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Health care in the United States

Government Centers for Medicare and Medicaid Services Medicare Medicaid Military Health System TRICARE Department of Veterans Affairs (VA) Indian Health Service State Children's Health Insurance Program (SCHIP) EMTALA Federal Employees Health Benefits Program Reform Canadian and American health care systems compared National health insurance Prescription drug prices in the United States Single-payer health care Uninsured in the United States United States National Health Insurance Act Universal health care Reform advocacy groups American Medical Student Association California Nurses Association/National Nurses Organizing Committee Healthcare-NOW! Physicians for a National Health Program Progressive Democrats of America Private Health maintenance organization (HMO) Managed care Medical underwriting Preferred provider organization (PPO) Private consumer driven Flexible spending account (FSA) Health Reimbursement Account Health savings account High Deductible Health Plan (HDHP) Medical savings account

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Health care in the United States is provided by many separate legal entities. Including private and public spending, more is spent per person on health care in the United States than in any other nation in the world.^[1] A study of international health care spending levels published in the health policy journal Health Affairs in the year 2000, found that while the U.S. spends more on health care than other countries in the Organisation for Economic Co-operation and Development (OECD), the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study conclude that the prices paid for health care services are much higher in the U.S.^[2] In 1996, 5% of the population accounted for more than half of all costs.^[3][4] bitch

Active debate over health care reform in the United States concerns questions of a right to health care, access, fairness, efficiency, cost, and quality. The World Health Organization (WHO), in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study).^[5][6] The WHO study has been criticized in a study published in Health Affairs for its methodology and lack of correlation with user satisfaction ratings.^[7] A 2008 report by the Commonwealth Fund ranked the United States last in the quality of health care among the 19 compared countries.^[8] However, the U.S. is a leader in medical innovation, with three times higher per-capita spending than Europe.^[9] The U.S. also has higher survival rates than most other countries for certain conditions, such as some less common cancers, but has a higher infant mortality rate than all other developed countries.^[10]

As a proportion of GDP, public health care spending in the United States is larger than in most other large Western countries.^[11] On top of that, there is substantial expenditure paid from private insurances. According to the Institute of Medicine of the National Academy of Sciences, the United States is the "only wealthy, industrialized nation that does not ensure that all citizens have coverage" (i.e. some kind of insurance).^[12][13]

Contents 1 Health care providers 1.1 Facilities 1.2 Medical products, research and development 2 Health care spending 3 Health care payment 3.1 Private 3.2 Public 3.3 The uninsured 3.4 Role of government in health care market 4 Health care regulation and oversight 5 Overall system effectiveness 6 System efficiency and equity 6.1 Efficiency 6.1.1 Delays in seeking care and increased use of emergency care 6.1.2 Shared costs of the uninsured 6.1.3 Variations in provider practices 6.1.4 Care coordination 6.1.5 Administrative costs 6.2 Equity 6.2.1 Coverage 6.2.2 Mental health 6.2.3 Medical underwriting and the uninsurable 6.2.4 Demographic differences 7 Regulatory efficiency and equity 7.1 Healthcare regulatory costs 7.2 Emergency Medical Treatment and Active Labor Act (EMTALA) 8 Political issues 8.1 Prescription drug prices 8.2 Health care debate 9 See also 10 References 11 External links

[edit] Health care providers

[edit] Facilities

In the United States, ownership of the health care system is mainly in private hands, though federal, state, county, and city governments also own certain facilities.

The non-profit hospital's share of total hospital capacity has remained relatively stable (about 70%) for decades.^[14] There are also privately owned for-profit hospital as well as government hospitals in some locations, mainly owned by county and city governments.

There is no nationwide system of government-owned medical facilities that is open to the general public. The federal Department of Defense operates field hospitals as well as permanent hospitals (the Military Health System),to provide military-funded care to active military personnel. The federal Veterans Health Administration operates VA hospitals open only to veterans, though veterans who seek medical care for conditions they did not receive while serving in the military are charged for services. The Indian Health Service operates facilities open only to Native Americans from recognized tribes. These facilities, plus tribal facilities and privately contracted services funded by IHS to increase system capacity and capabilities, provide medical care to tribespeople beyond what can be paid for by any private insurance or other government programs.^[15]

Hospitals provide some outpatient care in their emergency rooms and specialty clinics, but primarily exist to provide inpatient care. Hospital emergency departments and urgent care centers are sources of sporadic problem-focused care. "Surgicenters" are examples of specialty clinics. Hospice services for the terminally ill who are expected to live six months or less are most commonly subsidized by charities and government. Prenatal, family planning, and "dysplasia" clinics are government-funded obstetric and gynecologic specialty clinics respectively, and are usually staffed by nurse practitioners.

A research brief published in December 2008 by the Center for Studying Health System Change found that most U.S. consumers rely on word of mouth and physician referrals when choosing health care providers.^[16]

[edit] Medical products, research and development

The United States is a leader in medical innovation. In 2004, the nonindustrial sector spent three times as much as Europe per capita on biomedical research.^[9] Companies provide medical products such as pharmaceuticals and medical devices. The nation spends a substantial amount on medical research, mostly privately funded. As of 2000, non-profit private organizations (such as the Howard Hughes Medical Institute) funded 7%, private industry funded 57%, and the tax-funded National Institutes of Health supported 36% of medical research in the U.S.^[17] However, by 2003, the NIH provided only 28% of medical research funding; finance from private industry increased 102% from 1994 to 2003.^[18] Research and development for applications is primarily done in commercial labs, while the government and universities fund the majority of general research.^{[citation needed]} Much of this basic research is funded or conducted by governmental research institutes such as the NIH.

