groups and communities within Australia's scattered population has been problematic for more than a century. When modern scientific medicine was developing its present form, in the 1880s, Australia was composed of six self-governing colonies of the United Kingdom. Half of the population was dispersed in an agricultural and extractive economy supporting a few regional service towns, but commercial, financial, and governmental activities were concentrated in the seaboard capital cities. Numerous small hospitals were established by voluntary initiative in the country towns and voluntary initiative, often aware of a British model if not appealing directly to it, was responsible for a considerable part of the hospital services in the urban metropolitan areas. Dispersed voluntaryism may have worked in the United Kingdom, where landed wealth also was dispersed, but it was not adequate to the Australian situation, where hospital boards quickly fell into the habit of seeking subsidy from the colonial government for their institutions. The trouble with the subsidy was that it created political and financial obligations on governments to maintain institutions over whose establishment and expansion they had no control. The system
A parliamentary committee of inquiry was convened in response to growing concern--among the general public and the scientific community--about new techniques in human fertilization and research in embryology. The committee had to enter that jurisprudential minefield, the theoretical relation between morality and the law. When issues arise in which there is no historical tradition, the voice of morality may be genuinely confused and uncertain. But the law, unlike moral opinion, cannot be contradictory; it must be definite, unambiguous, and universally applicable.
Persons aged 85 years and over have been the most rapidly growing group for some time, although their numbers are yet relatively small. However meager the official data, they do reveal striking differences from other Americans, including a unique sex ratio, higher rates of institutionalization, and lower family income. Examination of recent demographic trends portends the direction of future changes among the oldest old.
High technology--complex, expensive, restricted in availability, and requiring some form of explicit rationing--is bound to influence the medical task. Diagnosis, prognosis, decision, and management have all incorporated high technology, changing the hospital physician's role from one of private contractor to one of team member. Attitudes toward the balance between burden and benefit of high technology are as varied as are the conflicting vested interests among patients, professionals, society, industry, and government. Above all, it will take time for both patients and professionals to learn how to redefine expectations in a changing relationship.
The general public, physicians, and policy makers have all come to accept constraints on public expenditures for medical care as a reasonable means to redirect resources to competing sectors of national life, and to reflect changing political and social values. "Rationing" of facilities and services by explicit and implicit methods seems inevitable; the poor and disabled must not bear the brunt of stringency. The politics of competition and altered power relationships among providers offer new opportunities for system-wide reform.
A focus on persons aged 85 and over is a timely measure for better understanding the implications of population aging. Yet, it may generate inaccurate stereotypes that reinforce anxieties about conflicts between age groups in the allocation of health and social welfare resources. Alternative constructs enable consideration of a variety of options that differ from unnecessary extrapolations from existing public policies. These range from market initiatives, through state and local government actions, to federal intervention for meeting the challenges of becoming "an aging society."
Proposals to shift more of Medicare's costs to beneficiaries raise the question of whether the oldest old--the heaviest users--have the resources to bear these costs. Information on cash income, assets, other economic resources, and in-kind benefits provides an assessment of the economic status of the very old. When all factors and adjustments are considered, the oldest old, as a group, are shown to have substantially lower economic status than the young old.
Economic, demographic, and technological pressures have led at the same time to increased demands upon health services and the need to contain spending on health care. As the United States has focused singularly on an array of market mechanisms, Western European countries have each adopted a broader set of strategies along with limited de-insurance: innovative regulatory approaches and a move from compulsory health insurance models to flexible national health service models of providing health care. Pursuit of cost-containment in Western Europe has proceeded along with pursuit of quality and, above all else, equity.
Health survey data are an important and efficient source of information for policy makers and administrators. But caution is warranted: surveys do not show cause-and-effect relations, and they are no substitute for randomized controlled experimentation in predicting behavior. The variety of surveys--governmental and private--is increasing, and both methodology employed and interpretation of results can be improved in suggested ways.
major trend reversals in most social welfare programs; legal services for the poor, housing finance, health care for the poor, school lunches, student aid, food and nutrition programs, to name a few, were particularly targeted. Notably absent from the list in the beginning were programs for the aging, especially Social Security and veterans programs. Only as the economic situation tightened this past year did the Reagan administration begin to touch the social insurance system, and even then it proceeded with much caution. How did the special public concern for the aging come about and how pervasive has it been as a matter of public policy? The politically privileged position of the elderly is marked both by change and continuity. On the one hand, aged, native white men had secured substantial benefits from the Civil War pensions through the late nineteenth century. But the pensions did not cover most women or nonwhites. And when the Civil War veterans and their dependents died the extended coverage lapsed so that by 1920, there was virtually no coverage. By the time of the development of the Social Security insurance system in 1935, the aging were one of the poorest groups in American society. Thus, it is only in the relatively recent past that
The National Center for Health Statistics is embarked on a major project to combine the respective strengths of cognitive psychologists and survey researchers in a common effort to improve the design of survey questionnaires. This methodological research is conducted within the framework of the National Health Interview Survey, the nation's main source of information on the health of civilians. Better quality of such information--from recall to response rates--can aid both scientific inquiry and public policy.
