an appropriate amount of health care because they lacked the financial resources to purchase the care. The second justification was that, even though individuals might be able to pay for care, their financial resources were so limited that the care would cut heavily into their discretionary income.6 Thus, the debate related both to the financial ability to pay for the care that was needed and to the impact of large and unpredictable medical expenses on the financial status of the aged. In a situation that has the characteristics of a lottery in which some will be heavy losers, there will be great concern about developing insurance safeguards. That concern is undoubtedly increased by the fact that the lower the individual's income, the greater the losses as a percentage of that income. In some cases, the lack of money to pay for medical care (given required expenditures on housing, clothing and food) will prevent people from seeking care. In other cases, the monetary conditions result in a psychological barrier: individuals will postpone seeking care in the hope of avoiding an expenditure that would be large in relation to disposable income. In still other cases, persons may seek and pay for care but with a significant impact on their discretionary income. It is necessary to distinguish between these different situations if we are to develop a public policy designed to meet the various financial problems. If I am correct, the public is concerned not only about the impact of the income distribution on the utilization of medical care, but also about the impact of the utilization of and expenditures on care on the income distribution itself. It is the second problem that calls for specific financing programs for health services rather than the provision of money to achieve a more equal distribution of pre-illness income. Were we dealing with a category other than health care, it would not be as clear that the financing or provision of the specific good or service would be necessary. Outside of the health care sector, for example, it is often argued that an income distribution problem can (and should) be met by the provision of money.7 This would permit the consumer to determine whether he chooses to spend those funds on the product that others had in mind or on some other product that he prefers. It is sometimes suggested that these considerations should also guide us in relation to health care, and that government should not provide assistance for specified services or support specifically for health expenditures. Instead government should provide individuals with money that they could use to purchase care (or insurance), but that they could also use for other goods and services if they so preferred. If, however, our concern is the ex post income distribution, it is not sufficient to provide ex ante income (valuable as that may be) inasmuch as the sick would “lose” the money and the well would retain it. A solution to the various problems requires that health services, like education, be provided free.8 Even if we cannot eliminate the “lottery” that causes some to be ill and others well, we can eliminate some of the monetary losses associated with the lottery. There are additional reasons for the view that targeted dollars are required: (1) There is evidence that taxpayers prefer to support programs not people. The categorical, targeted legislation fares better than does the broad and all inclusive. Cancer support would fare better than national health insurance; the latter better than general income maintenance. Taxpayers want to retain a measure of control over the uses to which their dollars are put. (2) Unless funds are channeled through a single payment mechanism, it is difficult to achieve important changes in the health delivery system. (3) In the absence of government intervention, private expenditures on health care may be sub-optimal because of “externalities;” i.e., my well-being is affected by the next person's state of health (and the next person does not consider that when he determines his health expenditures). What is meant by equity in the provision of health services? Were we speaking of tax matters and of dollars rather than services, the criteria would be simpler. In the health field a consensus on definitions is sorely lacking, in part because we have failed to specify objectives and the criteria by which to measure their attainment. Is our concern solely with the health producing aspects of the service or do we care—and if so, how much—about the amenities and the conditions under which the money or service is provided? What is the relation between equity and equality? Is equity realized when equal numbers of dollars (or services) are available for the health care of different persons, or when equal numbers of dollars (or services) are utilized, or when equal health outcomes are achieved? As can be seen, the issues we discuss are not unique to the health sector. In different forms they are found in other sectors. The fact that they have not been solved adequately in other sectors can give us little comfort. Yet, we can gain some useful perspective from the experience elsewhere. In the field of education, for example, we find similar problems—and this in spite of the fact that in many important respects the educational sector is easier to understand than is the health sector. In the early 1960s, the definition of equality in education related to per pupil expenditures. Though we have not achieved even that limited goal, our definitions have changed and become broader. From a criterion of equality in dollar inputs, we moved to a definition of equality in terms of outcomes. At present, it is argued that there should be inequality in dollar inputs per student; inequalities that compensate for the dispersion of advantages and disadvantages that, in turn, make for variation in output per dollar of input and in outcomes. As they have in education, the newer definitions of equality will overtake the health field. In education, we are still groping for answers to problems associated with equity and equality, with “basics” and “extras,” in the public sector. Recent court decisions will help in the search for answers, but the achievement of equality at a basic minimum level is only one part of the problem. How do we