[edit] Health care spending

Current estimates put U.S. health care spending at approximately 15.2% of GDP, second only to the tiny Marshall Islands among all United Nations member nations.^[1] The health share of GDP is expected to continue its historical upward trend, reaching 19.5 percent of GDP by 2017.^[19][20]

The Office of the Actuary (OACT) of the Centers for Medicare and Medicaid Services publishes data on total health care spending in the United States, including both historical levels and future projections.^[21] In 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person, up from $2.1 trillion, or $7,026 per capita, the previous year.^[22] Spending in 2006 represented 16% of GDP, an increase of 6.7% over 2004 spending. Growth in spending is projected to average 6.7% annually over the period 2007 through 2017. Health insurance costs are rising faster than wages or inflation, and medical causes were cited by about half of bankruptcy filers in the United States in 2001.^[23]

The Congressional Budget Office has found that "about half of all growth in health care spending in the past several decades was associated with changes in medical care made possible by advances in technology." Other factors included higher income levels, changes in insurance coverage, and rising prices.^[24] Hospitals and physician spending take the largest share of the health care dollar, while prescription drugs take about 10 percent.^[25] The use of prescription drugs is increasing among adults who have drug coverage.^[26]

One analysis of international spending levels in the year 2000 found that while the U.S. spends more on health care than other countries in the Organisation for Economic Co-operation and Development (OECD), the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study concluded that the prices paid for health care services are much higher in the U.S.^[2]

Health care spending in the United States is concentrated. An analysis of the 1996 Medical Expenditure Panel Survey found that the 1% of the population with the highest spending accounted for 27% of aggregate health care spending. The highest-spending 5% of the population accounted for more than half of all spending. These patterns were stable through the 1970s and 1980s, and some data suggest that they may have been typical of the mid-to-early 20th century as well.^[3][4] One study by the Agency for Healthcare Research and Quality (AHRQ) found significant persistence in the level of health care spending from year to year. Of the 1% of the population with the highest health care spending in 2002, 24.3% maintained their ranking in the top 1% in 2003. Of the 5% with the highest spending in 2002, 34% maintained that ranking in 2003. Individuals over age 45 were disproportionately represented among those who were in the top decile of spending for both years.^[27]

Seniors spend, on average, far more on health care costs than either working-age adults or children. The pattern of spending by age was stable for most ages from 1987 through 2004, with the exception of spending for seniors age 85 and over. Spending for this group grew less rapidly than that of other groups over this period.^[28]

The 2008 edition of the Dartmouth Atlas of Health Care^[29] found that providing Medicare beneficiaries with severe chronic illnesses with more intense health care in the last two years of life—increased spending, more tests, more procedures and longer hospital stays—is not associated with better patient outcomes. There are significant geographic variations in the level of care provided to chronically ill patients. Only a small portion of these spending differences (4%) is explained by differences in the number of severely ill people in an area; rather, most of the differences are explained by differences in the amount of "supply-sensitive" care available in an area. Acute hospital care accounts for over half (55%) of the spending for Medicare beneficiaries in the last two years of life, and differences in the volume of services provided is more significant than differences in price. The researchers found no evidence of "substitution" of care, where increased use of hospital care would reduce outpatient spending (or vice versa).^[30][31]

Increased spending on disease prevention is often suggested as a way of reducing health care spending. Research suggests, however, that in most cases prevention does not produce significant long-term costs savings. Preventive care is typically provided to many people who would never become ill, and for those who would have become ill is partially offset by the health care costs during additional years of life.^{[32][citation needed]}

In September 2008 The Wall Street Journal reported that consumers were reducing their health care spending in response to the current economic slow-down. Both the number of prescriptions filled and the number of office visits dropped between 2007 and 2008. In one survey, 22% of consumers reported going to the doctor less often, and 11% reported buying fewer prescription drugs.^[33]

[edit] Health care payment

In the United States, doctors and hospitals are generally funded by payments from patients and insurance plans in return for services rendered.

Around 84.7% of citizens have some form of health insurance; either through their employer or the employer of their spouse or parent (59.3%), purchased individually (8.9%), or provided by government programs (27.8%; there is some overlap in these figures).^[34] All government health care programs have restricted eligibility, and there is no national system of health insurance which guarantees that all citizens have access to health care. Americans without health insurance coverage at some time during 2007 totaled about 15.3% of the population, or 45.7 million people.^[34]

Among those whose employer pays for health insurance, the employee also usually contributes part of the cost of this insurance, while the employer usually chooses the plan and, for large groups, negotiates with the insurance company. In 2004, private insurance paid for 36% of personal health expenditures, private out-of-pocket 15%, federal government 34%, state and local governments 11%, and other private funds 4%.^[35]

Insurance for dental and vision care is usually sold separately, and prescription drugs are often handled differently than medical services, including by the government programs. Major federal laws regulating the insurance industry include COBRA and HIPAA.

Individuals with private or government insurance must generally find a medical facility which accepts the particular type of medical insurance they carry. Visits to facilities outside the insurance program's "network" are usually either not covered or the patient must bear more of the cost (usually waived for emergencies). Hospitals and doctors negotiate with insurance programs to set reimbursement rates; some rates for government insurance programs are set by law. The sum paid to a doctor for a service rendered to an insured patient is generally less than that paid "out of pocket" by an uninsured patient. In return for this discount, the insurance company includes the doctor as part of their "network", which means more patients are eligible for lowest-cost treatment there. The negotiated rate may not cover the cost of the service, but hospitals and doctors can refuse to accept a given type of insurance, including Medicare and Medicaid. Low reimbursement rates have generated complaints from providers, and some patients with government insurance have difficulty finding nearby providers for certain types of medical services.

Charity care for those who cannot pay is sometimes available from any given medical facility, and is usually funded by non-profit foundations, religious orders, government subsidies, or services donated by the employees. Massachusetts and New Jersey have programs where the state will pay for health care when the patient cannot afford to do so.^[36] The City of San Francisco is also implementing a citywide health care program for all uninsured residents, initially available to those whose incomes are below an eligibility threshold. Some cities and counties operate or provide subsidies to private facilities open to all regardless of the ability to pay, but even here patients who can afford to pay or who have insurance are generally charged for the services they use.

