While researching the topic of mobile health services for an article I was writing, I came across this report from the Robert Wood Johnson Foundation.
In June 2012, The foundation supported a symposium by The Institute for Alternative Futures that examined the 20-year future of U.S. healthcare and services through 2032. The event was held and the report issued before the U.S. Supreme Court upheld the Affordable Care Act.
They framed the discussion in four possible scenarios. This is brainstorming, so some of the outcomes are not factual, but imagined. But some, many, are real:
Scenario 1: Slow Reform, Better Health:
Health and effectiveness of health care vary among states. Health, not health care, becomes the main political issue.
Scenario 2: Health If You Can Get It: Medicare and Medicaid experience severe budget cuts, most Americans are underinsured, medical tourism increases, epidemics spread and health and inequality worsen. The public becomes highly fractured and disillusioned with the ineffectiveness of governance.
Scenario 3: Big Data, Big Health Gains:
Health becomes the primary concern. Initiatives regarding health innovation, health equity, the social determinants of health and health in all policies reduce health care expenditures. The public demands anticipatory democracy, cooperation, sustainability and transparency.
Scenario 4: A Culture of Health:
Leaders create environments to support and improve all domains of health as a “health culture” arises. The nation’s focus shifts to disenfranchised youth, and to the development and comprehensive health for children. “Health wisdom” expands as social networks “crowdsource” health. Environmental monitoring is widely implemented among communities.

The full report is available at : http://www.altfutures.org/pubs/RWJF/IAF-HealthandHealthCare2032.pdf.

What follows are excerpts from the second scenario, “Health If You Can Get It.”
It is clearly a case of the future reflecting on the present. Some of what this report says is familiar; if does not worry you, you are not paying attention.

“Health If You Can Get It.”
“The budget sequestration in late 2012 led to draconian cuts that paralyzed many government agencies, created business uncertainty and sparked a recession worse than what Europe was suffering.
Unemployment peaked at 14 percent in 2014.
Medicare was “modernized” in 2014 with vouchers for those turning 65 beginning in 2020 and with payment cuts that made it difficult for those already over 65 to find providers willing to accept them.

Society fragmented into demographic, ethnic and economic factions, each of which looked out for its own interests at the expense of the others. With an ever growing gulf between the “haves” and the “have-nots,” the affluent cared little about society’s most vulnerable, the ranks of which expanded every year as unemployment bounced up and down around an average of 10 percent.
In periods of economic growth, more than 95 percent of new wealth was captured by the richest five percent. In periods of economic decline, the poorest 50 percent experienced the greatest suffering.

Spiritual health eroded as hope turned to despair. The optimism for which Americans were once known became a pronounced pessimism over a political and economic system that no longer seemed to care about the poor and middle class.
Social health declined terribly for families and communities, as the psychosocial burden of illness spread apathy, fed further economic malaise, and diminished Americans’ desire to interact with one another.
Economic downturns saw many people lose their jobs, homes and hopes and then start turning to junk foods, alcohol and drugs for relief. Heart disease, cancers and diabetes all became more prevalent, with incidence rates increasing for youth as well as for elders.

The political consequences were pronounced: the center did not hold and elections oscillated between ideological extremes as policy battles raged over health care, energy, climate change, immigration, taxes and budgets.
Each election cycle was more passionate and less reasoned than the last, and while each political party blamed the other, neither could govern effectively.
Americans became increasingly alienated from a process that consistently produced divided governments in which the minority sabotaged any majority-led legislative effort, often using arcane rules and procedures.

As a result, national politics were at best ineffective and at worst toxic, with major policy decisions increasingly made by the Supreme Court, often by narrow majorities.
In this political context, the national government was unable to address the crisis in health care
State governments were similarly unable to address the crisis given their own fiscal constraints and the massive cuts to government services that they had already enacted.

Among health care providers, the business ethic of profitability trumped long-standing medical ethics.
Further, medical associations aggressively lobbied the Department of Health and Human Services to cut federal funding for community health centers, which as the “health care provider of last resort” had achieved high standards of quality and were taking more business from private practice physicians. Thus, it became harder for the poor to find good care and easier to be sold bad care.
While some U.S. consumers were able to discern good care from bad, many affluent consumers sought care overseas when they needed major medical procedures. This further challenged U.S. hospitals for some of their best-paying business.

Sensationalistic media and misleading measures of community risk had fed into an “us versus them” narrative that stigmatized the sick and thus further marginalized poor and minority populations. Some ethnic populations were scapegoated as having overburdened the health care system with their unhealthy cultural norms.
The vitality visible online stood in stark contrast to the solutions put forth by the country’s elected leaders, who often relied on the ignorance of the many and the wealth of the few to advance narrow, short-term objectives.

The transparency afforded by the new technologies exposed the failings of established power structures and fueled a frustration with the political and economic status quo. As a result, in the elections of 2016 a majority of
Americans recognized that competitive excesses had converted the political system into a win-lose venture that was inefficient at best. Power was controlled by a small number of people who had benefited from what many perceived as a “winner-take-all” economy.”

Despite all that gloom, the report ends this scenario with hope:

“A series of stories about political manipulation of legislation for corporate gain galvanized the public to demand better representation. While some longtime politicians were able to see the parade and get in front of it, many others could not and were swept from office. In subsequent elections, voters rewarded candidates who articulated a vision of political cooperation, transparency and “anticipatory democracy” – a democracy where citizens and decision-makers are active, future-conscious partners who collectively shape the future of their community, state and nation.”

We’ll see.