Health care in the United States is dictated by these market forces. The substantial growth in HMO's and PPO's in the past decade is testament to the fact that the primary "gatekeeper" in medicine may very well be the insurer who is footing the bill, rather than the physician providing acute medical services. The insurer is now paying for prevention and wellness services, even though wellness per se is not part of the medical model at all - it is part of the health model (public health, physical education, holistic health programs, etc.). It is because the combination of the evidence of enhanced fitness and that wellness programs have been shown to have the ability to save insurers and corporations money and will save more in future health care expenditures (10, 15, 19, 23, 25).

The October, 1994 issue of the Naisbitt Trends Newsletter states that the "wellness reflux" may have potential cost savings of $188 billion dollars in the coming years (16). Insurers are betting that a small portion of their yearly expenditures on wellness will help defer future costs of major medical intervention and hospitalization. It is a gamble that is paying off for some insurers, such as California's PacifiCare Corp., whose Senior Fit program is growing exponentially in the past few years. Seeing this trend, other insurers in California such as Take Care and Health Net are considering or have already implemented similar health promotion programs. A recent agreement between MetraHealth and the Arizona Fitness Network to provide wellness services on a capitated basis is further evidence of this trend.

Licensure Feasibility
Licensure is a state-mandated quality assurance marker. However, the fitness industry in its foresight has instituted its own quality assurance marker in the form of certifications. The wide variety and lack of concensus in quality of certifications are not indicative of the lack of direction and leadership, but are a testament to the diversity of the profession, and the entrepreneurship of those who administer the tests. Unfortunately, there are no internal regulations on those who are negligent or who are un-knowledgeable. At present, most Americans are dissatisfied and distrustful of the way our government is run. Over 60% of American's think that local, state, and federal governments are too bureaucratic and move like dinosaurs, and with good reason. Take for example, the recent debacle of the California State Assembly spending three months of partisan wrangling just to choose a speaker; or the 1993 California budget process causing millions of dollars in delays and the eventual issue of IOU's. Why should the fitness industry lobby for a licensure bill (which is costly, time consuming, and has the possibility of fighting a turf war with other allied health professions) only to have the control of who is labeled a fitness instructor taken out of their hands? Issuance of a certification is a visible sign of recognition of the organization. It is a privilege of that organization. Institutionalization by the state of some form licensure would be contrary to the changing environment off allied health medicine and to the long term public interest.

This may be difficult to believe, but if a law were passed a law that states, for example, that no one person or organization could give prudent nutritional advise other than those designated by law as being qualified, then persons with insight such as Nathan Pritikin (originally an electrical engineer) would have been barred by law from practicing and counseling persons about nutritional habits and prescribing nutritional advice. The revolution he helped create in the medical and nutritional world would have been delayed or prohibited. As it was, it took the profession more than twenty years to realize his concepts as having benefit to disease control and health lifestyle.