deal with the fact that some persons will be able to purchase even more services than the basic minimum, that some communities will be willing and able to do more? If a community has no public kindergarten should we (can we) deny some individuals the opportunity to organize and finance their own kindergarten, i.e., to have a private kindergarten? If the school system does not provide librarians for all schools (and chooses, therefore, not to supply them to any) should we deny some (generally, upper income) mothers the right to volunteer their services as librarians in their school? The difficulty in saying “no” is clear. The implications of saying “yes” should be equally clear. The battle of equity and equality has not yet been fought in the field of health in the United States. One can predict that, at some point in the future, it will be fought. If society, looking at the benefits to society, should decide not to provide various health services to the population, will it permit individuals who want those services and can afford to purchase them in the private market to do so? What if those services involve matters of life and death? If society were to conclude that it would not finance kidney dialysis for all who need it, will it finance it for some (and, if so, how will it select the “some”)? Will it permit individuals who have the resources to finance the service privately? If society should decide that it will not invest significant resources in keeping individuals alive in the latter stages of a terminal illness, will it allow the individual who has the resources to do so? Nor is this a problem that exists only in the case of exotic and expensive procedures. It should not surprise us that in today's market, a blend of the public and the private, similar issues arise in Medicare. If a physician, more highly qualified and providing a higher quality of medical care, charges more than the prevailing and customary charge in the community, the patient must pay the difference. This can be interpreted to mean that the Medicare program is prepared to pay for an average level of physician competence for all individuals while permitting individuals interested in a higher quality of care, and who can pay for that higher quality, to seek it out. Even though Medicare does, therefore, bring an adequate or average quality of service to all, it does not bring equality. It is clear that it does not provide what public officials often set as a goal: the highest quality for all. With limited resources one cannot have the highest quality for all. If the quest is for equality, the slogan might well be: the highest quality for none. That, however, is hardly a slogan that will find its way into a Presidential message (in part because it is not of such slogans that Presidents are made). It is not clear, of course, that the objective is full equality. It may be that a more limited objective—say the elimination of income as a rationing device—is sought. With scarce resources, society may decide not to withhold services from everyone because it cannot provide services to all, but instead to provide them to some who are selected on a basis other than their ability to pay for the services. Tables of random numbers or other criteria could be used to determine the allocation of the scarce resources. Though I have raised these issues because it seems to me that, at some point, the body politic will wrestle in some continuing fashion with many of them, we should not be misled. The fact that there is no consensus on these matters and that they cannot all be solved does not imply that we cannot move forward. We are not required to have a solution to every possible dilemma before we develop a public policy to resolve those that we can do something about. In considering equity, we can adapt some of the approaches used in discussions of tax equity. We can distinguish between horizontal and vertical equity. By horizontal equity we mean that the health care system shall provide essentially the same set of health services (or a distribution of services that equalize outcomes) for persons in approximately the same economic circumstances. Most often horizontal equity considerations are assumed to relate to questions of access affected by the availability of services (e.g., rural-urban differences). These, of course, are important. Horizontal equity, however, is also affected by the nature of government support for the purchase of health services. If such support, as in the Medicaid program, leaves the states free to determine eligibility and the level of benefits (i.e., if the system is based on matching grants rather than on 100 per cent federal funding) horizontal equity will not be achieved. Indeed, the existing inequities are likely to be compounded. The achievement of vertical equity requires government involvement in the financing of care. The achievement of horizontal equity requires that it be the federal level of government. This is not surprising for horizontal equity requires that the residents of different states be treated in like fashion (i.e., as Americans). Only the federal dollar can insure that that occurs.9 Vertical equity, “fairness,” in the provision of services for persons in different economic circumstances, is more difficult to define. Because health benefits must be financed, an examination of the progressivity of the distributional impact must consider the distribution of the tax, premium or other device that finances the benefits as well as the distribution of the benefits themselves (the availability and distribution of the services). It must also consider the proportion of health care costs that is covered by the program. We achieve relatively little even if we devise a highly progressive tax structure, but one that finances services that play only a small part in the consumer's budget. If our goal is equity in the distribution of health expenditures, we must consider the distribution of total health care costs in relation to income. At the present time, the individual's medical care costs are often met both by out-of-pocket expenditures and by voluntary health insurance benefits. Out-of-pocket expenditures occur because voluntary health insurance coverage usually involves deductibles and co-insurance, is not comprehensive in its scope