July 27, 1994
INTRODUCTION
These health scenarios were developed as assignments for classes and consulting work. They are not meant to be linked together, but reflect various angles or perspectives on how health in Hawaii could evolve by the year 2000 and 2010. In both cases, a "snap shot" approach to writing scenarios was used, attempting to convey the "essence" of a particular future.
FIVE SCENARIOS OF HEALTH IN HAWAII: 2010
The following scenarios were developed in 1993, and apply the five economic systems, Blue, Red, Green, Yellow and Pink, developed by Prof. J. Galtung to the future of health care in Hawai'i. These five systems provide the internal logic with which we can develop and compare 5 macro scenarios or visions of health care and their impact on health care delivery and health status of Hawai'i residents in the year 2010.
Key trends that could shape the future of health and healing in Hawai'i, and are consistent with the five economic systems, are identified for each scenario. A brief description of each economic system is included.
GREEN:
Economic Attributes: Pantheistic. Decentralization and local self-reliance, community-ownership, de- emphasis on technology, recognition of environmental limits, "small is beautiful" or "human-sized" organizations. Focus on survival, well-being, identity, self-reliance, isolation (relation to others), horizontal, pluralistic, static. Production is kept in check and tends to be need-based. Use local factors optimally.
Trends:
* Growing environmental movement emphasizes low-tech, "natural" approaches to healing, decreasing health care costs. Hi-tech approaches exist but they are used sparingly.
* State-mandated cost-containment measures and benefits reach their limits -- self-responsibility, health promotion and disease prevention, and community-based approaches are necessary to ensure access to all.
* The Sovereignty movement and growing strength of Green Party force the State to relinquish some of its authority to the community and neighborhoods, including health care decisions.
* Mind/body/spirit healing takes hold nationally and in the State. Local hospitals and health care organizations support and promote patient-focused, high-touch care as well as health promotion.
Health care in 2010:
The health of the community (and consequently the State), is linked to the health of the individual. Personal accountability, supported by culturally-sensitive community health centers result in people adopting healthier lifestyles. "A healthy city shares the same living qualities a health body has." (Duhl, pg. 89). Increased emphasis on health promotion and prevention result in improved health status, particularly for Native Hawaiians, greatly diminishing health costs.
Health care is redefined to include family and community-interventions. Community-based efforts such as Worksite wellness programs, the University of Hawaii at Manoa Wellness Center and other public/private partnerships improve many environmental conditions predisposing people to ill health. Managed care organizations such as Kaiser were well positioned to work with the State and private sector to implement group-based health promotion programs.
This scenario is very similar to that developed by Ira Rohter in his book, A Green Hawaii, and the "conserver society" scenario described by Jim Dator and others. Most of Hawai'i's residents subscribe to the "limits to growth" concept, creating policy to replace tourism and the military with more environmentally-sound industries. With the reduction in these two sectors, Hawai'i devotes more time to cultivating social services such as health care and cross-cultural relations.
The Hospital of the Future
Health care as an industry grows in importance. Promotion of traditional healing techniques and the recognition of Hawai'i as a spiritual healing center makes Hawai'i a leading learning center in the healing arts. Hawai'i's ideal weather and island ambiance attract healers and patients from around the world. While Hawai'i hospitals struggled with the transition (in fact some hospitals were forced to close down) many were already emphasizing primary care and were able to adapt accordingly. In addition, many Hawai'i' providers adopted the patient-focused care and increased patient participation in their healing process.
BLUE (CAPITALISM -- "LET THE MARKET DECIDE"):
Economic Attributes: Monotheistic. Characterized by: freedom, exploitation and penetration into other markets, pluralism, dynamic, "history is on our side" attitude, competition, ego-centered, capital-centered, individuality-centered (private property), expansion, monetization of capital, work and land, unchecked production based on demands (v. needs) and inequality. Includes element of risk.
Trends:
* Universal access flounders at the National level due to economic recovery and decreased unemployment. Local businesses revolt against mandated health benefits, diminishing State control.
* Physician costs continue to rise, unchecked by state controls.
* Consumers demand high tech approaches, pushing up health care costs.
Health care in 2010:
This scenario closely resembles health care in the 1990s, minus the influence of the State. Only the rich can afford health care, leaving the State in a bind as it tries to assure people the basics. The result is that more people are denied health care, e.g., low-income, service sector employees, students and part-time workers. However, as the national economy recovers, so does the State economy, increasing employment and better coverage for some. Efforts to diversify Hawai'i's economy see an infusion of new businesses: telecommunications, biotechnology and computer software/hardware.
There is an increase in employment for those with adequate training. However, the gap widens between the "haves" and the "have nots," reducing access to care for the unemployed, children, elderly and Native Hawaiians. In addition, residents pay more out-of-pocket for health care. The State adopted the Oregon Plan for the Medicaid/SHIP populations, denying high-tech services to many.
The Hospital of the Future
Health care providers, stimulated by the new era of competition and developments in R&D emphasized high-technology, pushing up costs. Although these high tech approaches could make people healthier, e.g., "gene fixers" that repair or replace genes for heart disease, only those who can afford to pay benefit.
The usual providers, HMSA and Kaiser, have maintained their hold on the marketplace, pushing for an increase in prices as more high tech approaches are introduced. While managed care is popular with individuals and organizations alike, the medical community made a token effort to provide it to a limited pool of clients, preferring fee-for-service. There is a sizable population who can afford to pay for more expensive services.