The Emergency Medical Treatment and Active Labor Act requires virtually all hospitals to accept all patients, regardless of the ability to pay, for emergency room care. This does not provide patients who cannot afford to pay for health care access to non-emergency care, nor does it provide the benefit of preventive care and the continuity of a primary care physician. This is also generally more expensive than an urgent care clinic or a doctor's office visit, especially if an condition has worsened due to putting off needed care. Emergency rooms are typically at, near, or over capacity. Long wait times have become a problem nationally, and in urban areas some ERs are put on "diversion" on a regular basis, meaning that ambulances are directed to bring patients elsewhere.^[37]

[edit] Private

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Most Americans (59.3%), receive their health insurance coverage through an employer (which includes both private as well as civilian public-sector employees) under group coverage, although this percentage is declining. Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation.^[38] Workers with employer-sponsored insurance also contribute; in 2007, the average percentage of premium paid by covered workers is 16% for single coverage and 28% for family coverage.^[38] In addition to their premium contributions, most covered workers face additional payments when they use health care services, in the form of deductibles and copayments.

Just less than 9% of the population purchases individual health care insurance.^[34] Insurance payments are a form of cost-sharing and risk management where each individual or their employer pays predictable monthly premiums. This cost-spreading mechanism often picks up much of the cost of health care, but individuals must often pay up-front a minimum part of the total cost (a ‘’deductible’’), or a small part of the cost of every procedure (a copayment).

Today, most employer-provided health coverage is provided through managed care organizations, which pay substantially lower prices for health care services than an individual patient would be charged if paying out-of-pocket. The defining characteristic of managed care, as distinct from traditional insurance, is selective contracting, meaning that the health plan has contracts with some (selected) health care providers. Selective contracting is the mechanism through which managed care organizations bring their market power to bear in negotiating price reductions from health care providers. Managed care organizations also often employ a variety of "incentive payment" schemes which shift onto the provider some of the risk if the enrollee uses a lot of health care. Capitation, in which the provider is paid a fixed sum to care for the enrollee regardless of how much care the enrollee uses, is an example of an incentive payment system. Many managed care organizations also use a "gatekeeper" model, in which an enrollee's primary care physician must provide a referral before the enrollee will be covered to receive specialist care. Both managed care organizations and traditional insurers also sometimes make use of non-payment cost control mechanisms, such as requiring prior administrative approval or second opinions before covering high-cost procedures.

Managed care organizations include both health maintenance organizations (HMOs) and preferred provider organizations (PPOs). In an HMO, health care is covered only for services delivered by providers (such as doctors or hospitals) in the network with whom the health plan has contracts. A PPO covers health care delivered by either in-network or out-of-network providers, but the enrollee's cost is higher when using out-of-network providers. Defying many analysts' expectations, PPOs have gained market share at the expense of HMOs over the past decade.^[39]

Just as the more loosely managed PPOs have edged out HMOs, HMOs themselves have also evolved towards less tightly managed models. The first HMOs in the U.S., such as Kaiser Permanente in Oakland, California, and the Health Insurance Plan (HIP) in New York, were "staff-model" HMOs, which owned their own health care facilities and employed the doctors and other health care professionals who staffed them. The name health maintenance organization stems from the idea that the HMO would make it its job to maintain the enrollee's health, rather than merely to treat illnesses. In accordance with this mission, managed care organizations typically cover preventive health care. Within the tightly integrated staff-model HMO, the HMO can develop and disseminate guidelines on cost-effective care, while the enrollee's primary care doctor can act as patient advocate and care coordinator, helping the patient negotiate the complex health care system. Despite a substantial body of research demonstrating that many staff-model HMOs deliver high-quality and cost-effective care, they have steadily lost market share. They have been replaced by more loosely managed networks of providers with whom health plans have negotiated discounted fees. It is common today for a physician or hospital to have contracts with a dozen or more health plans, each with different referral networks, contracts with different diagnostic facilities, and different practice guidelines.

In 2009, the New York state government accused Dr. John Muney of charging co-payments that were too low, and ordered him to triple the cost of his co-payments. ^[40]

[edit] Public

The government subsidizes employer-paid health care by exempting employer contributions from taxation as income. The value of this tax subsidy is an estimated $150 billion a year.^[41]

Government programs directly cover 27.8% of the population (83 million),^[34] including the elderly, disabled, children, veterans, and some of the poor, and federal law mandates public access to emergency services regardless of ability to pay. U.S. government programs accounted for over 45% of health care expenditures, making the U.S. government the largest insurer in the nation. Per-capita spending on health care by the U.S. government placed it among the top ten highest spenders among United Nations member countries in 2004.^[42]

Federally funded programs include:

• Medicare, generally covering citizens and long-term residents 65 years and older.
• Medicaid, generally covering low income people in certain categories, including children, pregnant women, and the disabled. (Administered by the states.)
• State Children's Health Insurance Program, which provides health insurance for low-income children who do not qualify for Medicaid. (Administered by the states, with matching state funds.)
• Various programs for federal employees, including TRICARE for military personnel (for use in civilian facilities)
• The Veterans Administration, which provides care to veterans, their families, and survivors through medical centers and clinics.^[43][44]

There are also various state and local programs for the poor. In 2007, Medicaid provided health care coverage for 39.6 million low-income Americans (although Medicaid covers approximately only 40% of America's poor),^[45]and Medicare provided health care coverage for 41.4 million elderly and disabled Americans.^[34] Enrollment in Medicare is expected to reach 77 million by 2031, when the baby boom generation is fully enrolled.^[46]

It has been reported that the number of physicians accepting Medicaid has decreased in recent years due to relatively high administrative costs and low reimbursements.^[47] In 1997, the federal government also created the State Children's Health Insurance Program (SCHIP), a joint federal-state program to insure children in families that earn too much to qualify for Medicaid but cannot afford health insurance.^[48] SCHIP covered 6.6 million children in 2006,^[49] but the program is already facing funding shortfalls in many states.^[50] The government has also mandated access to emergency care regardless of insurance status and ability to pay through the Emergency Medical Treatment and Labor Act (EMTALA), passed in 1986,^[51] but EMTALA is an unfunded mandate.^[52]

