When Austin Powers, ace British secret agent, is thawed out after thirty years of suspended animation, he is greeted by his old boss, accompanied by a Russian general. Powers is alarmed by the presence of the Russian general, and complains about the breach of security. Powers' boss tells him “a lot's happened since you were frozen. The Cold War is over.” Powers thinks for a moment, and then responds, “finally those capitalist pigs will pay for their crimes eh, eh comrades, eh?“ His boss gently interrupts, and informs Powers that “we won.” Powers clumsily responds, “Oh groovy, smashing, yeah capitalism,” his tactlessness prefiguring his behavior through the rest of the movie. Despite Powers' noteworthy skills as a secret agent, he has foolishly disregarded the first rule of forecasting the future: don't be around when your predictions are assessed for accuracy and completeness.

The cost containment innovations offered by managed care have been needed corrections to the excesses of the fee-for-service health care system. Yet, implementing these innovations raises inevitable questions about conflicts of interest regarding the allocation of resources under managed care. The inherent conflict faced by physicians and health plan administrators between the health care needs of individual patients and the need to preserve scarce resources for patient populations is at issue in the managed care era. The sources of the conflict are the economic incentives that underlie the managed care revolution, such as capitated funding arrangements, limitations on referrals to specialists, bonuses and withholds. In making individual clinical decisions, physicians and administrators potentially infuse their own economic interests into the process.

If any trend can be confidently predicted for the next millennium (or, more modestly, for our lifetimes) it is the globalization of health law. We live in an age of global markets and global communications. While care of the individual patient has remained largely local, national borders are quite porous to health care professionals. The cross-border flow of patients is a significant factor in some regions, and the development of telemedicine and internet pharmacies is radically expanding the possibility of cross-border medical practice.

My experience and reflections concerning tobacco litigation stem from representing the American Cancer Society in November of 1998,' when the State of Oregon asked Judge Anna Brown of the Circuit Court of Multnomah County in Portland to approve the settlement agreement reached between Oregon and the major tobacco manufacturers. The American Cancer Society inteivened in opposition. The agreement was a part of a multi-state settlement reached by forty-six state Attorneys Generals and the tobacco industry proposed to state courts during that same week and the ensuing weeks around the country. By October of 1999, the Master-Settlement Agreement (MSA) was approved by enough states that it was effectuated. Distributions pursuant to the agreement will begin in 2000 or 2001. Total disbursements over twenty years will exceed $240 billion, a huge amount of money by anyone's standards.

In 1999, the United States Census Bureau reported that 16.3% of Americans did not have health insurance in 1998, up from 16.1% in 1997 and 13% in 1990. The increased lack of health insurance is particularly troubling because the unemployment rate is down and the economy is vibrant. The Census Bureau also reported that Hawafi led the Nation in providing health insurance, with only 8.8% of the population uninsured. This fact alone makes Hawai'i a model for the U.S. Hawaii's success goes beyond providing health insurance coverage. “Coverage is not care.” The state is also a model in terms of providing care through community health centers. Broad insurance coverage, and access to care through community based primary care centers, help to make the people of Hawai'i healthy. Further, Hawai'i's health care costs are lower than costs in the rest of the nation.

Perhaps no single policy topic better illustrates the tensions within American politics at the beginning of a new millennium than does Medicare, the nation's thirty-five year commitment to ensuring senior citizens' financial protection against the costs of acute medical care. Our politics seems nearly overwhelmed by conflicting promises to balance the budget and pay down the national debt, enact tax cuts and protect broadly popular “entitlements.” Medicare, one of the largest of such entitlement programs, has become a lightning rod for conflicts over how to resolve these competing goals. As a result, the nation finds itself in the midst of a bewildering mix of crisis talk, fact throwing and ideological name calling, with all the confusion and distortion one would expect from such a mix.

“On the Internet, nobody knows you're a dog,” says one canine to another as they sit in front of a computer in the classic New Yorker cartoon. This can also apply to those who seek or provide medical care online. On the Internet, nobody knows if you're male or female, elderly or adolescent, fit or obese, hirsute or bald, virile or impotent. In addition, in many cases, nobody knows if the “physician” or “pharmacist” on the other end of the line is a properly licensed physician or pharmacist, where they are located, what the knowledge level or training of the consulting practitioner is, or whether the medications being shipped are of the appropriate level of quality, potency or dosage. And, if the ease with which one is able to procure pharmaceuticals online is any indication, there are plenty of unscrupulous entrepreneurs selling drugs on the Internet who do not appear to care.

My thoughts about the status of American health care as it enters the twenty-first century have less to do with any theory or model—or even my own politics—and more to do with my efforts as a teacher. For the past twenty-five years I have taught introductory health law courses in law and public health schools. While what I teach and how I do so have changed enormously during that time, my basic objective has changed very little: preparing my students for the political and legal issues that they will likely confront in their individual and professional lives. It is a task that I find endlessly challenging. I have to amass and continually update a tremendous amount of information concerning individual and institutional providers, various financing arrangements, state and federal programs, and all the other things that many Americans only partially understand or ignore altogether. But the real challenge is in delivering this information. It must be presented in some useful and retainable way. As in all other important things, the devils in American health care can only be found in the details; but the trick for a teacher ultimately, is figuring out which devilish details are important, which are not and why, and how to pass all that along to tomorrow's decision makers—whether tomorrow is just tomorrow or whether it is the beginning of a new century.

Alternative medicine has been rapidly expanding as consumers drive the demand for more cost-effective, accessible and individualized healthcare. A commonly cited survey in the New England Journal of Medicine (NEJM) found that more Americans were consulting alternative care providers than allopathic/conventional physicians. In 1998, David Eisenberg published a follow up to this landmark survey, showing a marked increase in both the use of alternative care and the number of individuals seeking such care. The study revealed that 42.1% of Americans consulted at least 1 of 16 alternative therapies during 1997, an increase from 33.8% in 1990. Total visits to alternative practitioners soared from 427 million in 1990 to 629 million in 1997. This explosion of alternative care in the United States has begun to force prominent medical schools across the country to offer courses in alternative medical techniques. Over seventy-five major medical schools have begun to teach courses in alternative modalities. Moreover, the alternative care industry has established several journals to cover its expanding field.