The great demographic trap.

As this is my last editorial as your editor, I thought it would be appropriate to range a bit more widely. To wit, what’s going to happen to the system under which we all earn our living? Despite the undeniable fact that most of us feel we’re “doing good,” there is great discontent among politicians, journalists, and policy wonks about the functioning of the health care system in the United States. Even among the general public there is discontent, although paradoxically most (not all!) feel the system works well for them. Actually, this is worldwide. The British worry about the National Health Service, of which they are inordinately proud. Other Europeans are forever tinkering with their national systems. Even the Canadians think their system is poorly responsive and inadequately funded, but they still think it’s a great system. Angst is widespread worldwide, at least in developed countries. Many say that health care is too expensive, too complicated, too unresponsive, or too hard to obtain. But theirs is still better than those over the border. Odd, isn’t it? Everyone’s unhappy. But everyone likes what they have. To an extent, that’s a product of our postmodern outlook. The postmodern ethos is basically unhappy with everything. But that’s sort of like saying we’re unhappy because we’re unhappy. Let’s look for the deeper reasons. There are indeed flaws in the health care system. Consider the safety issue. Health care is not as safe as it could be. It’s not as dangerous as some would have us believe, because many frightening estimates are simply overblown. And we can remove only some of the dangers. If you get an illness, or you get shot, or you’re in an auto crash, there is a certain probability you’re going to die, regardless of how good or safe your health care is. Still, it’s wrong that people die or become ill from medication errors, failures of diagnosis, or management mistakes. There are many ongoing efforts to make things better by hospitals, health care professionals, accrediting bodies, and government at all levels. These efforts seem to be bearing fruit. But they aren’t free, and for each physician or nurse employed to promote safety, that’s one less professional to go to the bedside. Is that important? Yes, it is, and for reasons we’ll see in a bit. I’ve written before about the economic issues of our health care system. We have a pretty good health care system, for 70% of us. For those without any insurance, or even those receiving Medicaid, well . . . as I’ve discussed before, health care is available, but the options are greatly limited. The problem of the uninsured is receiving a great deal of political attention recently. My prediction is that it will still be with us down the road, if only because Medicaid was the government’s last effort to solve the problem, and it still doesn’t work. But there’s another problem that is more intractable and which is going to occupy us for the next couple of decades. Perhaps fortunately, the politicians haven’t discovered it, so it may yet be solvable. This is the demographic trap. We are going into a generation-long time of increasing demand for health care services, combined with a decreasing number of people who are trained and able to provide services. The demographic trap will work to make the health care system more stressed, less responsive, and less accessible. How can I say these things? Well, the increasing demands for health care are well known. I’ll spare you most of the statistics on Medicare, which are both dismal and boring. But consider this: The number of people over 65, now 36 million, will double to 72 million by 2030. And those older people will require progressively more health care as they live longer. So what’s the trap? The demographic trap is that as the demand for health care is rising, the number of health professionals is decreasing. I’ve looked over some of the data on the 4 groups that concern the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.): nurses, pharmacists, physicians, and dietitians. There are very good data on nurses, pretty good data on pharmacists and physicians, and fair data on the dietitian work force. The outlook, at least for the first 3, is not good. The nursing shortage has been recognized for at least 10 years. The nursing workforce is aging because insufficient numbers of young people are enrolling in nursing schools. This is despite the development of 2-year “associate” schools, which are shorter and less demanding than the last generation’s 3-year “diploma” schools. About two-thirds of new RNs come from associate schools, with a third coming from 4-year baccalaureate schools. An actual drop of RNs per capita is Received for publication June 12, 2007. Accepted for publication June 12, 2007. Correspondence: Charles W. Van Way III, MD, UMKC Department of Surgery, 2301 Holmes Street, Kansas City, MO 64108. Electronic mail may be sent to charles.vanway@tmcmed.org. 0148-6071/07/3105-0449$03.00/0 Vol. 31, No. 5 JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Printed in U.S.A. Copyright © 2007 by the American Society for Parenteral and Enteral Nutrition