An analysis of the 2002 Medical Expenditure Panel Survey published in 2008 found that public spending represented slightly over half (56.1%) of U.S. health care spending. Public spending is highly correlated with age; average per capita public spending for seniors was more than five times that for children ($6,921 versus $1,225). Average public spending for non-Hispanic blacks ($2,973) was slightly higher than that for whites ($2,675), while spending for Hispanics ($1,967) was significantly lower than the population average ($2,612). Total public spending is also strongly correlated with self-reported health status ($13,770 for those reporting "poor" health versus $1,279 for those reporting "excellent" health).^[53]

[edit] The uninsured

Some Americans do not qualify for government-provided health insurance, are not provided health insurance by an employer, and are unable to afford, cannot qualify for, or choose not to purchase, private health insurance. When charity or "uncompensated" care is not available, they sometimes simply go without needed medical treatment. This problem has become a source of considerable political controversy on a national level.

In 2007, 45.7 million people in the U.S. (15.3% of the population) were without health insurance for at least part of the year. This number was down slightly from the previous year, with nearly 3 million more people receiving government coverage and a slightly lower percentage covered under private plans than the year previous.^[34]

Among the uninsured population, nearly 37 million were employment-age adults (ages 18 to 64), and more than 27 million worked at least part time. About 38% of the uninsured live in households with incomes of $50,000 or more.^[34] According to the Census Bureau, nearly 36 million of the uninsured are legal U.S citizens. Another 9.7 million are non-citizens, but the Census Bureau does not distinguish in its estimate between legal non-citizens and illegal immigrants.^[34] It has been estimated that nearly one fifth of the uninsured population is able to afford insurance, almost one quarter is eligible for public coverage, and the remaining 56% need financial assistance (8.9% of all Americans).^[54] However, extending coverage to all who are eligible remains a fiscal challenge.^[55]

A 2003 study in Health Affairs estimated that uninsured people in the U.S. received approximately $35 billion in uncompensated care in 2001.^[56] The study noted that this amount per capita was half what the average insured person received. The study found that various levels of government finance most uncompensated care, spending about $30.6 billion on payments and programs to serve the uninsured and covering as much as 80–85 percent of uncompensated care costs through grants and other direct payments, tax appropriations, and Medicare and Medicaid payment add-ons. Most of this money comes from the federal government, followed by state and local tax appropriations for hospitals. Another study by the same authors in the same year estimated the additional annual cost of covering the uninsured (in 2001 dollars) at $34 billion (for public coverage) and $69 billion (for private coverage). These estimates represent an increase in total health care spending of 3–6 percent and would raise health care’s share of GDP by less than one percentage point, the study concluded.^[57] Another study published in the same journal in 2004 estimated that the value of health forgone each year because of uninsurance was $65–$130 billion and concluded that this figure constituted "a lower-bound estimate of economic losses resulting from the present level of uninsurance nationally."^[58]

[edit] Role of government in health care market

Numerous publicly funded health care programs help to provide for the elderly, disabled, military service families and veterans, children, and the poor,^[59] and federal law ensures public access to emergency services regardless of ability to pay;^[60] however, a system of universal health care has not been implemented nation-wide.

Massachusetts has adopted a universal health care system through the Massachusetts 2006 Health Reform Statute. It mandates that all residents who can afford to do so purchase health insurance, provides subsidized insurance plans so that nearly everyone can afford health insurance, and provides a "Health Safety Net Fund" to pay for necessary treatment for those who cannot find affordable health insurance or are not eligible.^[61]

The cost impact of a mixed public-private system is subject to debate. Free-market advocates claim that there is direct correlation between government's health care spending and intervention in the health care market and increases in health care costs. Government intervention contributes to a "dysfunctional system of third-party payments" that removes the patient as a major participant in the financial and medical choices that affect costs.^[62] Increased utilization is indeed the primary driver of rising health care costs in the U.S., according to a recent study by PriceWaterhouseCoopers.^[63] The study cites numerous causes of increased utilization, including rising consumer demand, new treatments, more intensive diagnostic testing, lifestyle factors, the movement to broader-access plans, and higher-priced technologies.^[63] The study also mentions cost-shifting from government programs to private payers. Low reimbursement rates for Medicare and Medicaid have increased cost-shifting pressures on hospitals and doctors, who charge higher rates for the same services to private payers, which eventually affects health insurance rates.^[64] On the other hand, advocates for single-payer health care often point to other countries, where national government-funded systems produce better health outcomes at lower cost.

As an example of how government intervention has had unintended consequences, in 1973, the federal government passed the Health Maintenance Organization Act, which heavily subsidized the HMO business model — a model that was in decline prior to such legislative intervention. The law was intended to create market incentives that would lower health care costs, but HMOs have never achieved their cost-reduction potential.^[65] Piecemeal market-based reform efforts are complex. One study evaluating current popular market-based reform policy packages concluded that if market-oriented reforms are not implemented on a systematic basis with appropriate safeguards, they have the potential to cause more problems than they solve.^[66]

[edit] Health care regulation and oversight

In the federal government of the United States, the United States Department of Health and Human Services is the executive department responsible for health. It is managed by the Secretary of Health and Human Services, a member of the Cabinet.

On March 2, 2009, President Barack Obama introduced Kansas Gov. Kathleen Sebelius as his choice to fill the office of secretary of health and human services (still to be confirmed by the Senate) and Nancy-Ann Min DeParle, a health policy figure during the Presidency of Bill Clinton, to head the White House Office for Health Reform. President Obama also said he would release $155 million in the $787 billion economic stimulus measure to support 126 new health centers, with the goal of giving people more access to primary and preventive health care services.^[67]

State governments maintain state health departments, and local governments (counties and municipalities) often have their own health departments, usually branches of the state health department. Regulations of a state board may have executive and police strength to enforce state health laws. In some states, all members of state boards must be health care professionals. Members of state boards may be assigned by the governor or elected by the state committee. Members of local boards may be elected by the mayor council.

