the social waste of denying children the chance to mature as healthy competent members of society; and the cost of institutional care for elderly people who, with proper treatment, can remain independent for many more years. Other reasons include preventing as much pain and suffering as possible, and giving the poor as well as the rich a chance to survive medical crises.

Many countries, including En^and, Sweden, Denmark, and West Germany, have national health plans that take care of the medical needs of all the people. Althou^i not above criticism, these plans are now looked upon as ri^hits of the people and arc changed very little if at all when political leadership changes. In the United States, until passage of legislation for medicare in the 1960s，medical care remained largely a private and family concern, except for the very poor, who could go to county hospitals in most (but not all)coundesy if needed. Medical care was, and still is，particularly difficult for people who may not get treatment at public expense in county hospitals because they earn amounts above a certain level but arc often unable to pay high cost medical bills, especially in cases of mcdical disaster. Although medical insurance has become much more common than，in the past, ^proximately 40 million Americans are not covered, and even when there is insurance, the amounts are often inadequate for catastrophic illness.

The costs of health care, both public and private, are mounting more and more rapidly. A study shows that the total cost of health care in 1962 amounted to 4.5 percent of Gross National Product, but by 1976 it had risen to 8 percent Joseph Galifano, former Secretary of Health, Education, and Welfare, states that by 1980 the cost had risen to 9 percent of GNP. These figures indicate that health care is the single largest item of expense in America, a total of $ 287 billion as of 1982. Medical costs arc the leading cause of fsunily bankruptcy. Americans spend 2 dollars on health care for every dollar they spend on oil.

Reasons for Medical Costs

The reasons for extremely hi medical costs are many and can by no means be attributed solely to inflation. During the period 1962 to 1976，while the price index rose 75 percent, the cost of medical carc rose 330 percent. At the present rate of increase, Americans will be spending 12 percent of GNP on health carc by the year 2000. In other words, health care is expected to continue to rise more rapidly than inflation, takii^ a rising percentage of total national income.

1. Demographic Problems and Medical Care

One of the reasons that medical costs rise more rapidly than other expenses is because of the age distribution of the population. Older people require more medical care than people in the prime of life. Such carc, of course, should not be denied them, especially if medical care will give them prolonged years of a reasonably happy life, and possibly even prolonged years of independence. However, by 1980，25 percent of all medicare costs were spent on patients in their last year of life, often prolonging life at the cost of prolonged pain and misery. Medicare has guaranteed income to hospitals for high - technology equipment that can extend life under extraordinary conditions. The obligation of social securicy and/or insurance companies to pay the costs has motivated hospitals to do things expensively. Doctors prescribe more and more tests, since the costs arc paid for by insurance, and since malpractice suits are always a possibility if any aid Co diagnosis is not utilized.

What applies to the problems of the aged is true to some extent across the range of medical carc. The simpler problems of medicine have been solved to a great degree. In 1900, the three major causes of death were infectious or parasitic diseases such as influenza and pneumonia, tuberculosis, and gastritis, accounting for 31 percent of deaths. By 1960, they accounted for only 5 percent of deaths. At present, the leading causes of death are heart disease, cancer, and stroke, which are much more difficult to conquer， and more expensive to treat chan diseases that yield to inoculations, antibiotics，and improved sanitation. These three conditions now account for two-thirds of all deaths, often late in life. In many cases, treatment brings only a brief, and very expensive, extension of life.

2. Hospital Costs

Between 1965 and 1978, the cost of the average stay in a hospital increased fourfold, far more than the general rate of inflation. Secretary Califano, alarmed over rising costs, approached the President and Congress with a plan to try to limit increases in hospital charges to onc-arid-one-half times the consumer-price-index increase. At that time, charges were actually rising two-and^onc-half times as fast as the consumer price index. Other savings, Califano hoped, would be made by slowing the cost of hospital construction; by that dme wc had an excess of 130,000 hospital beds, which had cost taxpayers $4 billion.

Some of the hospital costs result from a high staff-to-patient ratio, much higher than in West Germany, where medical care is considered very good. Another cost results from what appears to be excessive hospitalization. In some states, for instance, the average stay for a particular condition is 6.4 days; in others it is 10 days or more. Much of the most unusual and expensive equipment is bought for hospitals almost more for prestige than utility. People requiring the most sophisticated equipment could be moved to ccrtain specialty hospitals. Radiation is often overused, partly to justify buying the equipment Atlanta alone has seventeen CAT scanners, while the entire state of Connecticut finds six to be adequate. Opcn-heart surgery units and artificial - transplant units are matters of hospital prestige, but in practice they are used so little that it would make more sense to have such units in a few strategically located hospitals, to which patients could be sent when needed, rather than have the units in all hospitals.

