Looking Into Health

To be healthy, wealthy, and wise, as the old saying puts it, is the goal of nearly everyone. Perhaps it's no accident that health comes first, for getting and staying well is the basis for enjoying everything else life has to offer. Health care workers in the United States have the privilege of providing Americans with the most valued kind of care, that which preserves and prolongs their very lives. Because people will continue to be born, get sick or injured, and die, health care workers will always be in great demand and held in high esteem.

Every day millions of Americans turn to trained care providers for their medical needs. In private medical offices around the nation, physicians—assisted by nurses and aides—treat minor injuries such as sprained ankles and illnesses such as strep throat and childhood mumps, test patients to diagnose their ailments, and screen people for potential problems. They examine pregnant women and provide prenatal care. They also perform checkups for children and adults. For children and individuals at high risk for certain diseases, they administer immunizations.

In hospitals, a greater variety of health care professionals perform a wider variety of tasks. Medical professionals help individuals who have immediate, severe, or longer-term needs. Emergency room physicians examine and treat people with immediate life-threatening illnesses or those who suffer from severe bleeding or injuries. Internists diagnose and treat medical problems and prescribe medications that pharmacists prepare. Surgeons, with the help of anesthesiologists, nurses, and others, perform surgical operations.

As the demand for health care services rises, some of the fastest-growing occupations will be in allied health. (©StevePrezant/Corbis.)

Every day, technicians in hospitals take X-rays and perform lab analyses and other diagnostic tests. Hospital nurses check the vital signs of patients, administer medications, and maintain charts on patient progress. Orderlies, nursing aides, and others tend to the physical needs of patients, bathe them, and deliver their meals. Dietitians, social workers, and physical, occupational, and other therapists help patients prepare for release from the hospital. Behind the scenes, supervisors, managers, accountants, maintenance workers, admitting interviewers, medical records and health information technicians, and other staff members keep the hospital running smoothly.

On the road, ambulance drivers rush paramedics and emergency medical technicians to people injured in car accidents, caught in fires, and endangered by other emergencies. These medical workers provide immediate first aid, set fractures, and keep injured or ill people safe until they get to the hospital. In private homes, outpatient treatment centers, and residential health care facilities, nurses, aides, and doctors tend to elderly people and people with chronic medical problems, providing more of the services traditionally delivered in hospitals.

Keeping Americans healthy requires millions of workers and billions of dollars—and the numbers keep growing. In 2004 the health care industry in the United States employed about 13.5 million trained workers. By 2014 health care and social assistance—including private hospitals, nursing homes and residential care facilities, and family services—is expected to add 3.6 million jobs over the 2004 level. Registered nurses (RNs) make up the largest health care occupation, numbering well over two million. Yet these numbers will need to grow if Americans are to keep enjoying some of the world's best health care. It is expected that nursing will see a 30.5 percent growth in the number of RNs between 2004 and 2014. Other jobs in the health care field that will grow at an even higher percentage rate than RNs between 2004 and 2014 include chiropractors, physician's assistants, dental hygienists, home health aides, physical therapist assistants and aides, dental assistants, and medical assistants. A current shortage of health care workers means faster-than-average job growth for workers who like helping people to get and stay well.

FROM MAGIC TO
MODERN MEDICINE

In ancient times, people knew little about what caused disease or how the human body worked. They concluded that evil spirits or angry gods caused illness. Some of their cures—boring holes in the skull to let out evil spirits, for example—did more harm than good. Nevertheless, ancient people made some important medical discoveries. More than four thousand years ago, people in ancient Egypt were already using castor oil to purge the digestive system and tannic acid to treat burns. An Egyptian text written around 2500 B.C. describes how to use compression to stop bleeding.

The man considered to be the founder of modern medicine was a Greek physician named Hippocrates, who lived in the 5th century B.C. Hippocrates and his followers wrote about seventy books describing a new philosophy of medicine, based not on folklore or magic but on careful observation of patients and detailed records of their symptoms. With this information, physicians could draw accurate conclusions about what caused disease and how it could be treated. This procedure—collecting data and using the data to draw conclusions—is the basis of what we call the "scientific method."