In 1980 the United States Congress legislated that the Department of Welfare and Health become the Department of Health and Human Services. The agencies of the Public Health Service are the Health Administration, which regulates health care to people without health care, the Food and Drug Administration, which certifies the safety of food, effectiveness of drugs and medical products, the Centers for Disease Prevention, which prevents disease, premature death, and disability, the Agency of Health Care Research and the Agency Toxic Substances and Disease Registry, which regulates hazardous spills of toxic substances.

There are government institutes such as the Centers for Disease Control and Prevention that identify threats to public health. In addition there are regulatory bodies such as the FDA that identify and approve drugs for medical use and sale. Many health care organizations also voluntarily submit to inspection and certification by the Joint Commission on Accreditation of Hospital Organizations, JCAHO.

A report issued by Public Citizen in April 2008 found that the number of serious disciplinary actions against physicians by state medical boards declined from 2006 to 2007. This was the third yearly decline in a row. The authors concluded that additional action is needed to improve the oversight provided by state medical boards.^[68][69]

The Centers for Medicare and Medicaid Services (CMS) publishes an on-line searchable database of performance data on nursing homes.^[70] CMS also publishes a list of Special Focus Facilities - nursing homes with "a history of serious quality issues."^[71][72] The Government Accountability Office (GAO), however, has found that state nursing home inspections understate the number of serious nursing home problems that present a danger to residents. The GAO concluded that while CMS oversight has improved, there are still weaknesses in its oversight of nursing homes.^[73][74]

The U.S. has a joint federal/state system for regulating insurance, with the federal government ceding primary responsibility to the states under the McCarran-Ferguson Act. States regulate the content of health insurance policies and often require coverage of specific types of medical services or health care providers.^[75][76] State mandates generally do not apply to the health plans offered by large employers, due to the preemption clause of the Employee Retirement Income Security Act.

[edit] Overall system effectiveness

The debate about U.S. health care concerns questions of access, efficiency, and quality purchased by the high sums spent. The World Health Organization (WHO) in 2000 ranked the U.S. health care system first in both responsiveness and expenditure, but 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).^[5][6] The WHO study has been criticized by the free market advocate David Gratzer because "fairness in financial contribution" was used as an assessment factor, marking down countries with high per-capita private or fee-paying health treatment.^[77] One study found that there was little correlation between the WHO rankings for health systems and the satisfaction of citizens using those systems.^[78] Some countries given the highest ratings by WHO were ranked poorly by their citizens. Others note that the WHO analysis does reflect system "responsiveness", and argue that this is a superior measure to consumer satisfaction, which is influenced by expectations.^[79]

The CIA World Factbook ranked the United States 41st in the world for lowest infant mortality rate^[80] and 46th for highest total life expectancy.^[81] A recent study found that between 1997 and 2003, preventable deaths declined more slowly in the United States than in 18 other industrialized nations.^[82] On the other hand, the National Health Interview Survey, released annually by the Centers for Disease Control's National Center for Health Statistics reported that approximately 66% of survey respondents said they were in "excellent" or "very good" health in 2006.^[83] According to a 2006 study published by The Lancet, survival rates in the U.S. for a broad range of cancer types are the highest in the world, with five year survival rates for men surpassing those of Britain's National Health Service by an average of more than 20%.^[10][84]

Recent studies find growing gaps in life expectancy based on income and geography. Life expectancy declined from 1983 to 1999 for women in 180 counties, and for men in 11 counties. Most of the declines occurred in the Deep South, Appalachia, along the Mississippi River, in the Southern Plains and in Texas. The life expectancy gap between counties with the highest and lowest life expectancies grew by 2 years for men and 10 months for women. The gap is growing between rich and poor and by educational level, but narrowing between men and women and by race.^[85] A study published in May 2008 found that the mortality gap between the well-educated and the poorly educated widened significantly between 1993 and 2001 for adults ages 25 through 64. Premature death is increasing for people who drop out of high-school, while death rates are dropping among college graduates. Mortality increased most rapidly for white, female drop-outs, and declined the most for African-American college graduates. While the study did not directly examine the underlying causes, the authors speculate that risk factors such as smoking, obesity and high blood pressure may lie behind these disparities.^[86][87][88]

A report released in April 2008 by the Foundation for Child Development, which studied the period from 1994 through 2006, found mixed results for the health of children in the U.S. Mortality rates for children ages 1 through 4 dropped by a third, and the percentage of children with elevated blood lead levels dropped by 84 percent. The percentage of mothers who smoked during pregnancy also declined. On the other hand, both obesity and the percentage of low-birth weight babies increased. The authors note that the increase in babies born with low birth weights can be attributed to women delaying childbearing and the increased use of fertility drugs.^[89][90]

A poll released in March 2008 by the Harvard School of Public Health and Harris Interactive found that Americans are divided in their views of the U.S. health system, and that there are significant differences by political affiliation. When asked whether the U.S. has the best health care system or if other countries have better systems, 45% said that the U.S. system was best and 39% said that other countries' systems are better. Belief that the U.S. system is best was highest among Republicans (68%), lower among independents (40%), and lowest among Democrats (32%). Over half of Democrats (56%) said they would be more likely to support a presidential candidate who advocates making the U.S. system more like those of other countries; 37% of independents and 19% of Republicans said they would be more likely to support such a candidate. 45% of Republicans said that they would be less likely to support such a candidate, compared to 17% of independents and 7% of Democrats.^[91][92]

[edit] System efficiency and equity

[edit] Efficiency

[edit] Delays in seeking care and increased use of emergency care

Uninsured Americans are less likely to have regular health care and use preventive services. They are more likely to delay seeking care, resulting in more medical crises, which are more expensive than ongoing treatment for such conditions as diabetes and high blood pressure. A 2007 study published in JAMA concluded that uninsured people were less likely than the insured to receive any medical care after an accidental injury or the onset of a new chronic condition. The uninsured with an injury were also twice as likely as those with insurance to have received none of the recommended follow-up care, and a similar pattern held for those with a new chronic condition.^[93] Uninsured patients are twice as likely to visit hospital emergency rooms as those with insurance; burdening a system meant for true emergencies with less-urgent care needs.^[94]