Despite these facts，however, the hospitals fou^hit back against efforts to cut costs. One reason is that they are lucrative businesses with rising profits. The Hospital Corporation of Amcrica increased its profits by 23.5 percent between 1977 and 1978, and American Medical International was up 523 percent in profits. Another problem is chat hospitals are a matter of community pride, with each community wanting the latest and best. The fate of the cost-reduction proposal is informative in terms of lobbying and financing campaigns. Of the 234 House members who voted against the cost - containment proposal, 202 had received contributions from the American “Medical Association' averaging $8000 each.

3. Medical Budget

Current estimates put U.S. health care spending at approximately 16% of GDP, second highest to East Timor (Timor-Leste) among all United Nations member nations. The Health and Human Services Department expects that the health share of GDP will continue its historical upward trend, reaching 19.5 percent of GDP by 2017. Of each dollar spent on health care in the United States 31% goes to hospital care, 21% goes to physician services, 10% to pharmaceuticals, 8% to nursing homes, 7°/o to administrative costs, and 23% to all other categories diagnostic laboratory services, pharmacies, medical device manufacturers, etc.

Health care spending in the United States is concentrated. An analysis of the 1996 Medical Expenditure Panel Survey found that the 1% of the population with the highest spending accounted for 27% of aggregate health care spending. The hi^iest-spending 5% of the population accounted for more than half of all spending. These patterns were stable through the 1970s and 1980s，and some data suggest that they may have been typical of the mid-to-early 20th century as well.

In September 2008 the Wall Street Journal reported that consamcrs were reducing their health care spendii^ in response to the current economic slow-down. Both the number of prescriptions filled and the number of office visits dropped between 2007 and 2008. In one survey, 22% of consumers reported going to the doctor less often, and 11% reported buying fewer prescription drugs. In 2009，the average private room in a nursing home cost $219 daily. Assisted living costs averaged $3,131 monthly. Home health aides averaged $21 per hour. Adult day care services averaged $67 daily.

4. Insurance Escalation

There are certain difficulties with the types of health insurance policies held in the United States.

One problem is that they arc generally intended as disaster insurance, not as insurance against minor illness. Althou^i there is much to be said for such policies, they are often inadequate for the family with small children. Many firms medical costs mount up for small children because of a series of sicknesses, not because of a sin每e major disaster, and with most insurance policies，usually only surgery or chronic complaints are paid for.

Another problem with present policies is that there in a tendency for insurance costs to keep escalating. If the insurance policy reads “for hospitalization of at least two days，duration, then there is 汪 fair chance that the patient will be hospitalized for at least two days, even thou^i he or she might have been just as well as at home. The intent of the doctor in such a case is to be considerate of the patient, but a result of such policies is that the insurance companies must pay larger claims and hence increase their rates.

Even the Medicare program for the aged is not a complete solution to the problem of medical costs. All people over 65 are automatically covered for hospital benefits under Medicare, as part of their social security, but patients still pay a share of their medical costs, which can nm to as much as one-fourth of the total bill. Medicaid，in contrast, is jointly financed by federal and state governments; it can be thought of as a welfare provision rather than a social security program. In most states, to qualify for Medicaid, people are generally not allowed to have savings or property except a home and must turn over all but a small amount of their income to contribute toward costs. The major objections to health • rare arrangements for the aged are that Medicare is less chan adequate, and that Medicaid requires the receiver to be a virtual pauper.

5. The Mcdicalization of Life

A number of primitive peoples have looked upon death not as a natural occurrence but rather as the result of witchcraft or ocher evil forces. Youi^cr generations now tend to look upon death in a comparable manner. Death is something the medical profession should be able to control. Doctors who lose patients must be guilty of some kind of malpractice — the modem equivalent of witchcraft. Such an attitude leads to the expectation of the impossible from medicine, one result of which is the effort to prolong life. One-quarter of all medicare costs are devoted to the last year of life.

Another part of the Mmedicalizadon of life” is the belief that only the medical profession can care for health. Home care and health measures are often neglected. Somehow doctors should be able to perform magic that will compensate for a life of heavy smoking, heavy drinking, little or no exercise，and a bad diet Many people waste the doctor’s time on common colds or other conditions that the body is capable of handling in a fairly short time. Some of the fault, however, can be laid to the medical profession. In its effort to do away with quackery, the profession has achieved v\iiat Dlich calls a “mystification” of medicine, meaning that all medical practice is beyond the comprehension of lesser minds. The result is that the home is no longer seen as a proper place for caring for the sick or havir^ babies, or for caring for people near death whose only desire is for love and comfort in their last days. Instead，the hospital has bccomc the only place to care for any of these conditions — and at an incredible expense to family and sodcty. The trend toward mystification of medicine,皿ch charges, occurs in all parts of the world with the sin^e exception of China. There, the so-called barefoot doctors make health care a matter of family and village.