The United States' health care system: problems and solutions.

The problems facing the U.S. health care system are not new; they have been discussed for the last 60 years. The problems have not been solved because, due to fears of government involvement, we have been reluctant to impose central planning and management on the system. Reliance on the free market and fee-for-service reimbursement to allocate health resources, to contain costs and to determine who has health insurance has failed. The result is that the U.S. spends more per capita on health services than any other country in the world, but lags behind many other countries on such health indicators as life expectancy and infant mortality. Several criteria for evaluating proposals for health reform are offered and ten such proposals are discussed. It is likely that, in the short run, the U.S. will adopt reforms that require the least change in the current system. However, these changes will not address adequately the fundamental problems with the system and, ultimately, major changes will have to be undertaken. [This article is followed by an editorial by Dr. Jonathan Trobe relating its concepts to the objectives set forth in the recently proposed Clinton Health Plan.]

Licensed physicians who work in prisons: a profile.

A profile of the personal and professional characteristics of the physicians who work in America's prisons was obtained by analyzing data from a larger study of all licensed physicians in the United States who worked in a prison at least 12 hours a month during the fall of 1979. Psychiatrists were not included, nor were physicians working in jails. The population of 382 prison physicians comprised two major groups--those who worked in prisons full time and those who worked in them part time. Part-time physicians, who represented the majority of physicians involved in prison work (58 percent), were found to resemble closely the typical physician in the United States; they were predominantly trained in America, specialized, and board certified. In contrast, full-time prison physicians, who accounted for 73 percent of the total hours physicians spent working in prisons, differed significantly from the typical U.S. physician. They were older, less specialized, less likely to be board certified, and more likely to be graduates of non-U.S. medical schools. The professional characteristics of the full-time prison physicians raise serious questions about the quality of medical care they are likely to provide. It would seem, based on their professional attributes, that the part-time physicians are able to provide better quality care than their full-time colleagues. Prison health system could thus assure higher quality care to inmates by relying primarily on part-time rather than full-time practitioners.

Disentangling measures of individual perceptions of community social dynamics: results of a community survey.

This study examined how different measures of individual perceptions of community social dynamics relate to each other and how these measures relate to self-reported general health and depressive symptoms. Results of a principal components analysis conducted to investigate the interrelationships between these individual measures suggest that these measures measure separate phenomena. In addition, in results of multiple-regression analyses conducted to examine associations between the various measures of individual perceptions of community social dynamics and the dependent variables of self-reported general health and depressive symptoms, sense of community, perceived neighborhood control, and neighborhood participation were all associated with the outcome variables in separate regression models. In a regression model with these three variables added to control variables, only sense of community was significantly, albeit modestly, associated with depressive symptoms and self-reported general health.

Black/white differences in attitudes toward physician-assisted suicide.

In 1994, as the Michigan legislature considered whether to continue a law banning physician-assisted suicide, we conducted a series of surveys on this topic. One of these surveys, conducted in Detroit, was designed to measure the attitudes of a largely black population toward physician-assisted suicide. Questionnaires were mailed to 500 residents of Detroit. The questionnaire described a plan for legalizing physician-assisted suicide, called Plan A, that incorporated eligibility standards and safeguards to minimize abuse. Attitudes on three issues were investigated: 1) Should physician-assisted suicide be banned or legalized? 2) Should voluntary euthanasia also be permitted? 3) Might respondents request legalized physician-assisted suicide for themselves? Majorities of both whites and blacks supported Plan A; however, support was much lower among blacks than whites. Blacks were also less likely to support voluntary euthanasia or to envision asking for physician-assisted suicide themselves. Our analysis indicates that when age and sex are held constant, strength of religious commitment may account for much of the black-white difference in attitudes. We also consider alternative explanations based on cultural attitudes and degree of trust in the medical system.

Supporting assisted suicide. How do the public and physicians feel about aiding in death?

In January 1997, the Michigan State Medical Society began a series of interdisciplinary forums to discuss guidelines and safeguards for physician-assisted suicide as part of its ongoing analysis of that vexing issue. The forums derive from the minority statement in the MSMS official position, from physicians who would approve of assisting suicide in a limited number of cases, but only upon the patient's voluntary request and as a last resort. Is it possible to develop guidelines which would succeed in limiting the practice of physician-assisted suicide to that small group of patients? Or, as opponents charge, would guidelines predictably fail to contain the practice and lead to the feared slippery slope?

A comparison of self-reported measures of perceived health and functional health in an elderly population.

In studies of large elderly populations, two types of measures of physical health status, perceived health and functional health, are commonly used. Although they represent very different conceptions of health, these two types of measures appear often to be used interchangeably. In this paper, we examine changes over time in self-reported measures of perceived health and functional health for a sample of Medicare beneficiaries. By investigating the patterns of change in the two measures for different subgroups of the population, we are able to draw inferences about the appropriateness of each type of measure for specific administrative and/or research situations. The perceived health status measure appears suitable for descriptive studies of the health of elderly populations, while the greater stability of functional health makes this type of measure generally more appropriate in studies investigating relationships between an individual's physical health status and subsequent behavior.

Attitudes of Michigan physicians and the public toward legalizing physician-assisted suicide and voluntary euthanasia.

BACKGROUND: There has been a continuing public debate about assisted suicide and the proper role, if any, of physicians in this practice. Legislative bans and various forms of legalization have been proposed. METHODS: We mailed questionnaires to three stratified random samples of Michigan physicians in specialties likely to involve the care of terminally ill patients: 500 in the spring of 1994, 500 in the summer of 1994, and 600 in the spring of 1995. Similar questionnaires were mailed to stratified random samples of Michigan adults: 449 in the spring of 1994 and 899 in the summer of 1994. Several different questionnaire forms were used, all of which included questions about whether physician-assisted suicide should be banned in Michigan or legalized under certain conditions. RESULTS: Usable questionnaires were returned by 1119 of 1518 physicians eligible for the study (74 percent), and 998 of 1307 eligible adults in the sample of the general public (76 percent). Asked to choose between legalization of physician-assisted suicide and an explicit ban, 56 percent of physicians and 66 percent of the public support legalization, 37 percent of physicians and 26 percent of the public preferred a ban, and 8 percent of each group were uncertain. When the physicians were given a wider range of choices, 40 percent preferred legalization, 37 percent preferred "no law" (i.e., no government regulation), 17 percent favored prohibition, and 5 percent were uncertain. If physician-assisted suicide were legal, 35 percent of physicians said they might participate if requested--22 percent would participate in either assisted suicide or voluntary euthanasia, and 13 percent would participate only in assisted suicide. Support for physician-assisted suicide was lowest among the strongly religious. CONCLUSIONS: Most Michigan physicians prefer either the legalization of physician-assisted suicide or no law at all; fewer than one fifth prefer a complete ban on the practice. Given a choice between legalization and a ban, two thirds of the Michigan public prefer legalization and one quarter prefer a ban.