older adults (e.g., Beck et al., 2009), one travels to an office or clinic to see a health care professional today or is taken by ambulance to a hospital in an emergency. (The author can remember a childhood visit by a physician to diagnose and schedule an emergency appendectomy.) Perhaps the greatest change is the treatment of patients with serious health conditions at home instead of in hospitals, a trend being driven in part by treatment cost considerations.

A motivator for such treatment locale changes is the rapidly rising cost of health care coupled with a shift in the burden of payment. Individuals now pay directly for less than half their medical care expenses, with public and private insurance entities picking up the bulk of the payment, whereas as few as 50 years ago these relationships were reversed. Finally, people a century ago came in contact (sparingly) with medical care providers to address acute health concerns, such as communicable illnesses and injuries. In contrast, it was estimated that about 78 percent of health care expenditures in the United States in 1996 were made to treat people with chronic conditions (Anderson and Horvath, 2002). By 2005 that figure had risen to 90 percent (Machlin, Cohen, and Beauregard, 2008), in part because of the high prevalence of these conditions in the population. About 60 percent of adult civilian noninstitutionalized people have at least one chronic condition, although only about half of total medical care expenditures were for treatment of them. (Those with chronic conditions also experience disproportionate treatment for acute conditions.) The definition of chronic diseases by the Centers for Disease Control and Prevention is that they are “noncommunicable illnesses that are prolonged in duration, do not resolve spontaneously, and are rarely cured completely.” The five most costly ones in 2006 were (1) heart conditions, (2) cancer, (3) trauma-related disorders, (4) mental disorders, and (5) asthma that includes chronic obstructive pulmonary disease (Soni, 2009). Many of these disorders are experienced throughout the life course (trauma-related, such as auto accidents), although some are more strongly associated with childhood (asthma), some are associated more with young adulthood (mental disorders, such as schizophrenia), and some are most associated with old age (heart disease, cancer, Alzheimer’s disease). I focus primarily on older adult health care examples because that part of the population bears the greatest burden from chronic diseases.

Given the aging of the population, the percentage of health care cost expended to treat chronic diseases will undoubtedly rise because of the strong relation between age and chronic disease prevalence (see Figure 6-1). The Government Accountability Office projected a quadrupling of spending on older adult long-term care alone between 2000 and 2050 (Allen, 2005). There is also concern that other trends, such as increased prevalence of diabetes, which is variously projected to increase from 11 million in 2000



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