Hippocrates made two other lasting contributions to medical science. His observations led him to conclude that disease is often the result of diet, climate, occupation, or other environmental factors. Hippocrates also established a standard of conduct for physicians, which still guides the medical profession today. These standards are summarized in the Hippocratic Oath, which most new physicians take in one form or another. Depending on where they earn their medical degrees, some physicians take another oath or pledge instead of one of the forms of the Hippocratic Oath. One of those oaths is the World Medical Association Declaration of Geneva Physician's Oath, which was adopted in 1948. It includes this vow: "I will practice my profession with conscience and dignity; the health of my patient will be my first consideration."

The Search for Causes

Ideas like those of Hippocrates did not have a widespread effect on medicine until the Renaissance in the sixteenth century. The Renaissance was a period of intense intellectual awakening and scientific inquiry in all fields, including medicine. The first accurate anatomy text was published in 1543, about the same time that serious research began into the cause of infectious diseases. A century later, the first precise description of blood circulation appeared, along with an explanation of how the lungs work.

Until then, no one had developed compelling evidence to show how disease spread. In the mid-nineteenth century, a series of experiments by Louis Pasteur showed that microorganisms called bacteria can invade the body and cause infection and disease. More important, Pasteur discovered how to prevent this bacterial invasion through immunization. Robert Koch, considered a cofounder with Pasteur of the science of bacteriology, identified the specific bacteria that cause tuberculosis and cholera.

The pace of medical progress quickened in the nineteenth and twentieth centuries. In the 1840s, the use of ether as an anesthetic made possible many surgical operations that were previously too painful for patients to bear. Wilhelm Roentgen's discovery of X-rays in 1895, and Marie Curie's pioneering research, revolutionized the diagnostic process. Alexander Fleming's 1928 discovery of penicillin, the first antibiotic, was also a landmark achievement. For the first time a drug could kill disease-causing organisms inside the body of a person who was already ill.

Medical Science and Public Health

By the beginning of the twentieth century, medical science provided convincing evidence for what Hippocrates had suspected: Disease is often caused by an unsafe environment. This knowledge led officials to begin massive programs to improve public health. They drained swamps to eliminate disease-carrying insects, sanitized drinking water supplies, and quarantined people with infectious diseases. They also began programs of education and vaccination, which led to the virtual eradication of diseases such as cholera, typhus, typhoid fever, and yellow fever in the United States.

Today public health agencies continue their work to keep the public safe and well informed. The United States Center for Disease Control and Prevention (CDC), the World Health Organization (WHO), and other agencies continue to research new ways to prevent the spread of infectious diseases, promote health, and prolong life.

The CDC's mission is to track diseases in the United States and help control them. Statisticians and lab workers at the agency pay close attention to epidemics, their spread, and their prevention. The role of the WHO is to oversee the public health of all member nations of the United Nations. The WHO helps governments to promote family planning and provide their citizens with access to primary health care. It also watches population patterns and funds public health research and development. The WHO employs researchers, primary health care providers, and others who focus on education, food and water supply, sanitation, immunization, and the prevention and control of disease.

Public health agencies also serve as educators, warning people of health hazards such as those posed by smoking, alcohol and drug abuse, occupational hazards, and environmental pollution. Outbreaks of the E. coli bacterium, found in tainted food, are often reported on the national news. The fight against the deadly AIDS epidemic continues to be a key focus of public health agencies around the world. One of 2005's major health stories was the threat of the spread of bird flu. Epidemiologists worried that this bird virus, which can be spread from birds to humans, could be spread from human to human. If that were possible, a highly deadly worldwide pandemic could result.

