Health care in the United States is provided by many separate legal entities.
HealthHealth is the level of functional or metabolic efficiency of a living being. In humans, it is the general condition of a person's mind, body and spirit, usually meaning to be free from illness, injury or pain...
care facilities are largely owned and operated by the
private sectorIn economics, the private sector is that part of the economy, sometimes referred to as the citizen sector, which is run by private individuals or groups, usually as a means of enterprise for profit, and is not controlled by the state...
.
Health insuranceThe term health insurance is commonly used in the United States to describe any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a non-insurance social welfare program funded by the government...
is now primarily provided by the government in the public sector, with 60-65% of healthcare provision and spending coming from programs such as
MedicareMedicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
,
Medicaid Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
,
TRICARETRICARE, formerly known as the Civilian Health and Medical Program of the Uniformed Services , is a health care program of the United States Department of Defense Military Health System. TRICARE provides civilian health benefits for military personnel, military retirees, and their dependents,...
, the Children's Health Insurance Program, and the
Veterans Health AdministrationThe Veterans Health Administration is the component of the United States Department of Veterans Affairs led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VA outpatient clinics,...
.
The
U.S. Census BureauThe United States Census Bureau is the government agency that is responsible for the United States Census. It also gathers other national demographic and economic data...
reported that a record 50.7 million residents (which includes 9.9 million non-citizens) or 16.7% of the population were uninsured in 2009. More money
per person is spent on health care in the USA than in any other nation in the world, and a greater percentage of
total income in the nationGross domestic product refers to the market value of all final goods and services produced within a country in a given period. GDP per capita is often considered an indicator of a country's standard of living....
is spent on health care in the USA than in any United Nations member state except for
East TimorThe Democratic Republic of Timor-Leste, commonly known as East Timor , is a state in Southeast Asia. It comprises the eastern half of the island of Timor, the nearby islands of Atauro and Jaco, and Oecusse, an exclave on the northwestern side of the island, within Indonesian West Timor...
. Although not all people are insured, the USA has the third highest public healthcare expenditure per capita, because of the high cost of medical care in the country. A 2001 study in five states found that
medical debtMedical debt refers to debt incurred by individuals due to health care costs and related expenses.Medical debt is different from other forms of debt, because it is usually incurred accidentally or faultlessly...
contributed to 46.2% of all
personal bankruptciesBankruptcy in the United States is governed under the United States Constitution which authorizes Congress to enact "uniform Laws on the subject of Bankruptcies throughout the United States." Congress has exercised this authority several times since 1801, most recently by adopting the Bankruptcy...
and in 2007, 62.1% of filers for bankruptcies claimed high medical expenses. Since then, health costs and the numbers of uninsured and underinsured have increased.
Active debate about
health care reform in the United StatesHealth care reform in the United States has a long history, of which the most recent results were two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act , signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 , which amended the PPACA and...
concerns questions of a
right to health careRights are legal, social, or ethical principles of freedom or entitlement; that is, rights are the fundamental normative rules about what is allowed of people or owed to people, according to some legal system, social convention, or ethical theory...
, access, fairness, efficiency, cost, choice, value, and quality. Some have argued that the system does not deliver equivalent value for the money spent. The USA pays twice as much yet lags behind other wealthy nations in such measures as
infant mortalityInfant mortality is defined as the number of infant deaths per 1000 live births. Traditionally, the most common cause worldwide was dehydration from diarrhea. However, the spreading information about Oral Re-hydration Solution to mothers around the world has decreased the rate of children dying...
and
life expectancyLife expectancy is the expected number of years of life remaining at a given age. It is denoted by ex, which means the average number of subsequent years of life for someone now aged x, according to a particular mortality experience...
, though the relation between these statistics to the system itself is debated. Currently, the USA has a higher infant mortality rate than most of the world's industrialized nations.