RED (SOCIALIST, GOVERNMENT CONTROL):
Attributes:
Monotheistic. Produces to meet needs first, then demands. Keeps production in check. State controls surplus and minimum standards -- low prices, high quality. Promotes economic growth in others. Focuses on reducing the income differential in society and abolishing misery. Little foreign trade.
Trends:
* Universal care was mandated nationally, preempting Hawai'i's financing system. The national system resembles the Canadian plan.
* High tech approaches to health are curtailed as the importance of prevention and health promotion are emphasized.
* Hawai'i providers dwindle in numbers as "market forces" are replaced with tight government control.
Health care in 2010:
The Clinton Administrations' "managed competition" health plan assured access to all, but undermined Hawai'i's efforts to coordinate all the key stakeholders. Instead of proceeding with plans to create a "seamless" system, the state went through a lengthy process to convert to the National system.
All Hawai'i residents have access to health care under the national system. However, like the Oregon Plan, these services are substantially limited. Community-based clinics flourish. There is moderate improvement in the delivery of services to Native Hawaiians and the underinsured.
The Hospital of the Future
The National plan created an untenable situation for some providers. Low prices and mandated benefits force some fee-for-service providers to leave the Islands. Health care costs are significantly decreased but services are diminished as well. Luckily Hawai'i had emphasized primary care early on, assuring care to many.
While research continued into high tech approaches on the Mainland, most Hawai'i providers were unable to procure the latest in information systems or biomedical devices. Those able to afford these treatment went to the Mainland. This created a problem for retirees who had migrated to Hawai'i from the Mainland, forcing many to return as they got older and sicker.
PINK (THE NORTHERN EUROPEAN MODEL):
Attributes: Polytheistic. Less vertical, uniform and more dynamic. Emphasis on negotiation with some conflict. Social democrat. National focus. Mix or "compromise" of Blue and Red.
Trends:
* While national health reform occurs, it does not pre-empt State efforts. In fact, Hawaii serves as a model for designing a national plan that is administered at the State level.
* State control continues to be balanced by "managed competition" among providers.
* Prevention, wellness, health promotion and self-responsibility are emphasized.
* High tech approaches to health care are balanced with high touch, spiritual approaches.
Health in 2010:
This scenario builds on the system that is in place in 1993, balancing State control with the private sector. There are no major changes other than some major medical breakthroughs, e.g., a cure for AIDS. With a stable economy, Hawaii was able to "fine tune" its health care system, creating a "seamless system" in which the Prepaid Health care Act, Medicaid, SHIP and Medicare are coordinated. Through improved information systems and the "one stop shopping" approach to coordinated services, access to care is facilitated.
Native Hawaiians, as well as other disenfranchised cohorts, benefit in this scenario. The Sovereignty movement kept health issues at the forefront, stimulating State action.
Businesses continue to chafe under mandated benefits. However, many have included or bought into worksite wellness plans, reducing employee copayments if they participate in the program.
Hospital of the Future
Keeping health care costs down is a constant challenge for health care providers. However, reduced administrative costs and increased prevention efforts keep costs in check.
Health care providers further diversified their services. Age groups at both ends of the spectrum are assured high quality care. The vaccination program initiated during the Clinton administration paved the way for new health care delivery strategies, including: home visitation, school-based clinics, "well family" programs. Hawai'i passed a mandatory universal state-sponsored long-term insurance program in the mid-90s to deal with increasing costs from an aging population. In addition, home care and "healthy aging" helped to contain costs.
YELLOW (EAST MEETS WEST):
Attributes: Polytheistic. Strong government control. Based on diversity and symbiosis, vertical-uniform-dynamic. Emphasis on cooperation at the global level. Combination of Blue and Red (reconciles the two).
Trends:
* Communication technologies position Hawai'i as the knowledge hub between the East and West, making Hawai'i an important global player in a variety of domains, including health.
* Hawai'i's private and public sector stakeholders increase their ability to leverage change through improved decision making and leadership. New private/public partnerships are created as collaborative efforts between the two prove to be more effective and profitable.
* The consumer comes first. Patient-focused care, total quality management and other approaches to assuring high quality care for all positively influence health care organizations and public agencies.
* Like the Blue Scenario, efforts to diversify Hawai'i's economy prove successful, decreasing resistance to mandated health benefits as the number of businesses employing professionals increases.
* High technology in health care is balanced with high touch.
Health care in 2010:
Hawai'i is at the forefront in addressing cultural diversity in health care, serving as a model for other nations. Complementary therapies from around the world are studied and administered in local hospitals and clinics. The University of Hawai'i at Manoa Medical School includes acupuncture and other treatment modalities in its curriculum.
Consumer advocacy coupled with improved delivery of services results in an efficient, high quality health care system, at reduced cost. The Department of Health and most health care providers instituted total quality management, empowering staff and increasing greater coordination with other agencies.
Hospital of the Future
The health care industry thrives as Hawai'i becomes recognized as one of the preeminent "healing centers" in the world. Tourists flock to health spas and retreat centers. Many high rise buildings in Waikiki were torn down and replaced with park areas and sports facilities.
Information systems such "team diagnosis" and "home health" computer systems greatly reduce hospital stay and shift responsibility to the patient. However, high technology approaches are balanced with "spiritual" or mind/body therapies.