THE TECHNOLOGY REVOLUTION

Technology has revolutionized the practice of medicine throughout the 20th century and into the twenty-first century. The first three high-tech diagnostic tools—X-ray machines, electroencephalographs (EEGs), and electrocardiographs (EKGs or ECGs)—were all developed early in the twentieth century. X-ray machines aim X-ray beams at patients' bodies. Since X-rays are better absorbed by bone and other dense structures than by soft tissue such as the lungs, their beams cast shadows of varying intensity. These shadows can be captured on X-ray film. Trained physicians and X-ray technicians can read this film to detect bone fractures and locate unexplained shadows that may be cast by tumors, infections, or foreign objects. EEGs and EKGs use electrical impulses to diagnose physical problems. By placing electrodes on a patient's scalp or chest, medical personnel can study the patterns generated by electrical impulses within the body. Certain distinct, abnormal patterns of electrical activity are signs of epilepsy, stroke, or brain tumors. These patterns may also indicate disorders in the heart muscle. Advanced EKG technology, in conjunction with imaging technology such as ultrasound and nuclear-imaging equipment, works with imaging computer software to construct a three-dimensional model of the heart, showing problem areas.

Computers and
the Medical Profession

In recent decades computer technology has continued to have a tremendous effect on medicine. Computerized axial tomography (CAT) scanners, first used in the 1970s, process X-rays into computerized three-dimensional images of slices of the body, giving physicians even greater detailed information about tumors, cysts, and other tissue abnormalities within the body. Magnetic resonance imaging (MRI) scanners use a powerful magnet and radio waves to make computerized two- or three-dimensional images of the inside of the body, which helps physicians diagnose disorders as well.

Positron-emission tomography (PET) scanners are a more recent visualizing technology. PET scanners can show the level of cell activity in certain parts of the body. These diagnostic tools are used primarily to detect cancer cells, which generally grow more quickly than normal cells. PET scans are also used to gather information about patients' heart disease, dementia, or seizures.

Another new technology—magnetoencephalography (MEG)—permits physicians to characterize electrical activity within the brain by mapping associated magnetic fields, providing even greater detail on brain activity than EEGs can provide. With these high-tech computer-aided tools, and others, physicians are learning more about the body—both its functions and its malfunctions.

Computer technology also helps physicians, technicians, and nurses manage the vast amount of medical information and patient data they need to make diagnoses and decide on treatment plans. Some computer programs permit physicians to input the medical history of a patient along with information on the patient's current symptoms. The program then compares this information to databases of general medical and pharmaceutical information. After analyzing the symptoms, the program suggests several possible diagnoses, ranks their probability, and lists the tests, treatments, and drug therapies appropriate for each one. Of course, computer technology cannot replace the role of the physician, but it can save physicians and patients time and money.

Computers can also aid in patient therapy. Besides helping medical personnel design artificial bones and limbs, prosthesis software gives orthopedic surgeons the ability to customize artificial limbs to match patients' individual needs. In the future, prostheses will likely be available that contain computers embedded in them. Nerve signals from the patient's brain will "tell" the prosthesis how to move. Prototypes of this technology were being studied in 2005.

Computer-assisted training also is a major part of medical school education. Research developed from detailed CAT scans of cadavers, for example, has resulted in detailed computer-based anatomy texts, which give medical students the ability to use computers to study their subjects in color, from any angle, and with enhanced detail. Interactive diagnostic programs provide students with experience that cannot be found in ordinary textbooks. The programs allow students to practice observing and diagnosing medical problems. Computers are also playing a growing role in patient care, with some physicians using personal digital assistants to prescribe medication and check for drug interactions and others using portable computers to review and enter information into computerized patient records. Computers also help nursing staff and records technicians keep patient records up to date and accessible at a keystroke.

THE PEOPLE DOING THE WORK

All the technology available today is useless without trained, educated health care workers. Inside the hospitals, in doctors' offices, and elsewhere, experts with a wide variety of skills provide medical care. Within the broad categories of doctors, nurses, and technicians are scores of specialized occupations.

Physicians

Physicians today make up slightly over three percent of the health care workforce. Until World War I, almost all doctors were general practitioners who treated anyone who came to them, young and old alike. These professionals delivered babies, set broken bones, prescribed medicines and other treatments for disease, and comforted the dying.