[Falling from 12th in 1960 to 23d in 1990 to 29th in 2004] In the United States life expectancy is 42nd in the world, after some other industrialized nations, lagging the other nations of the
G5The Group of Five encompasses five nations which have joined together for an active role in the rapidly evolving international order. Individually and as a group, the G5 nations work to promote dialogue and understanding between developing and developed countries. The G5 seek to find common...
(Japan, France, Germany, UK, USA) and just after Chile (35th) and Cuba (37th).
Life expectancy in the USA is 42nd in the world, below most developed nations and some developing nations. It is below the average life expectancy for the European Union. The
World Health OrganizationThe World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
(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). The
Commonwealth FundThe Commonwealth Fund is a private U.S. foundation whose stated purpose is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, especially for society's most vulnerable.-History:...
ranked the United States last in the quality of health care among similar countries, and notes U.S. care costs the most.
The USA is the "only wealthy, industrialized nation that does not ensure that all citizens have coverage" (i.e., some kind of private or public health insurance). In 2004, the
Institute of MedicineThe Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
report observed "lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States." while a 2009 Harvard study estimated that 44,800 excess deaths occurred annually due to lack of health insurance.
On March 23, 2010, the
Patient Protection and Affordable Care ActThe Patient Protection and Affordable Care Act is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law is the principal health care reform legislation of the 111th United States Congress...
(PPACA) became law, providing for major changes in health insurance.
Health care providers
Health care providerA health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....
s in the United States encompass individual health care personnel, health care facilities and medical products.
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 hospitalA non-profit hospital, or not-for-profit hospital, is a hospital which is organized as a non-profit corporation. Based on their charitable purpose and most often affiliated with a religious denomination they are a traditional means of delivering medical care in the United States...
s share of total hospital capacity has remained relatively stable (about 70%) for decades. There are also
privately owned for-profit hospitalsFor-profit hospitals, or alternatively investor-owned hospitals, are investor-owned chains of hospitals which have been established particularly in the United States during the late twentieth century. In contrast to the traditional and more common non-profit hospitals, they attempt to garner a...
as well as
government hospitalsA public hospital or government hospital is a hospital which is owned by a government and receives government funding. This type of hospital provides medical care free of charge, the cost of which is covered by the funding the hospital receives....
in some locations, mainly owned by county and city governments.
There is no nationwide system of government-owned medical facilities open to the general public but there are local government-owned medical facilities open to the general public. The federal
Department of DefenseThe United States Department of Defense is the U.S...
operates field hospitals as well as permanent hospitals (the
Military Health SystemThe Military Health System is the enterprise within the United States Department of Defense responsible for providing health care to active duty and retired U.S. Military personnel and their dependents...
), to provide military-funded care to active military personnel.
The federal
Veterans Health AdministrationThe Veterans Health Administration is the component of the United States Department of Veterans Affairs led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VA outpatient clinics,...
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 ServiceIndian Health Service is an Operating Division within the U.S. Department of Health and Human Services . IHS is responsible for providing medical and public health services to members of federally recognized Tribes and Alaska Natives...
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.
HospitalA hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
s provide some outpatient care in their emergency rooms and specialty clinics, but primarily exist to provide inpatient care. Hospital
emergency departmentAn emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
s and
urgent careUrgent care is the delivery of ambulatory care in a facility dedicated to the delivery of medical care outside of a hospital emergency department, usually on an unscheduled, walk-in basis. Urgent care centers are primarily used to treat patients who have an injury or illness that requires immediate...
centers are sources of sporadic problem-focused care. "Surgicenters" are examples of specialty clinics.
HospiceHospice is a type of care and a philosophy of care which focuses on the palliation of a terminally ill patient's symptoms.In the United States and Canada:*Gentiva Health Services, national provider of hospice and home health services...
services for the terminally ill who are expected to live six months or less are most commonly subsidized by charities and government. Prenatal,
family planningFamily planning is the planning of when to have children, and the use of birth control and other techniques to implement such plans. Other techniques commonly used include sexuality education, prevention and management of sexually transmitted infections, pre-conception counseling and...