and sets upper limits on benefits. This approach has a long tradition and has found its way into public programs, e.g., Medicare. Deductibles and co-insurance are supported on two rationales. The first is that the larger the amount the individual must pay on an out-of-pocket basis, the smaller the premium charge (or tax) can be. The second rationale is based, if not on empirical analysis of the demand for health care, on well-established economic principles. It is assumed that if the individual is required to share in the cost of care at the time that the care is sought his utilization of care will be reduced. In the absence of deductibles and co-insurance, care is “free.” At that zero price the individual would seek more care than if he were required to pay a small sum, sufficient to deter him from seeking unnecessary care, but insufficient to deter him from seeking care when it is required. This second rationale is closely associated with yet another that is put forward: if the consumer is required to pay a share of the cost, he will be more cost conscious than would otherwise be the case. This cost consciousness, in turn, will induce providers of care, including hospitals, to exercise price restraint and to compete on a price basis. Although these arguments carry some weight, it is possible to advance arguments on the other side of the co-insurance and deductible issue. It is clear, for example, that a fixed deductible and a fixed percentage co-insurance cannot hit with equal impact on families in different income brackets. The amount that is appropriate for one family (i.e., it deters only unnecessary medical care) may be trivial for another (serving not to deter at all) and too large for yet another (serving to deter even important care). It is true that, in theory, this particular objection can be met by letting the size of the deductible or the per cent of co-insurance vary with the income of the family. Yet, deductibles and co-insurance may entail significant administrative costs and the more refined the approach, the greater the costs of administration. Nor do we have the requisite information to construct a sliding scale that would have the particular impacts we desire. One must, therefore, ask whether the claimed benefits of deductibles and coinsurance are sufficient to justify the costs. We have little information concerning the degree to which utilization would be affected by different co-insurance and deductibles.10 We also lack information that would enable us to assess whether an increase in utilization is unwarranted. Costs of travel and waiting time, possible loss of income from work, fear, concern and so forth, all associated with visiting the physician, may lead persons to underutilize medical care services. If utilization should be higher—even then it would be at a zero price—one would not want to erect a financial deterrent. We can also indicate some doubt concerning the effectiveness of deductibles and co-insurance as cost-control devices. Even in spite of existing financial barriers, the health sector has not had an enviable cost-control record. Furthermore, though we know relatively little about how prices and expenditures are determined in the marketplace, what we do know suggests that the physician is the critical actor in the determination both of unit costs (the price of the product) and total cost (unit cost times quantity, the degree to which the product is utilized). The largest savings on the expenditure side are likely to come as ways are found to affect utilization (rather than price). Since utilization is largely physician (not patient) determined, efforts to contain the total costs of a program require that the programs be structured to provide incentives to change physician behavior.11 Deductibles and co-insurance (at levels that do not deter necessary care) are not likely to do that. Costs associated with treatment for conditions not covered through the insurance mechanism are also part of out-of-pocket expenditures. The failure of insurance to be comprehensive in scope has taught us that the medical care system can be distorted by virtue of what is and what is not covered through insurance. Economics does make a difference. In theory, such distortions could be for good or for bad. One could, presumably, structure a health insurance program so as to reduce unnecessary and expensive procedures. It would, however, be difficult to leave the most expensive procedures without coverage. Even though, for example, some may overutilize expensive hospital procedures, others utilize the services because they need them. Shall they be uninsured? As contrasted with other types of insurance, our problem is compounded by the fact that the provider and consumer help determine whether the insured service is utilized. If some services are insured and others are not we are likely to find distortions in utilization. Because we are called on to insure expensive procedures, we are providing incentives for their use. One is, therefore, almost inevitably led to comprehensiveness of coverage, in part for medical reasons, in part to prevent unfavorable impacts on the allocation of resources within the medical system and in part to achieve the equity we spoke of earlier. There is a third element of medical care that is paid for by the patient on an out-of-pocket basis: those costs that occur after the insurance has reached the upper limits on the number of days of hospital care or on the total cost that will be covered. In many ways this is the anomaly in the insurance field. Had health insurance not originally been developed by the hospital sector as a way of protecting itself from bad debts, we would likely have had larger deductibles and greater protection at the upper end. Since most patients spend a limited amount of time in the hospital, the emphasis, however, was on shallow-end coverage. The consequence—incorporated into federal legislation in the Medicare program and duplicated in a variety of proposals that have been offered to the Congress—is that those who stay in the hospital the longest time (and who often are most sick) run out of benefits. Insurance, in general, tries to protect against high expenses that occur relatively infrequently and the occurrence of which is not under the control of the person having the insurance, but that upper-end coverage is lacking. The costs associated with exceeding the upper limits may not significantly affect the distribution of medical care costs by income class (because the upper li