As medicine became more complex, medical doctors became more specialized. In 2003 roughly 60 percent of all physicians and surgeons in the United States were specialists. The majority practice near major medical centers in and around large cities. Cardiologists treat heart patients; nephrologists treat individuals with kidney problems; geriatricians work with the elderly; hematologists deal with diseases of the blood; and dermatologists treat skin diseases and skin problems. Occupational medicine physicians study problems caused by the workplace, such as noise-induced hearing loss, multiple chemical sensitivity, and repetitive stress injury. Today there are specialists in every field, including gynecology, ophthalmology, urology, neurology, otolaryngology, psychiatry, and dozens of others.

Although the long-standing trend has been toward specialization, an increasing portion of medical students are preparing for a career in general practice (often called family practice). Family physicians often run private practices. They treat minor and chronic ailments; teach disease prevention, nutrition, and good health care; and screen for potential problems. This trend toward family practice has been spurred in part by federal student loan programs designed to help students who agree to work Although the long-standing trend has been toward specialization in medicine, increasing numbers of medical students are preparing for careers in general practice. (© Terry Wild Studio. Reproduced by permission.) in urban and rural areas facing a shortage of primary caregivers. Although family practice has traditionally been a lower-paying field than most specialties, the current trend is toward equalization of salaries among family practitioners and specialists.

Not all doctors are M.D.s (doctors of medicine). D.O.s (doctors of osteopathy), for example, receive much the same education and training as M.D.s and employ many standard medical techniques. However, osteopaths approach medicine with a different philosophy. They take a holistic approach to medicine, looking for a connection between diet, lifestyle, and environmental factors in diagnosis and treatment. Osteopaths generally focus on the effect of the musculoskeletal system on illness and disorders and often use physical manipulation, rather than medicine or surgery, to diagnose and treat problems.

Some health care practitioners have advanced degrees and licenses but are neither M.D.s nor D.O.s. These include chiropractors, who concentrate on skeletal and muscular wellness and treat pain and problems of alignment by manipulating the bones and muscles; optometrists, who prescribe corrective lenses for sight or eye muscle problems and, in most states, perform other tasks connected with eye health; and psychologists, who treat mental problems such as bipolar disorder and depression.

Nurses and Nurse Practitioners

According to some estimates, the current supply of physicians and surgeons (about 567,000 in 2004) exceeds the demand throughout much of the country, although many urban and rural areas still suffer a shortage. In stark contrast, nurses, pharmacists, and technicians have been in short supply for the past several decades, and the demand will continue to grow in the next few decades. On top of this is an increased demand for nurses in home and outpatient services.

One reason for the increased demand is that as people live longer, they need more nursing care. Also, the level of training required to operate high-tech monitoring and treatment equipment has led many hospitals and other health care facilities to require that nurses have advanced training. Like people in other medical professions, many nurses now specialize, getting additional training beyond a four-year degree or diploma. In hospitals and clinics, some nurses work in a particular area of care, such as cardiology, pediatrics, or psychiatry. Others become nurse anesthetists, nurse clinicians, or nurse educators. Nurse-midwives, who are qualified to provide gynecological care and obstetric care, are able to deliver babies when no medical complications exist.

Nurse practitioners are registered nurses with advanced training. Some practice alongside physicians; others work independently. Nurse practitioners perform many of the same tasks as physicians. Frequently they examine and treat patients in settings where physicians are not available.

Allied Health Professionals

Changes in technology and escalating health care costs combined with an increased demand for health care have all led to an increased need for workers who can provide medical services. Virtually every health care occupation, including physicians, can expect above-average growth between 2004 and 2014. This includes home care aides, medical assistants, audiologists, dental assistants, and pharmacy technicians.

Medical assistants work in hospitals and doctors' offices, performing both clinical and administrative work. Physical therapists, occupational therapists, respiratory therapists, recreational therapists, speech pathologists, and other therapists help patients regain or improve their physical skills. Therapy assistants and aides work with therapists and prepare patients for therapy. Medical social workers help patients and health care providers to navigate the complex health care system to find necessary services and the means to pay for them.