, and "
dysplasiaDysplasia , is a term used in pathology to refer to an abnormality of development. This generally consists of an expansion of immature cells, with a corresponding decrease in the number and location of mature cells. Dysplasia is often indicative of an early neoplastic process...
" clinics are government-funded obstetric and gynecologic specialty clinics respectively, and are usually staffed by nurse practitioners.
Physicians
Physicians in the United States include those trained by the
US medical educationMedical education in the United States includes educational activities involved in the education and training of medical doctors in the United States, from entry-level training through to continuing education of qualified specialists....
system, and those that are
international medical graduateAn International Medical Graduate or "IMGs", earlier known as a Foreign Medical Graduate or "FMGs", is a term used to describe a physician who has graduated from a medical school outside of the country in which he or she intends to practice...
s who have progressed through the necessary steps to acquire a
medical licenseIn most countries, only persons with a medical license bestowed either by a specified government-approved professional association or a government agency are authorized to practice medicine. Licenses are not granted automatically to all people with medical degrees...
to practice in a state.
The
American College of PhysiciansThe American College of Physicians is a national organization of doctors of internal medicine —physicians who specialize in the prevention, detection, and treatment of illnesses in adults. With 130,000 members, ACP is the largest medical-specialty organization and second-largest physician group in...
, uses the term
physician to describe all medical practitioners holding a professional
medical degreeA medical degree is, broadly defined, any academic degree which places its holder in a position to engage in the practice of medicine. BBC has reported that Medicine related degree programs such as MBBS, BDS and PharmD are the most difficult degree programs of all the other Bachelor degree programs...
. The
American Medical AssociationThe American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
as well as the
American Osteopathic AssociationThe American Osteopathic Association is the representative member organization for the over 78,000 osteopathic medical physicians in the United States...
both currently use the term
physician to describe members.
Medical products, research and development
As in most other countries, the manufacture and production of
pharmaceuticalsA pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
and medical devices is carried out by private companies. The research and development of medical devices and pharmaceuticals is supported by both public and private sources of funding. In 2003, research and development expenditures were approximately $95 billion with $40 billion coming from public sources and $55 billion coming from private sources.
These investments into medical research have made the United States the leader in medical innovation, measured either in terms of revenue or the number of new drugs and devices introduced. In 2006, the United States accounted for three quarters of the world’s biotechnology revenues and 82% of world R&D spending in biotechnology. According to multiple international pharmaceutical trade groups, the high cost of patented drugs in the U.S. has encouraged substantial reinvestment in such research and development.
Health care spending
Current estimates put U.S. health care spending at approximately 16% of
GDPGross domestic product refers to the market value of all final goods and services produced within a country in a given period. GDP per capita is often considered an indicator of a country's standard of living....
, second highest to
East Timor (Timor-Leste)The Democratic Republic of Timor-Leste, commonly known as East Timor , is a state in Southeast Asia. It comprises the eastern half of the island of Timor, the nearby islands of Atauro and Jaco, and Oecusse, an exclave on the northwestern side of the island, within Indonesian West Timor...
among all
United NationsThe United Nations is an international organization whose stated aims are facilitating cooperation in international law, international security, economic development, social progress, human rights, and achievement of world peace...
member nations. The Health and Human Services Department expects that the health share of GDP will continue its historical upward trend, reaching 19.5% of GDP by 2017. Of each dollar spent on health care in the United States, 31% goes to hospital care, 21% goes to
physicianA physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
/clinical services, 10% to pharmaceuticals, 4% to
dentalDentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...
, 6% to
nursing homeA nursing home, convalescent home, skilled nursing unit , care home, rest home, or old people's home provides a type of care of residents: it is a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living...
s and 3% to home health care, 3% for other retail products, 3% for government public health activities, 7% to administrative costs, 7% to
investmentInvestment has different meanings in finance and economics. Finance investment is putting money into something with the expectation of gain, that upon thorough analysis, has a high degree of security for the principal amount, as well as security of return, within an expected period of time...
