Scenarios for 21st-century health care in the United States of America: perspectives on time and change.

Scenarios are a powerful way to bound the uncertainty of the future--to sketch the major pathways that the future might take. This article contains five scenarios depicting the United States health care system in the 21st century. These explore: an extrapolation of the current system; a single-payer driven system; a market-oriented system which forces more choice on the individual: a scenario which traces a transformation in health care; and a fifth scenario focuses on the healing role of health care. These scenarios acknowledge certain changes which relevant in all of them, e.g., by the early 21st century health care providers in the United States will have shifted to predicting likely health conditions, preventing what can be prevented and managing optimally those conditions which do arise (optimal in the sense of cost-effective treatment in light of the best practices of the day applied in ways which recognize and take advantage of the biochemically unique nature of each individual. Developed in 1991, these scenarios have been successful as a tool for identifying a range of likely paths which health care might take. The scenarios did not foresee the assertiveness of the President of the United States towards health care reform, although it did identify the difficulty which the President's and any other reform efforts would face. At their base, however, the scenarios trace the fundamental shift taking place in health care in spite of financing reforms. This fundamental shift is being driven largely by outcome measures; a commitment to accountability; better and more accessible health knowledge; enhanced technology; and a greater willingness on the part of some sectors of the health care system to deal with the broader determinants of health (e.g., community and economic factors).