Athletic trainers and sports therapists work with athletes and others to keep them physically fit and less prone to injury. Dietitians and nutritionists, working both inside and outside hospitals, help individuals learn how what they eat can affect their health. Physician assistants, like nurse practitioners, have some of the training of medical doctors and may examine patients alongside doctors. Physician assistants and nurse practitioners may perform laboratory tests, make preliminary diagnoses, and work without physician supervision depending on state regulations.

As health care becomes even more dependent on technology, the demand for medical technicians continues to rise. Three of the fastest-growing occupations are physician assistants, medical assistants, dental hygienists, and home care aides.

Alternative Medicine Professionals

Although many alternative medicine treatments are considered unorthodox, or even worthless, by the medical establishment, an increasing number of people are turning to these methods. In addition, more and more doctors trained in conventional medicine are incorporating these alternatives into their practices to treat certain disorders, such as chronic pain. Some health insurers, in exchange for slightly higher monthly payments, cover the costs of certain alternative treatments, such as visits to a chiropractor or acupuncturist. Sometimes unconventional treatments test the limits of legality. By January 2006 over a dozen states allowed some provision for the medical use of marijuana.

Some health care practitioners specialize in one area of alternative medicine. For example, herbologists use herbs and other plants to heal and prevent disease. Homeopaths work under the theory that giving an individual a minute amount of a substance that causes a disease can cure or prevent that disease. Acupuncturists insert thin needles into certain parts of the body to ease pain and cure problems. Acupressurists use pressure and touch to help relieve patients' physical problems. These and other alternative healing methods date back centuries.

The art of healing is as old as humankind, and while the marvels of modern medicine have transformed the world, some people consider medicinal drugs, invasive tests, and surgery unnatural. They might begin their search for treatment with a holistic health practitioner, who emphasizes "natural" remedies and lifestyle changes. Chinese medicine, dating back five thousand years, is also gaining new adherents. But responsible alternative health providers usually recommend modern medical attention when an injury or illness warrants it.

BEYOND THE MEDICAL OFFICE AND HOSPITAL

Not all health care is delivered in medical offices or hospitals. Hospitals today have diversified their services to include hospital-run convalescent units, outpatient clinics, rehabilitation centers, and treatment centers for patients suffering from substance abuse.

Ambulatory surgical centers, also known as "surgicenters," and free-standing emergency centers, or "urgicenters," play an important role in giving individuals greater access to medical care. Low-risk minor surgical procedures such as hernia repairs, tissue biopsies, and some forms of cosmetic surgery are performed in surgicenters. These centers can keep their costs low because they do not need sophisticated backup equipment or provisions for long hospital stays.

Urgicenters (called urgent care centers in many areas) operate much like hospital emergency rooms. They are often open seven days a week, twelve to twenty-four hours a day. Doctors, physician assistants, and nurse practitioners at urgicenters treat minor problems such as broken bones, sprained ankles, sore throats, stomachaches, and cuts that require stitches. A visit to an urgicenter is usually more expensive The demand for home-based health care, especially for the elderly, is increasing rapidly. One of the reasons for that is that patients are being released from hospitals more quickly than they used to be in order to reduce costs. (© LWA-Dann Tardif/Corbis.) than a visit to a doctor's office but less costly than a visit to a hospital emergency room.

While these centers often prevent the need to enter a hospital, home-based health care is becoming an alternative to staying in the hospital longer than necessary. Home-based care helps hospitals work to keep costs down by shortening patients' hospital stays. More patients are now sent home while still requiring full-time or frequent medical care. Thousands of agencies in this country offer home health care services for the elderly, people who are recovering after surgery, and people who are chronically ill. Some of these agencies are hospital-based, whereas others are affiliated with community health centers or religious groups. Skilled home health service agencies provide nursing, physical and occupational therapy, and speech therapy. Some agencies also provide support services such as personal care, light housekeeping, meal preparation, and transportation, which enable people to continue living independently despite their health limitations. A great number of elderly people now live on their own, with only occasional care from home health care aides who can help with chores or physical care.