, and 6% to other professional services (physical therapists, optometrists, etc).
The Office of the Actuary (OACT) of the
Centers for Medicare and Medicaid ServicesThe Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
publishes data on total health care spending in the United States, including both historical levels and future projections. 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. 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.
In 2009, the United States federal, state and local governments, corporations and individuals, together spent $2.5 trillion, $8,047 per person, on health care. This amount represented 17.3% of the GDP, up from 16.2% in 2008. 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.
The
Congressional Budget OfficeThe Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
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. Hospitals and physician spending take the largest share of the health care dollar, while prescription drugs take about 10%. The use of prescription drugs is increasing among adults who have drug coverage.
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 DevelopmentThe Organisation for Economic Co-operation and Development is an international economic organisation of 34 countries founded in 1961 to stimulate economic progress and world trade...
(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. Economist
Hans SennholzHans F. Sennholz was an economist of the Austrian school of economics who studied under Ludwig von Mises. After serving in the Luftwaffe in World War II, he took degrees at the universities of Marburg and Köln. He then moved to the United States to study for a Ph.D. at New York University...
has argued that the Medicare and Medicaid programs may be the main reason for rising health care costs in the U.S.
Health care spending in the United States is concentrated. An analysis of the 1996
Medical Expenditure Panel SurveyThe Medical Expenditure Panel Survey is a family of surveys intended to provide nationally-representative estimates of health expenditure, utilization, payment sources, health status, and health insurance coverage among the noninstitutionalized, nonmilitary population of the United States...
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.
One study by the
Agency for Healthcare Research and QualityThe Agency for Healthcare Research and Quality is a part of the United States Department of Health and Human Services, which supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective...
(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.
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.
The 2008 edition of the Dartmouth Atlas of Health Care 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 4% of which are explained by differences in the number of severely ill people in an area. 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).
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.
In September 2008
The Wall Street JournalThe Wall Street Journal is an American English-language international daily newspaper. It is published in New York City by Dow Jones & Company, a division of News Corporation, along with the Asian and European editions of the 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.
In 2009, the average private room in a nursing home cost $219 daily. Assisted living costs averaged $3,131 monthly. Home health aides averaged $21 per hour. Adult day care services averaged $67 daily.
Impact on U.S. economic productivity
On March 1, 2010, billionaire investor
Warren BuffettWarren Edward Buffett is an American business magnate, investor, and philanthropist. He is widely regarded as one of the most successful investors in the world. Often introduced as "legendary investor, Warren Buffett", he is the primary shareholder, chairman and CEO of Berkshire Hathaway. He is...
said that the high costs paid by U.S. companies for their employees’ health care put them at a competitive disadvantage. He compared the roughly 17% of GDP spent by the U.S. on health care with the 9% of GDP spent by much of the rest of the world, noted that the U.S. has fewer doctors and nurses per person, and said, “[t]hat kind of a cost, compared with the rest of the world, is like a tapeworm eating at our economic body.”
Health care payment
Doctors and hospitals are generally funded by payments from patients and insurance plans in return for services rendered (
fee-for-serviceFee-for-service is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care...
or FFS).
Around 84.7% of Americans have some form of
health insuranceThe term health insurance is commonly used in the United States to describe any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a non-insurance social welfare program funded by the government...
; 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). All government health care programs have restricted eligibility, and there is no government health insurance company which covers all Americans. Americans without health insurance coverage in 2007 totaled 15.3% of the population, or 45.7 million people.
Among those whose employer pays for health insurance, the employee may be required to contribute part of the cost of this insurance, while the employer usually chooses the insurance company 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%. Due to "a dishonest and inefficient system" that sometimes inflates bills to ten times the actual cost, even insured patients can be billed more than the real cost of their care.
