way anyone would react, "Who knows?" Then, I realized that not only would I be dead in the year 2036, but so would every single person who had read the article. It was a liberating moment, because I realized that I could say whatever I wanted and no one would know how wrong I was.

Now, with the year 2020, I think we are in a slightly more dangerous situation, because there is the prospect that a few of us will be alive in the year 2020. Christine Cassel, a gerontologist and a friend from the University of Chicago (who is now at Mount Sinai in New York), gave me these prevalence forecasts for Alzheimer's disease suggesting that the survivors among us probably will not remember what was said. So it seems worthwhile taking some predictive risks.

It seems to me that the central direction of change in our financing system in health care in the last 15 years, which I see persisting for the next generation, is the shifting of economic risk and responsibility for health care costs from the government and employers to health plans and the health care provider community, and subsequently to individuals. I see this trend accelerating in the next 15 years as high-risk populations enter managed care pools. Of course, the growing number of uninsured people in our country fits this trend because what we are seeing there is a shift in economic risk from the government and employers, who are trimming their responsibility for certain segments of the employed population, to individuals and to a lesser extent, to the health care institutions that have responsibility for them.

The idea of shifting economic risk is the central theme of this discussion—how we manage that shifting of risk and how an important societal institution, namely managed care, is going to change as it assumes a steadily increasing amount of risk—the risk involved in an aging population.

Even though managed care has been with us as an institution for the better part of 60 years, it is my contention that it is still in its adolescence as a societal form. Three powerful forces are operating now in the health care financing landscape that are going fundamentally to transform that business as it moves forward into the first part of the next century.

Fifteen years ago there were only about 10 million people enrolled in HMOs (health maintenance organizations) in the United States, and that population probably represented the healthiest 10 million people in the country. The typical HMO subscriber was probably white, a blue- or white-collar worker with a family comprised of people who did not get sick very often. The largest costs in a typical health plan were obstetrics and pediatrics.

Clearly, a major change that is taking place in the composition of the managed care population at risk is the flood of high-risk individuals entering that pool. These individuals come from the two highest-risk subgroups in our population: the multifunctionally impaired, chronically ill elderly population, for whom Medicare is currently responsible, and the poorest of the poor—people enrolled in Medicaid programs—who bring all of the societally driven risks associated with their socioeconomic status into the risk pool.

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