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The social and economic environment is the fourth domain. A key factor in this domain is crime (Lawton, Nahemow and Yeh, 1980). Fear of crime is an important factor in reducing physical activity outside the home for elderly persons (Dowd, Sisson and Kern, 1981). It is also a stressor that can influence health through pathways related to chronic stress. Fear of crime is related both to actual crime levels and to deteriorated aspects of the physical environment such as vacant buildings, litter and homeless persons (Rohe and Burby, 1988; Krause, 1996). Another important stressor in the social environment is the. | The Business Of Medicine Health Care for the Elderly How Much Who Will Pay For It By Victor R. Fuchs Health care expenditures on the elderly have outpaced the gross domestic product GDP by 3.5 to 4.0 percent per year in recent decades.1 This differential is partly attributable to demographic change with the number of elderly growing about 1.0 percent per year faster than the rest of the population. By far the more important factor however is the rapid growth of age sex-specific consumption of health care by the elderly.2 If the trends of the past decade or two continue until 2020 the elderly s health care consumption in that year will be approximately 25 000 per person in 1995 dollars compared with 9 200 in 1995.3 If the current public private shares remain unchanged a bit less than two-thirds public a bit more than one-third private an enormous increase in taxes will be necessary and the elderly still will be left with less income for other goods and services than they had in 1995. Without a dramatic change in health care costs income or both health spending on the elderly in 2020 is likely to be two to three times the income available for all other goods and services.4 AGE SEX-SPECIFIC EXPENDITURES. A more detailed picture of the rate of growth of age sex-specific expenditures Exhibit 1 shows the average annual percentage rate of change between 1987 and 1995 of Medicare payments in constant dollars. The calculations were made by single years of age from a 5 percent sample of Medicare patients and then smoothed with a five-term moving average to reduce the effects of sampling variabil-ity.5 The rate of change tended to be greater at older ages and somewhat greater for women than for men. On average the rate of increase was between 4 percent and 5 percent per year in constant dollars. During that same period real GDP per capita grew at only 1.2 percent per year. It is this gap that is at the heart ofthe Medicare problem. And because the private share of health care