Insurance for dental and vision care (except for visits to ophthalmologists, which are covered by regular health insurance) is usually sold separately. Prescription drugs are often handled differently than medical services, including by the government programs. Major federal laws regulating the insurance industry include
COBRAThe Consolidated Omnibus Budget Reconciliation Act of 1985 is a law passed by the U.S. Congress on a reconciliation basis and signed by President Reagan that, among other things, mandates an insurance program giving some employees the ability to continue health insurance coverage after leaving...
and
HIPAAThe Health Insurance Portability and Accountability Act of 1996 was enacted by the U.S. Congress and signed by President Bill Clinton in 1996. It was originally sponsored by Sen. Edward Kennedy and Sen. Nancy Kassebaum . Title I of HIPAA protects health insurance coverage for workers and their...
.
Individuals with private or government insurance are limited to medical facilities which accept 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. Hospitals 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 providers (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 careIn the United States, charity care is health care provided for free or at reduced prices to low income patients. The percentage of doctors providing charity care dropped from 76% in 1996-97 to 68% in 2004-2005. Potential reasons for the decline include changes in physician practice patterns and...
for those who cannot pay is sometimes available, 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. The City and County of San Francisco is also implementing a
citywide health care programHealthy San Francisco is a program to subsidize medical care for certain uninsured residents of San Francisco. The program's stated objective is to bring universal health care to the city, but eligibility and services are limited, and the program website states that insurance "is always a better...
for all uninsured residents, limited to those whose incomes and net worth 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 ActThe Emergency Medical Treatment and Active Labor Act is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act . It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to...
requires virtually all hospitals to accept all patients, regardless of the ability to pay, for emergency room care. The act does not provide access to non-emergency room care for patients who cannot afford to pay for health care, nor does it provide the benefit of preventive care and the continuity of a
primary care physicianA primary care physician, or PCP, is a physician/medical doctor who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis....
. Emergency health care is generally more expensive than an
urgent careUrgent care is the delivery of ambulatory care in a facility dedicated to the delivery of medical care outside of a hospital emergency department, usually on an unscheduled, walk-in basis. Urgent care centers are primarily used to treat patients who have an injury or illness that requires immediate...
clinic or a doctor's office visit, especially if a 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.
Private
Most Americans under age 65 (59.3%) receive their health insurance coverage through an employer (which includes both private as well as civilian public-sector employers) under
group coverageGroup insurance is an insurance that covers a group of people, usually who are the members of societies, employees of a common employer, or professionals in a common group....
, 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. 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. 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. 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
copaymentIn the United States, the copayment or copay is a payment defined in the insurance policy and paid by the insured person each time a medical service is accessed. It is technically a form of coinsurance, but is defined differently in health insurance where a coinsurance is a percentage payment after...
). Private insurance accounts for 35% of total health spending in the United States, by far the largest share among OECD countries. Beside the United States, Canada and France are the two other OECD countries where private insurance represents more than 10% of total health spending.
Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently. A survey issued in 2009 by America's Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees.
Defying many analysts' expectations, PPOs have gained market share at the expense of HMOs over the past decade.
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 PermanenteKaiser Permanente is an integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield...
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.
Public
Government programs directly cover 27.8% of the population (83 million), 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. Public spending accounts for between 45% and 56.1% of U.S. health care spending. 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.
Government funded programs include:
- Medicare
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
, generally covering citizens and long-term residents 65 years and older and the disabled.
- Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
, 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
The State Children's Health Insurance Program – later known more simply as the Children's Health Insurance Program – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children...
, 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
TRICARE, formerly known as the Civilian Health and Medical Program of the Uniformed Services , is a health care program of the United States Department of Defense Military Health System. TRICARE provides civilian health benefits for military personnel, military retirees, and their dependents,...
for military personnel (for use in civilian facilities)
- The Veterans Administration
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
, which provides care to veterans, their families, and survivors through medical centers and clinics.