Another recent study by researchers with the American Cancer Society found that individuals who lacked private insurance were more likely to be diagnosed with late-stage cancer than those who had such insurance. This was true of both the uninsured as well as those covered by Medicaid. “Individuals without private insurance are not receiving optimum care in terms of cancer screening or timely diagnosis and follow-up with health care providers," study authors concluded.^[95][96][97]

[edit] Shared costs of the uninsured

The costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost shifting and higher health insurance premiums, or paid by taxpayers through higher taxes.^[98]

A report published by the Kaiser Family Foundation in April 2008 found that economic downturns place a significant strain on state Medicaid and SCHIP programs. The authors estimated that a 1% increase in the unemployment rate would increase Medicaid and SCHIP enrollment by 1 million, and increase the number uninsured by 1.1 million. State spending on Medicaid and SCHIP would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion). This increased spending would occur at the same time state government revenues were declining. During the last downturn, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules. The authors conclude that Congress should consider similar relief for the current economic downturn.^[99]

[edit] Variations in provider practices

The treatment given to a patient can vary significantly depending on which health care providers they use. Research suggests that some cost-effective treatments are not used as often as they should be, while other health care services are over-used.^[100][101] Unnecessary treatments increase costs and can cause patients unnecessary anxiety.^[102] The use of prescription drugs varies significantly by geographic region.^[103]

One study has found significant geographic variations in Medicare spending for patients in the last two years of life. These spending levels are associated with the amount of hospital capacity available in each area. Higher spending did not result in patients living longer.^{[104][105][106][107]}

[edit] Care coordination

Primary care doctors are often the point of entry for most patients needing care, but in the fragmented health care system of the U.S., many patients and their providers experience problems with care coordination. For example, a Harris Interactive survey of California physicians found that:

• Four of every ten physicians report that their patients have had problems with coordination of their care in the last 12 months.
• More than 60 percent of doctors report that their patients "sometimes" or "often" experience long wait times for diagnostic tests.
• Some 20 percent of doctors report having their patients repeat tests because of an inability to locate the results during a scheduled visit.^[108]

According to an article in The New York Times, the relationship between doctors and patients is deteriorating.^[109] A study from Johns Hopkins University found that roughly one in four patients believe their doctors have exposed them to unnecessary risks, and anecdotal evidence such as self-help books and web postings suggest increasing patient frustration. Possible factors behind the deteriorating doctor/patient relationship include the current system for training physicians and differences in how doctors and patients view the practice of medicine. Doctors may focus on diagnosis and treatment, while patients may be more interested in wellness and being listened to by their doctors.^[109]

Many primary care physicians no longer see their patients while they are in the hospital. Instead, hospitalists are used, which fragments care because hospitalists usually have had no previous relationship with the patient they are treating and do not have a personal knowledge of the patient's medical history.^[110][111] The use of hospitalists is sometimes mandated by health insurance companies as a cost saving measure which is resented by some primary care physicians.^[112]

[edit] Administrative costs

The health care system in the U.S. has a vast number of players. There are hundreds, if not thousands, of insurance companies in the U.S.^[113][41] This system has considerable administrative overhead, far greater than in nationalized, single-payer systems, such as Canada's. An oft-cited study by Harvard Medical School and the Canadian Institute for Health Information determined that some 31% of U.S. health care dollars, or more than $1,000 per person per year, went to health care administrative costs, nearly double the administrative overhead in Canada, on a percentage basis.^[114]

According to the insurance industry group America's Health Insurance Plans, administrative costs for private health insurance plans have averaged approximately 12 percent of premiums over the last 40 years. There has been a shift in the type and distribution of administrative expenses over that period. The cost of adjudicating claims has fallen, while insurers are spending more on other administrative activities, such as medical management, nurse help lines, and negotiating discounted fees with health care providers.^[115]

A 2003 study published by the Blue Cross and Blue Shield Association also found that health insurer administrative costs were approximately 11% to 12% of premiums, with Blue Cross and Blue Shield plans reporting slightly lower administrative costs, on average, than commercial insurers.^[116] For the period 1998 through 2003, average insurer administrative costs declined from 12.9% to 11.6% of premiums. The largest increases in administrative costs were in customer service and information technology, and the largest decreases were in provider services and contracting and in general administration.^[117] The McKinsey Global Institute estimated that excess spending on “health administration and insurance” accounted for as much as 21% of the estimated total excess spending ($477 billion in 2003).[4]

According to a report published by the CBO in 2008, administrative costs for private insurance represent approximately 12% of premiums. Variations in administrative costs between private plans are largely attributable to economies of scale. Coverage for large employers has the lowest administrative costs. The percentage of premium attributable to administration increases for smaller firms, and is highest for individually purchased coverage.^[118] In Massachusettts, widely cited as an example of private insurance based health reform, adding Blue Cross Blue Shield's "claims adjustment expenses" to "administrative expense" yields an overhead of between 14% and 15% ^[119]

However, broader studies also factor in billing and insurance-related (BIR) costs borne not only by insurers but by physicians and hospitals. One study of these costs in California found that BIR among insurers, physicians, and hospitals represented 20-22% of privately insured spending in California acute care settings.^[120]

[edit] Equity

[edit] Coverage

Enrollment rules in private and governmental programs result in millions of Americans going without health care coverage, including children. The U.S. Census Bureau estimates that 45.7 million Americans (about 15.3% of the total population) had no health insurance coverage at some point during 2007.^[34] Most uninsured Americans are working-class persons whose employers do not provide health insurance, and who earn too much money to qualify for one of the local or state insurance programs for the poor, but do not earn enough to cover the cost of enrollment in a health insurance plan designed for individuals. Some states (like California) do offer limited insurance coverage for working-class children, but not for adults; other states do not offer such coverage at all, and so, both parent and child are caught in the notorious coverage "gap." Although EMTALA^[121] certainly keeps alive many working-class people who are badly injured, the 1986 law neither requires the provision of preventive or rehabilitative care, nor subsidizes such care, and it does nothing about the difficulties in the American mental health system.

