Voluntary hospitals handled the financial pressures by becoming more aggressive, competitive, expansionary, profit-oriented, and income-maximizing. Access to health care became increasingly dependent on ability to pay. Some hospitals, faced with prospects of financial doom, merged with others; others fled to the suburbs where the payer mix was more favorable. This contributed to the growing problem of limited access to health care for the uninsured: the poor, the part-time worker without benefits, and the unemployed.

Currently, the voluntary hospital is a central part of the changing scene in health care delivery. The idea of "managed competition" is driving hospitals into health care networks. The tempo of competition among urban hospitals has become fierce as they strive to set up networks for managed competition. Insurance companies are prominently engaged in the struggle for a piece of the pie. Drug companies are resorting to novel strategies in order to maintain prized relationships with physicians and hospitals while the restructuring is under way.

A variety of influences is diminishing our society's traditional reliance on hospitals as independent entities:

  • increased dissatisfaction of the public and of major political figures with the high cost of health care and the major role played by hospitals and their administrative costs in the genesis of this difficult burden;

  • growing ability of and financial incentive for outpatient care to substitute for in-hospital care due to advances in medical management and technology (e.g., cardiac catheterization, renal dialysis);

  • less need for hospitalization because of the development of noninvasive technologies for diagnosis and treatment (e.g., CAT scanning, MRI, or ultrasound);

  • restructuring of health care (e.g., through HMOs, which discourage referrals to hospital-based specialists, and greater strictures on reimbursement by third-party payers);

  • development of new effective therapeutic agents (e.g., antibiotics for cystic fibrosis);

  • expanded use of living wills advance directives, which may limit interventions and expenditures for terminal disease; and

  • greater effectiveness of preventive measures (e.g., education for AIDS, vaccines).

As the United States prepares itself for health care reform, it is important to recognize that in addition to unmet needs (e.g., preventive medicine), the aging of the population will introduce additional needs and related ethical questions. For example, disability from dementia, including Alzheimer's disease and stroke, will require research into etiology, medications, devices, and suitable treatment environments. The major

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