- Title X
The Title X Family Planning Program, officially known as Public Law 91-572 or “Population Research and Voluntary Family Planning Programs” was enacted under President Richard Nixon in 1970 as part of the Public Health Service Act...
which funds reproductive health care
- State and local health department clinics
- Indian health service
Indian Health Service is an Operating Division within the U.S. Department of Health and Human Services . IHS is responsible for providing medical and public health services to members of federally recognized Tribes and Alaska Natives...
- National Institutes of Health
The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...
treats patients who enroll in research for free.
- Medical Corps of various branches of the military.
- Certain county and state hospitals
- Government run community clinics
The exemption of employer-sponsored health benefits from federal income and payroll taxes distorts the health care market. The U.S. government, unlike some other countries, does not treat employer funded health care benefits as a taxable benefit in kind to the employee. The value of the lost tax revenue from a benefits in kind tax is an estimated $150 billion a year. Some regard this as being disadvantageous to people who have to buy insurance in the individual market which must be paid from income received after tax.
Health insurance benefits are an attractive way for employers to increase the salary of employees as they are nontaxable. As a result, 65% of the non-elderly population and over 90% of the privately insured non-elderly population receives health insurance at the workplace. Additionally, most economists agree that this tax shelter increases individual demand for health insurance, leading some to claim that it is largely responsible for the rise in health care spending.
In addition the government allows full tax shelter at the highest marginal rate to investors in
health savings accountA health savings account is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan . The funds contributed to an account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account...
s (HSAs). Some have argued that this tax incentive adds little value to national health care as a whole because the most wealthy in society tend also to be the most healthy. Also it has been argued, HSAs segregate the insurance pools into those for the wealthy and those for the less wealthy which thereby makes equivalent insurance cheaper for the rich and more expensive for the poor. However, one advantage of health insurance accounts is that funds can only be used towards certain HSA qualified expenses, including medicine, doctor's fees, and Medicare Parts A and B. Funds cannot be used towards expenses such as cosmetic surgery.
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 40% of America's poor), and Medicare provided health care coverage for 41.4 million elderly and disabled Americans. Enrollment in Medicare is expected to reach 77 million by 2031, when the
baby boomThe end of World War II brought a baby boom to many countries, especially Western ones. There is some disagreement as to the precise beginning and ending dates of the post-war baby boom, but it is most often agreed to begin in the years immediately after the war, ending more than a decade later;...
generation is fully enrolled.
It has been reported that the number of physicians accepting
Medicaid Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
has decreased in recent years due to relatively high administrative costs and low reimbursements. In 1997, the federal government also created the
State Children's Health Insurance ProgramThe State Children's Health Insurance Program – later known more simply as the Children's Health Insurance Program – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children...
(SCHIP), a joint federal-state program to insure children in families that earn too much to qualify for Medicaid but cannot afford health insurance. SCHIP covered 6.6 million children in 2006, but the program is already facing funding shortfalls in many states. The government has also mandated access to emergency care regardless of insurance status and ability to pay through the
Emergency Medical Treatment and Labor ActThe Emergency Medical Treatment and Active Labor Act is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act . It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to...
(EMTALA), passed in 1986, but EMTALA is an unfunded mandate.
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.
According to the US Census Bureau, 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. Other studies have placed the number of uninsured in the years 2007–2008 as high as 86.7 million, about 29% of the US population.
Among the uninsured population, the Census Bureau says, 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. 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. 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). Extending coverage to all who are eligible remains a fiscal challenge.
A 2003 study in
Health Affairs estimated that uninsured people in the U.S. received approximately $35 billion in uncompensated care in 2001. 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% 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% and would raise health care’s share of GDP by less than one percentage point, the study concluded. 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."