Coverage gaps also occur among the insured population—one study by the Commonwealth Fund published in Health Affairs estimated that 16 million U.S. adults were underinsured in 2003. The study defined underinsurance as characterized by at least one of the following conditions: annual out-of-pocket medical expenses totaling 10% or more of income, or 5 percent or more among adults with incomes below 200% of the federal poverty level; or health plan deductibles equaling or exceeding 5% of income. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes—73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level.^[122] Another study focusing on the effect of being uninsured found, however, that individuals with private insurance were less likely to be diagnosed with late-stage cancer than either the uninsured or Medicaid beneficiaries.^[95][96][97] A study examining the effects of health insurance cost-sharing more generally found that chronically ill patients with higher co-payments sought less care for both minor and serious symptoms. However, no effect on self-reported health status was observed. The authors concluded that the effect of cost sharing should be carefully monitored.^[123]

Coverage gaps and affordability also surfaced in a 2007 international comparison by the Commonwealth Fund. Among adults surveyed in the U.S., 37% reported that they had foregone needed medical care in the previous year because of cost; either skipping medications, avoiding seeing a doctor when sick, or avoiding other recommended care. The rate was even higher— 42%—among those with chronic conditions. The study reported that these rates were well above those found in the other six countries surveyed: Australia, Canada, Germany, the Netherlands, New Zealand, and the UK.^[124] The study also found that 19% of U.S. adults surveyed reported serious problems paying medical bills, more than double the rate in the next highest country.

[edit] Mental health

A lack of mental health coverage for Americans bears significant ramifications to the U.S. economy and social system. A report by the U.S. Surgeon General found that mental illnesses are the second leading cause of disability in the nation and affect 20 percent of all Americans.^[125] It is estimated that less than half of all people with mental illnesses receive treatment due to factors such as stigma and lack of access to care.^[126]

While the Mental Health Parity Act of 1996 forbade health insurance companies from providing less coverage (by dollar amount) for mental health care than other services, a loophole in the law allows companies to limit the number of doctor’s visits and hospital stays for mental illnesses.^[127] If a patient had a different, potentially life-threatening condition such as heart disease or cancer, this practice would not be legal.^[127]

In 2007, former First Lady Rosalynn Carter joined the son of the late Sen. Paul Wellstone to encourage Members of Congress to pass the "Paul Wellstone Mental Health and Addiction Equity Act", which would require greater parity for mental health care among policies that cover both physical and mental illnesses. Mrs. Carter and David Wellstone both testified during a House subcommittee hearing on the bill in July 2007.^[128]

On March 5, 2008, the House of Representatives passed the Wellstone bill.^[127] The Senate also has passed similar legislation.^[127] The Bush administration has said it opposes the House bill, but President Bush has not threatened to veto the legislation.^[129]

[edit] Medical underwriting and the uninsurable

In most states in the U.S., people seeking to purchase health insurance directly must undergo medical underwriting. Insurance companies seeking to mitigate the problem of adverse selection and manage their risk pools screen applicants for pre-existing conditions. Insurers may reject some applicants or quote increased rates for those with pre-existing conditions. Diseases that can make an individual uninsurable include serious conditions, such as arthritis, cancer, and heart disease, but also such common ailments as acne, being 20 pounds over or under weight, and old sports injuries.^[130] An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.^[131]

Proponents of medical underwriting argue that it ensures that individual health insurance premiums are kept as low as possible.^[132] Critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from obtaining health insurance.^[133]

One large industry survey found that 13 percent of applicants for individual health insurance who went through medical underwriting were denied coverage in 2004. Declination rates increased significantly with age, rising from 5 percent for those under 18 to just under one-third for those aged 60 to 64.^[134] Among those who were offered coverage, the study found that 76% received offers at standard premium rates, and 22% were offered higher rates.^[135] The frequency of increased premiums also increased with age, so for applicants over 40, roughly half were affected by medical underwriting, either in the form of denial or increased premiums. In contrast, almost 90% of applicants in their 20s were offered coverage, and three-quarters of those were offered standard rates. Seventy percent of applicants age 60–64 were offered coverage, but almost half the time (40%) it was at an increased premium. The study did not address how many applicants who were offered coverage at increased rates chose to decline the policy. A study conducted by the Commonwealth Fund in 2001 found that, among those aged 19 to 64 who sought individual health insurance during the previous three years, the majority found it unaffordable, and less than a third ended up purchasing insurance. However, this study did not distinguish between consumers who were quoted increased rates due to medical underwriting and those who qualified for standard or preferred premiums.^[136] Some states have outlawed medical underwriting as a prerequisite for individually purchased health coverage.^[137] These states tend to have the highest premiums for individual health insurance.^[138]

[edit] Demographic differences

In the United States, health disparities are well documented in ethnic minorities such as African Americans, Native Americans, Asian Americans, and Hispanics.^[139] When compared to whites, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes. Among the disease-specific examples of racial and ethnic disparities in the United States is the cancer incidence rate among African Americans, which is 25% higher than among whites.^[140] In addition, adult African Americans and Hispanics have approximately twice the risk as whites of developing diabetes. Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites.^[140] Caucasian Americans have much lower life expectancy than Asian Americans.^[141] A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.^[142]

Individual and institutional racism, along with the stigma of inferiority, can adversely affect health for minorities.^{[citation needed]} Racism can also directly affect health in multiple ways.^{[citation needed]} Residence in poor neighborhoods, racial bias in medical care, the stress of experiences of discrimination and the acceptance of the societal stigma of inferiority can have deleterious consequences for health.^[143]

