The changing demand for health services: a historical perspective and some thoughts for the future

Among the many factors contributing to the rise in health care costs, recent attention has concentrated on the supply side. Demand factors have generally been neglected or misunderstood. Developments discussed in this paper include: growing public skepticism toward new therapies and drugs; increasing emphasis on patient autonomy and other indications of willingness by the public to assume greater responsibility for its own health; changing relations between income, education, and health care use; the aging of the population and the concomitant rise in chronic conditions; the recent reversal of the former quest for greater equity in health care; and the shrinking American family. Despite the complexity and contradictions within these developments, I perceive a leveling off of demand, especially for acute hospital care, even apart from external financial constraints, accompanied by a rising demand for preventive services and primary and long-term care. It is time to recognize the policy implications of these developments and begin to reorganize our health care system accordingly. But is it too late? Have we the will to do so?