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, and federal law ensures
public access to emergency servicesThe Emergency Medical Treatment and Active Labor Act is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act . It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to...
regardless of ability to pay; however, a system of
universal health careUniversal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...
has not been implemented nation-wide. However, as the OECD has pointed out, the total U.S. public expenditure for this limited population would, in most other OECD countries, be enough for the government to provide primary health insurance for the entire population. Although the federal Medicare program and the federal-state Medicaid programs possess some
monopsonisticIn economics, a monopsony is a market form in which only one buyer faces many sellers. It is an example of imperfect competition, similar to a monopoly, in which only one seller faces many buyers...
purchasing power, the highly fragmented buy side of the U.S. health system is relatively weak by international standards, and in some areas, some suppliers such as large hospital groups have a virtual monopoly on the supply side. In most OECD countries, there is a high degree of public ownership and public finance. The resulting economy of scale in providing health care services appears to enable a much tighter grip on costs. The U.S., as a matter of oft-stated public policy, largely does not regulate prices of services from private providers, assuming the
private sectorIn economics, the private sector is that part of the economy, sometimes referred to as the citizen sector, which is run by private individuals or groups, usually as a means of enterprise for profit, and is not controlled by the state...
to do it better.
MassachusettsThe Commonwealth of Massachusetts is a state in the New England region of the northeastern United States of America. It is bordered by Rhode Island and Connecticut to the south, New York to the west, and Vermont and New Hampshire to the north; at its east lies the Atlantic Ocean. As of the 2010...
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.
In July 2009,
ConnecticutConnecticut is a state in the New England region of the northeastern United States. It is bordered by Rhode Island to the east, Massachusetts to the north, and the state of New York to the west and the south .Connecticut is named for the Connecticut River, the major U.S. river that approximately...
passed into law a plan called
SustiNetSustiNet is a Connecticut health care plan passed into law in July, 2009. Its goal is to provide affordable health care coverage to 98% of Connecticut residents by 2014.-Provisions of the legislation:...
, with the goal of achieving health-care coverage of 98% of its residents by 2014.
Health care regulation and oversight
Involved organizations and institutions
Healthcare is subject to extensive regulation at both the
federalThe federal government of the United States is the national government of the constitutional republic of fifty states that is the United States of America. The federal government comprises three distinct branches of government: a legislative, an executive and a judiciary. These branches and...
and the
state levelA U.S. state is any one of the 50 federated states of the United States of America that share sovereignty with the federal government. Because of this shared sovereignty, an American is a citizen both of the federal entity and of his or her state of domicile. Four states use the official title of...
, much of which "arose haphazardly". Under this system, the federal government cedes primary responsibility to the states under the
McCarran-Ferguson ActThe McCarran–Ferguson Act, 15 U.S.C. §§ 1011-1015, is a United States federal law that exempts the business of insurance from most federal regulation, including federal anti-trust laws to a limited extent. The McCarran–Ferguson Act was passed by Congress in 1945 after the Supreme Court ruled in...
. Essential regulation includes the
licensureLicensure refers to the granting of a license, which gives a "permission to practice." Such licenses are usually issued in order to regulate some activity that is deemed to be dangerous or a threat to the person or the public or which involves a high level of specialized skill...
of
health care providerA health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....
s at the state level and the testing and approval of pharmaceuticals and
medical deviceA medical device is a product which is used for medical purposes in patients, in diagnosis, therapy or surgery . Whereas medicinal products achieve their principal action by pharmacological, metabolic or immunological means. Medical devices act by other means like physical, mechanical, thermal,...
s by the
Food and Drug AdministrationThe Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
, and laboratory testing. These regulations are designed to protect consumers from ineffective or fraudulent healthcare. Additionally, states regulate the health insurance market and they often have laws which require that health insurance companies cover certain procedures, although state mandates generally do not apply to the
self-funded health careSelf-funded health care is a self insurance arrangement whereby an employer provides health or disability benefits to employees with its own funds. This is different from fully insured plans where the employer contracts an insurance company to cover the employees and dependents. In self-funded...
plans offered by large employers, which exempt from state laws under preemption clause of the
Employee Retirement Income Security ActThe Employee Retirement Income Security Act of 1974 is an American federal statute that establishes minimum standards for pension plans in private industry and provides for extensive rules on the federal income tax effects of transactions associated with employee benefit plans...