Individuals who cannot live on their own without frequent medical or nursing care often move into nursing homes, rehabilitation centers, assisted-living centers or other long-term care facilities. Here they have twenty-four-hour access to nurses and aides and ready access to physicians.

Hospices, which can be either part of residential health care facilities or home-based, are for terminal patients who need palliative care—treatment for pain or other symptoms that makes them as comfortable as possible during the last months or weeks of their lives.

The range of health care delivery options will grow even more diverse in the future, as health care delivery becomes more complex and providers look for new ways to hold down costs. The good news for health care workers is that the development of new health care delivery systems will mean more jobs. From an employment perspective, the health care industry will likely be a center of growth throughout the twenty-first century.

HEALTH CARE RESEARCH AND EDUCATION

A major area of health care is research and education. The current trends in federal funding are to increase spending on research in health services and health care policy issues (such as cost effectiveness studies) while maintaining or decreasing funding for scientific and medical research.

Health care researchers are constantly working to invent new technologies and improve existing technologies. Researchers and inventors continue to look for technology that will help individuals overcome or compensate for disabilities. Medical researchers, epidemiologists, and pathologists study diseases and seek cures and preventive measures. Geneticists study genes to determine how they may be used to predict or even prevent problems in patients. The Human Genome Project, launched in 1990 by the U.S. Department of Energy and the National Institutes of Health, finished mapping the approximately twenty-five thousand genes in human DNA in 2003. The hope is that this breakthrough will lead to new treatments of disease based on the identification and replacement of a patient's defective genes.

Biotechnology is one of the most exciting and promising new fields in health care research. The biotechnology revolution began in the late 1970s when small start-up companies, mainly in the San Francisco Bay area, developed a new generation of drugs made from genetically engineered copies of human molecules. By using living systems, such as those of bacteria, to produce human proteins, these companies created medicines that were more precise and predictable—with fewer side effects—than animal-derived versions.

The technologies currently used to diagnose illness are also being used to discover more about the human body and mind. PET scanners, for example, are used to discover how we learn and retain language. They are also an integral part of the study of the causes of hyperactivity disorders. EEG brain wave studies are used to learn more about depression and other mental problems. Other technologies are being developed that promise to diagnose heart and brain problems before they become acute.

Research into health care policy also is extremely active today. Health economists, for example, advise hospital administrators and public health officials on the financing of health services. Health economists are playing a role in developing reform measures for health care funding.

Health educators go to schools, public health clinics, and workplaces to teach people how to care for their own health. They teach about nutrition, exercise, alcoholism, smoking cessation, stress reduction, and ways to avoid sexually transmitted diseases. They also maintain libraries, serve as information resources for the public, and write articles for popular journals about health care.

PAYING FOR HEALTH CARE

While health care technologies and techniques continue to develop, the provision of health care has become increasingly expensive. From the point of view of many Americans, the cost of health care has reached a crisis level. Yet the nation is at odds about how to solve this problem and how health care should be paid for. Some are calling for major reform of the American health care system, but change in this area has traditionally been very slow to come. One of the major issues in the 2004 U.S. presidential election was a prescription drug benefit for the elderly on Medicare and the poor on Medicaid. Such a plan went into effect in January 2006, but not everyone agreed that it was beneficial. Many argued that the plan was complicated and difficult to understand, and that in some cases, benefits were worse than under the former plan. The benefit helped seniors with only part of the cost of prescription drugs.

The Increasing Cost of Health Care

Today the nation's skilled corps of health care professionals, supported by an army of scientists and a sophisticated array of diagnostic and treatment tools, provide an unprecedented level of health care. However, the cost of this care is unprecedented as well. In January 2006 the Centers for Medicare and Medicaid Services released a report stating that the United States spent $1.87 trillion in health care in 2004. Consumers paid an average of $6,280 for health care in 2004. Although health care spending rose 7.9 percent from 2003 to 2004, this increase is less than the increase of 8.2 percent from 2002 to 2003. Nonetheless, health care spending doubled from 1994 to 2004. Although the rate of increase is slowing somewhat, it continues to outpace inflation, and by 2014 total health spending is projected to constitute an 18.7 percent share of the national economy.