For an adequate understanding of the problem of cardiovascular diseases in the United States today, it is valuable to review the evolution of the health picture during the last 50 to 100 years. This has been a period of remarkahle advance, probably unparalleled in any previous era of human history. Progress has tjeen particularly great in lengthening the expectation of life at birth (Fig. 1 and 2, Tables I--IIIt).r-8 For all persons, life expectancy at birth has increased more than 20 years, from ahout 48 years in 1900 to about 69 years in 1959. For white males the increase has been 19.1 years (39.6 per cent), from 48.2 to 67.3 years, since the turn of the century; for white females it has increased by 22.8 years (44.6 per cent), from 51.1 to 73.9 years. Longevity of the nonwhite (chiefly Negro) population has also improved greatly during the twentieth century; the difference between whites and nonwhites in average length of life has decreased considerably, to 6.4 years for males and 7.7 years for females (Table I). This phenomenal advance in life expectancy is attributable first of all to the conquest of infectious diseases, particularly acute infectious diseases in young children, which previously took a heavy toll (Fig. 1 and 2, Tahle III).~-~ In 1901 less than 80 per cent of newborn infants in the United States could he expected to survive t Tables noted throughout paper will appear in author’s reprints. to their fifth birthday. The corresponding figure for 1959 was almost 97 per cent. In 1901 a little over 75 per cent of newborn infants could be expected to reach their fifteenth birthday; the figure for 1959 was over 96 per cent. Appreciable decreases in mortality among middle-aged and older people also have occurred during recent decades, largely as a result of advances in the control of infectious diseases, particularly pneumonia and tuberculosis (Fig. 1 and 2, Tables I and IV). A major consequence of these developments has been a marked increase in the number of middle-aged and elderly persons in the United States. By 1960 there were almost 17 million persons aged 65 and over-more than five times as many as in 1900. In the same period the number of middle-aged persons (45-64) increased from 10 million to 36 million. Persons 65 and over and those 45 to 64 constituted 4 per cent and 14 per cent, respectively, of the total population in 1900; by 1960 these percentages had increased to 9 per cent and 20 per cent9 Howeuer, for the incwusing millions of middleaged and elderly persons, the outlook for life rxpctancy today is only moderately better than it was at the turn of the century. The death rates for persons aged 45 to 64 and those 65 and over have declined much less than death rates for children and young adults (Fig. 2). Therefore, for white males and females aged 40, life expectancy has increased only 3.8 and 4.7 years, respectively, since 1900-l 902 ; for nonwhites, the corresponding figures are only 4.7 and 6.9 years (Table I). The situation is similar at age 60. Males have generally done less well than females, white males the least well. The fundamental reason for this is the slow progress against the cardiovascular diseases (Fig. l-3 and Table IV). In fact, for middleaged males, particularly white males, the
Policy making is fraught with difficulty. The long-range results are often far afield from the original expectation. This, of course, has been conspicuous in such fields as defense, foreign affairs and economics. Serious attempts to formulate a national policy for the delivery of medical services are relatively new for the United States. Foreseeing the ultimate result of any policy decision is quite difficult. It was certainly not perceived that the laudable Flexner reform of medical education, aided and implemented by the support of medical education through research funds from the federal government, would ultimately create a crisis in the access to primary medical care. The reforming of medical education to change and shorten the medical curriculum, the creation of a specialty of primary family practice and the genesis of new health professionals, such as the nurse practitioner and the physician's assistant, are all attempts to ameliorate the effects of a policy decision made sixty years ago. This is not to say that the policy decision was wrong; the inference is that the ultimate results were difficult to foresee.
Since December 1968, we have been conducting a prospective study of the prevalence and incidence of venous disease in hospitalized surgical patients. A combined clinical and Doppler ultrasound examination has been performed at the patient's bedside. This report will present a brief description of the technique, an estimate of the accuracy of clinical ultrasound examination and the initial prevalence and incidence findings in patients undergoing elective operation at The Medical College of Pennsylvania and the Philadelphia Veterans Administration Hospitals. The objectives of the prevalence and incidence study that is in progress is to determine the following information obtained by clinical and ultrasound examination about lower extremity venous disease in surgical patients:
Paru pour la premiere fois dans le Quarterly, Vol 50, No 4, Pt 1, 1972, cet article, partant des debats au Congres des Etats-Unis lors de l'approbation du Medicare (systeme d'assurance maladie en direction des personnes âgees) en 1965, ou seule etait posee la question du financement, la question de l'organisation y apparaissant comme secondaire, constate que, 6 ans plus tard, cette derniere question, celle de soins personnalises, adaptes aux caracteristiques de la population concernee, est arrivee au premier plan. Une planification rationnelle, basee sur les besoins sociaux, a longtemps ete absente des preoccupations de la politique de sante americaine, ce qui a eu pour consequence des deficiences majeures en termes de cout, d'efficacite et de satisfaction du consommateur. Dans cette perspective, l'A. emet plusieurs propositions pour l'organisation d'un tel systeme de sante personnalise au niveau federal.