There is a great deal of research into inequalities in health care. In some cases these inequalities are caused by income disparities that result in lack of health insurance and other barriers to receiving services.^[144] In other cases, inequalities in health care reflect a systemic bias in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of racism in science and medicine shows that people and institutions behave according to the ethos of their times.^[145] Nancy Krieger wrote that racism underlies unexplained inequities in health care, including treatment for heart disease,^[146] renal failure,^[147] bladder cancer,^[148] and pneumonia.^[149] Raj Bhopal writes that these inequalities have been documented in numerous studies. The consistent and repeated findings were that black Americans received less health care than white Americans —particularly when the care involved expensive new technology.^[150] However, one recent study has found that when minority and white patients use the same hospital, they are given the same standard of care.^[151][152]

[edit] Regulatory efficiency and equity

[edit] Healthcare regulatory costs

Some argue that the health care industry is likely to be the most heavily regulated industry in the United States.^[153] A study published by the Cato Institute suggests that this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion.^[153] The study concluded that the majority of the cost differential arises from medical malpractice, FDA regulations, and facilities regulations. Part of the cost is attributed to regulatory requirements that prevent technicians without medical degrees from performing treatment and diagnostic procedures that carry little risk.^[154]

[edit] Emergency Medical Treatment and Active Labor Act (EMTALA)

EMTALA, enacted by the federal government in 1986, requires that hospital emergency departments treat emergency conditions of all patients regardless of their ability to pay and is considered a critical element in the "safety net" for the uninsured. However, the federal law established no direct payment mechanism for such care. Indirect payments and reimbursements through federal and state government programs have never fully compensated public and private hospitals for the full cost of care mandated by EMTALA. In fact, more than half of all emergency care in the U.S. now goes uncompensated.^[155] According to some analyses, EMTALA is an unfunded mandate that has contributed to financial pressures on hospitals in the last 20 years, causing them to consolidate and close facilities, and contributing to emergency room overcrowding. According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26 percent, while in the same period, the number of emergency departments declined by 425.^[156] Hospitals attempt to bill uninsured patients directly under the fee-for-service model, but most such people cannot pay their hospital bills, and escape into bankruptcy when hospitals seek legal process against them. Although fee-for-service model can work in other service sectors, in the case of emergency care, such a model does not allow for the patient to shop for a better price and it does not force the hospital to reconsider its pricing.

Mentally ill patients present a unique challenge for emergency departments and hospitals. In accordance with EMTALA, mentally ill patients who enter emergency rooms are evaluated for emergency medical conditions. Once mentally ill patients are medically stable, regional mental health agencies are contacted to evaluate them. Patients are evaluated as to whether they are a danger to themselves or others. Those meeting this criterion are admitted to a mental health facility to be further evaluated by a psychiatrist. Typically, mentally ill patients can be held for up to 72 hours, after which a court order is required.

[edit] Political issues

[edit] Prescription drug prices

During the 1990s, the price of prescription drugs became a major issue in American politics as the prices of many new drugs increased exponentially, and many citizens discovered that neither the government nor their insurer would cover the cost of such drugs. In absolute currency, the U.S. spends the most on pharmaceuticals per capita in the world. However, national expenditures on pharmaceuticals accounted for only 12.9% of total healthcare costs, compared to an OECD average of 17.7% (2003 figures).^[157] Some 25% of out-of-pocket spending by individuals is for prescription drugs.^[158]

The U.S. government has taken the position (through the Office of the United States Trade Representative) that U.S. drug prices are rising because U.S. consumers are effectively subsidizing costs which drug companies cannot recover from consumers in other countries (because many other countries use their bulk-purchasing power to aggressively negotiate drug prices).^[159] The U.S. position (consistent with the primary lobbying position of the Pharmaceutical Research and Manufacturers of America) is that the governments of such countries are free riding on the backs of U.S. consumers. Such governments should either deregulate their markets, or raise their domestic taxes in order to fairly compensate U.S. consumers by directly remitting the difference (between what the companies would earn in an open market versus what they are earning now) to drug companies or to the U.S. government. In turn, pharmaceutical companies would be able to continue to produce innovative pharmaceuticals while lowering prices for U.S. consumers. Currently, the U.S., as a purchaser of pharmaceuticals, negotiates some drug prices but is forbidden by law from negotiating drug prices for the Medicare program due to a Medicare bill passed by the Republican-controlled 109th Congress and signed into law by President George W. Bush in 2005. Democrats have charged that the purpose of this provision is merely to allow the pharmaceutical industry to profiteer off of the Medicare program, which is already in imminent danger of becoming financially insolvent.[5]

[edit] Health care debate

According to the Institute of Medicine of the National Academy of Sciences, the United States is the only wealthy, industrialized nation that does not ensure universal coverage.^[12] There is currently an ongoing political debate centering around questions of access, efficiency, quality, and sustainability. Whether a government-mandated system of universal health care should be implemented in the U.S. remains a hotly debated political topic, with Americans divided along party lines in their views of the U.S. health system and what should be done to improve it. Those in favor of universal health care argue that the large number of uninsured Americans creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality.^[160] Opponents of government mandates or programs for universal health care argue that people should be free to opt out of health insurance^[161] and that government programs would require higher taxes, increase bureaucratic inefficiencies, increase utilization, and reduce health care quality.^{[citation needed]} Opponents also argue that the current level of government involvement in U.S. health care contributes to higher costs, and point to free-market solutions to increase efficiency, stimulate innovation, and make consumers rather than third parties more responsible for cost decisions.^{[citation needed]} Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.^[162][163]

[edit] See also

• Canadian and American health care systems compared
• Health care industry
• Health care politics
• Health care reform
• Health care systems
• HIV/AIDS in the United States
• List of healthcare accreditation organizations in the United States
• List of healthcare reform advocacy groups in the United States
• Medical cannabis
• Medicare Rights Center
• Military Health System
• Philosophy of healthcare
• School health services
• Sicko
• Single-payer health care
• United States National Health Insurance Act

[edit] References

[edit] External links

• National Health Expenditure Data (U.S.)
• National Center for Health Statistics
• Health Revolution Petition
• [6]-NOW on PBS episode "Gambling with Health Care"

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