US health care: a look ahead to 2025.

The chapter begins with a reminder that forecasting changes in the health care sector a quarter to a third of a century in the future is likely to be a losing effort, based on past experience. It next considers changing organization and financing and questions that managed care and market competition will be the key forces introducing change. The author looks forward to the passage of universal health insurance coverage for essential care by early in the new century, with patients having to pay for more choice and more quality. The analysis next focuses on the physician supply and points to three challenges: how to moderate the numbers being trained; whether to reconsider the conventional wisdom of training more generalists; and how to support more resources for the National Health Service Corps to improve coverage in underserved areas. The author predicts the restructuring of acute care hospitals, with a marked reduction of in-patient beds, and that leading-edge research-oriented academic health centers should be able to remain out in front. There are also potential gains in health status from prevention and molecular medicine in a nation where chronic disease will dominate.

The shift to specialism in medicine: the U.S. Army in World War II.

While many are aware that a rapid advance in medical specialism occurred as a result of the introduction in 1965 of Medicare, with its liberal funding for graduate medical education, not many realize that a perhaps more significant rise in the number of specialists began right after World War II. Specialists were in great demand as the army planned for the treatment of several hundred thousand battle casualties who were returned to the United States at the end of the war, and many recently discharged medical officers took advantage of the G.I. Bill to train in specialty and subspecialty medicine. The author describes his experiences as director of the Resources Analysis Division, which was charged with developing and implementing a plan for treating the battle casualties of World War II. In his role, the author was to ensure a military hospital system was in place to provide high-quality specialty care to returning soldiers. He discusses how he and others accomplished this goal and what happened in this specialty hospital system after the wounded returned and peace was declared.

Future spending for medical care.

Why does the U.S. spend more for health care than other countries? What do we get for our additional money? Who pays the bills and bears the costs for health care? The article answers these questions and also provides observations about future trends in U.S. health care and challenges facing this country in the new century.

The future supply of physicians.

Many health services researchers point to a growing surplus of physicians by the end of the century. The author discusses in detail a variety of policy positions, from the Flexner Report onward, that have affected the present and projected supplies of U.S. physicians. These include the American Medical Association's decades of efforts to control the numbers and types of U.S. medical students; effects of Medicare and Medicaid; changes in immigration and naturalization laws that increased the number of international medical graduates (IMGs); the medical community's non-response to the 1981 GMENAC Report's forecasts on physician oversupply; growth in the numbers of specialists; the fall and subsequent rise in the numbers of applicants to medical schools; the changing composition of the physician workforce; the refusal of the medical profession to consider a shorter training period for physicians; and other events from the past that can inform today's policymakers. The author then evaluates four policy recommendations that have evolved to deal with the problem of physician oversupply, and concludes that (1) reliance on the market to contain physician supply is unwarranted; (2) there is little prospect that Congress will soon reduce the inflow of IMGs, and even if it did, such action would have a marginal effect; (3) there is no prospect that 20-25% of U.S. medical schools will be closed by 2005, since the forces militating against such action are overwhelming; and (4) it remains to be seen whether the new health care environment will have more than a marginal effect in altering the current ratio of primary care to specialist physicians in the years ahead. In fact, if future outlays for health care increase as predicted, there should be sufficient funds for physician supply to continue to grow and for specialists to continue to make good incomes.