Several factors account for the rapid growth of health care costs over the past several decades. First and foremost, Americans are now living longer. Over the years, medical advances have reduced the number of people who die young from diseases such as polio and tuberculosis. Americans take better care of themselves through increased workplace safety and better preventive care, although the obesity epidemic is putting more people at risk for diabetes, heart disease, and other obesity-related ailments. Nonetheless, medical science has developed drugs and other therapies to help people lower their cholesterol and live healthier lives in spite of health-compromising lifestyle factors such as obesity. Longer life expectancy, combined with a lowered birth rate, has driven the median age of the population upward.

The number of expensive treatment and diagnostic options has also increased. Major organ transplants, coronary bypass surgery, and long-term kidney dialysis—all extremely costly procedures—have become commonplace. Technological innovations permit low-birthweight babies and individuals with serious physical impairments (such as accident victims) to survive, although at significant expense. Equipment costs, development costs, and usage costs can be extremely high. Some technologies, such as PET scanners, can cost millions of dollars and are expensive to maintain. Developing, testing, and receiving approval for new drugs can also prove very costly.

Another factor driving up the cost of health care is malpractice suits against doctors and other medical professionals. Physicians today pay tens of thousands of dollars each year in malpractice insurance premiums.

Insurance: The Traditional Payment Method

Americans' health care is typically paid for by medical insurance, which is supplied wholly or in part by their employers. Under traditional indemnity insurance, patients receive medical treatment from the providers of their choice and send the bills to the insurance companies for payment. Under this system, individuals have no incentive to shop around for bargains, and providers have no incentive to limit costs.

This situation has changed in recent years. As the cost of health care increases, the cost of health care insurance also rises, causing employers to cut back on insurance coverage or to limit the options available to employees. Data released by the U.S. Census Bureau in August 2005 showed that 16.7 percent of the American population—45.8 million people—had no health care coverage. The number has been rising each year in recent years. The uninsured face staggering medical bills when they become sick or injured.

Since the mid-1960s, the federal government has been paying medical costs for two groups that do not generally have employers—the elderly and the poor—through its Medicare and Medicaid plans. These plans help to make sure that everyone has access to health care. Nevertheless, increasing numbers of people have little or no health insurance and are at risk of not getting the care they need in a timely and comprehensive way.

Cost-Saving Initiatives

In recent years the nation's health care providers have been under increasing pressure to curb spiraling costs. Hospitals that are part of chains owned by for-profit corporations have also been under pressure to increase profits.

As a result, health care providers, economists, and regulators continue to look for more cost-effective ways to deliver and pay for health care. Political leaders, insurance companies, and providers are working together to find a solution to the dilemma of rising costs. One approach is to reduce costs through new delivery systems, such as outpatient (or ambulatory) surgery centers. In these facilities, patients have surgery performed but go home that same day. In October 2004 the American Society of Anesthesiologists reported that ambulatory surgery currently accounts for almost 80 percent of all surgical procedures performed in the United States (ASA Newsletter, vol. 68, no. 10). Another approach is to use less expensive providers, such as nurse practitioners, instead of doctors, whenever feasible.

Other innovations are directed at how health care is paid for. One innovation was the development of diagnostic related groups (DRGs). DRGs were first implemented by the U.S. government in its Medicare system. Under the older system, hospitals had treated Medicare patients and then billed the government. The longer patients stayed in the hospital and the more procedures they underwent, the more the hospital could charge. Under this system, the hospital had no incentive to minimize costs.