Inadequate insurance, whether private or public, can impose ruinous private hardship and unexpected public burdens. "Who are the underinsured?" is both a definitional and an empirical question. Data from the National Medical Care Expenditure Survey, applied under various concepts of risk and expense, reveal that over a quarter of the nonelderly population is inadequately protected against the possibility of large medical bills. The private burdens of the underinsured are widely distributed across the population.
Improvements in the medical/technical ability to transplant human organs have led to similar--yet importantly different--societal and organizational responses among the nations of the "Atlantic Community." The highly decentralized system of organ procurement in the United States yields greater numbers; centrally directed European systems reflect lower wastage rates. An emerging convergence of the two approaches promises significant benefits and efficiencies in organ transplantation.
The past 25 years have seen the development of a wide variety of sample surveys dealing with the nature and distribution of illness and disability, and with the utilization of health care services. The sample survey is currently the most widespread and influential instrument for judging the health status of the nation and for guiding health policy. The knowledge, beliefs, and attitudes of survey respondents "subjectively" affect what the survey seeks to "objectively" measure. Even as statistical sampling has been refined, so is it important to reexamine what the cognitive sciences have to offer for survey interview structure and content.
It is a well-understood principle of public health--and of disease control in general--that preventive efforts must be consistent with the natural history of a targeted disease. Governmental standards-setting and enforcement policies in occupational health confuse short-term strategies for safety hazard control with long-term disease control. Recent decisions in mining to rely on "significant and substantial" acute risk are incompatible with medical and epidemiological evidence on the nature and progress of chronic disease in many industries.
Questions surrounding withholding treatment from severely impaired newborns have elicited three significantly different substantive and procedural responses: from the Reagan administration's Department of Health and Human Services through the Carter President's Commission on Ethical Problems, and subsequent congressional legislation on child abuse. Movement from a rigid and simplistic application of medical imperatives to ambiguous and abstract criteria of the child's "best interest" represented limited progress. A new legislative compromise principle is an imperfect but practical accommodation to moral and medical realities.
The impact upon health of changes in public policy regarding health services has not been systematically assessed. The long-term, and largely irreversible, effects of reduced support for health services to children present special challenges to collaborative research between clinical and public health approaches. Preliminary evidence from such a collaborative study of a variety of illnesses and interventions is persuasive of real benefit from prompt access to medical care.
values and health care, no work addresses the divided Germany that was forced into existence following the conclusion of World War II. The omission is surprising since the resultant individualistic West and the Communist East provide the researcher with a natural in history, one in which a third of the world's oldest and perhaps most sophisticated health care system itself became an experiment in the application of Marxist/socialist ideology. Examining this experiment has distinct advantages over other comparisons of health care under Communist versus non-Communist governments. If one compares health care services .before and after a Communist takeover, one is unable to examine how the former society and its health care system would have evolved over time had a political upheaval not taken place. Alternately, if one compares a Communist and a non-Communist system in two countries during the same period, the problem of periodicity is solved but the problem of comparability is increased. Inevitably, there are differences of language, culture, history, medical institutions, forms of insurance, and other relevant variables. Happily, the German experience comes as close as is humanly possible to what Campbell (1969) calls a quasi experiment, in which
Little is known about the health problems of the fastest-growing segment of the population. Three major community-based studies present prevalence information on physical and mental disabilities among the oldest old. These data also illustrate the limitations of interpretations in cross-sectional studies, and emphasize the value of prospective investigations of populations aged 85 and older. Although more costly and time-consuming, such prospective longitudinal studies are indispensable to sound policy planning.
The federal government considers all persons aged 65 and over a single beneficiary group, and data collectors consider them a single cohort. As a result, the very old (80 years and over) are virtually invisible; little is known about their specific income benefits and economic resources. Costs for the very old--a more economically diverse group than the nonaged--are likely to grow disproportionately. Recent proposals to share costs will affect the distribution of income and assets among the aged and between generations.