The DRG plan, initiated by Congress in 1983, put health economists to work to predetermine how much a hospital should expect to spend for each of nearly five hundred categories of illnesses. The government established fees for each illness, based on the average cost of treating it, taking into account the length of a typical hospital stay, the number of diagnostic tests, and the cost of surgery and other procedures. Under this system, hospitals may charge the government only the DRG rate and no more. If the hospital's actual cost of treating a Medicare patient exceeds the set DRG rate, then the hospital loses money. On the other hand, hospitals that find ways to cut the cost of treatment are allowed to keep the overpayment amount. Unfortunately, this system sometimes results in abuses such as a patient not being kept in the hospital long enough to get well, or receiving a diagnosis more serious than is actually warranted.

Many private insurers have adopted a similar payment system. Because nearly all medical care in this country is paid for by private insurance or the government, this trend has significant implications. Specifically, it means that the control of health care is shifting from health care providers to insurance companies and others who pay for the health care. In fact, many health care providers must first obtain approval from an insurer before proceeding with a medical treatment.

More Innovations

Whereas the government took the lead in establishing the DRG system, private insurers and providers organized two managed health care plans in their effort to help curtail rising costs. Health maintenance organizations (HMOs) offer medical coverage in a way that is fundamentally different from standard private medical insurance. An HMO is a group of health care providers—including doctors, nurses, and other health care specialists—located at one or more of the facilities affiliated with an HMO. People join an HMO by paying a fixed monthly fee. When members become ill or need checkups, they visit physicians associated with the HMO, usually at little or no cost to the member. When necessary, HMO physicians refer patients to outside specialists and hospitals. However, some people feel that this requirement for a referral is too restrictive, and there has been legal and political controversy over the question of whether patients should have the right to sue their HMO if they are denied adequate care. Many employers will pay some or all of the costs for employees who join an HMO because the monthly fees are usually lower than comparable coverage under conventional medical insurance. Under an HMO system, the emphasis is on preventive care. Individuals are encouraged to visit doctors and other providers before their problems become severe.

A variation of the health maintenance organization is the preferred provider organization (PPO). A PPO is a network of physicians designated by a particular insurance company to provide medical service. The insurance company offers incentives to its subscribers for choosing a preferred provider. For example, if a patient visits a preferred provider, the insurance company may pay 80 percent of the charges, whereas it may pay only 50 percent of the bill if the patient visits a doctor who is not a member of its designated PPO network.

National Health Care Coverage Debate

Even with these new developments, the cost of health care continues to rise and access remains limited. Many political and business leaders believe that the time is ripe for a comprehensive reform of the health care system. Proposals vary, but one of the most frequently suggested alternatives to the current system is an organized delivery system based on managed competition. The idea originated with the Department of Defense in the 1960s and became dominant in discussions of health care reform in the 1980s and 1990s. By 2005, small companies were able to access managed competition through two companies: CaliforniaChoice (only in California) and BENU (in Oregon, Washington State, and the Washington, D.C., area). The way these plans work is that employers get one monthly bill no matter what plans their employees choose. This arrangement allows employers to contribute a specified amount. The result is that their health care costs stay fixed from year to year.

HEALTH CARE AND
YOUR FUTURE

This volume describes occupations in a career field that is exciting, stimulating, and rewarding. By carefully examining each occupation and honestly evaluating your talents and interests, you can decide if one is right for you. As you look into the health field, remember two key trends.

First, the health care industry as a whole will continue to grow rapidly in the twenty-first century, creating a wealth of new and diverse opportunities and jobs. For example, as new technologies develop, opportunities for medical technicians will continue to increase. As new treatment techniques are developed, the need for physical therapists, medical assistants, and other aides and assistants will also increase. Few other industries will offer as many opportunities for employment and advancement.

Second, health care providers will find themselves in an increasingly competitive environment in the future. The pressure to keep costs under control may force unprofitable hospitals to close down. Those in overstaffed professions will face stiff competition for jobs and slower salary growth. Nurses will see their roles change as they take over more responsibilities from doctors and relinquish some of their traditional duties to aides and other patient care workers. Wise job seekers will monitor these changes and evaluate their impact on employment.