. In 2010, the
Patient Protection and Affordable Care ActThe Patient Protection and Affordable Care Act is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law is the principal health care reform legislation of the 111th United States Congress...
(PPACA) was passed, and includes various new regulations, with one of the most notable being a
health insurance mandateA health insurance mandate is either an employer or individual mandate to obtain private health insurance, instead of a National Health Service or National Health Insurance.-United States:...
which requires all citizens to purchase health insurance. While not regulation per se, the federal government also has a major influence on the healthcare market through its payments to providers under Medicare and Medicaid, which in some cases are used as a reference point in the negotiations between medical providers and insurance companies.
At the federal level,
United States Department of Health and Human ServicesThe United States Department of Health and Human Services is a Cabinet department of the United States government with the goal of protecting the health of all Americans and providing essential human services. Its motto is "Improving the health, safety, and well-being of America"...
oversees the various federal agencies involved in health care. The health agencies are a part of the
United States Public Health ServiceThe Public Health Service Act of 1944 structured the United States Public Health Service as the primary division of the Department of Health, Education and Welfare , which later became the United States Department of Health and Human Services. The PHS comprises all Agency Divisions of Health and...
, and include 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 Quality, the Agency Toxic Substances and Disease Registry, which regulates hazardous spills of toxic substances, and the
National Institutes of HealthThe National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...
, which conducts medical research.
State governmentsState governments in the United States are those republics formed by citizens in the jurisdiction thereof as provided by the United States Constitution; with the original 13 States forming the first Articles of Confederation, and later the aforementioned Constitution. Within the U.S...
maintain state health departments, and
local governmentsLocal government in the United States is generally structured in accordance with the laws of the various individual states. Typically each state has at least two separate tiers: counties and municipalities. Some states have their counties divided into townships...
(
countiesIn the United States, a county is a geographic subdivision of a state , usually assigned some governmental authority. The term "county" is used in 48 of the 50 states; Louisiana is divided into parishes and Alaska into boroughs. Parishes and boroughs are called "county-equivalents" by the U.S...
and
municipalitiesA municipality is essentially an urban administrative division having corporate status and usually powers of self-government. It can also be used to mean the governing body of a municipality. A municipality is a general-purpose administrative subdivision, as opposed to a special-purpose district...
) 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. The McCarran–Ferguson Act, which cedes regulation to the states, does not itself regulate insurance, nor does it mandate that states regulate insurance. "Acts of Congress" that do not expressly purport to regulate the "business of insurance" will not preempt state laws or regulations that regulate the "business of insurance." The Act also provides that federal anti-trust laws will not apply to the "business of insurance" as long as the state regulates in that area, but federal anti-trust laws will apply in cases of boycott, coercion, and intimidation. By contrast, most other federal laws will not apply to insurance whether the states regulate in that area or not.
Self-policingSelf-policing, a form of self-regulation, is the process whereby an organization is asked, or volunteers, to monitor its own adherence to legal, ethical, or safety standards, rather than have an outside, independent agency such as a governmental entity monitor and enforce those standards.-To the...
of providers by providers is a major part of oversight. Many health care organizations also voluntarily submit to inspection and certification by the Joint Commission on Accreditation of Hospital Organizations, JCAHO. Providers also undergo testing to obtain
board certificationBoard certification is the process by which a physician , dentist , or podiatrist in the United States demonstrates through either written, practical, and/or simulator based testing, a mastery of the basic knowledge and skills that define an area of medical specialization...
attesting to their skills. A report issued by
Public CitizenPublic Citizen is a non-profit, consumer rights advocacy group based in Washington, D.C., United States, with a branch in Austin, Texas. Public Citizen was founded by Ralph Nader in 1971, headed for 26 years by Joan Claybrook, and is now headed by Robert Weissman.-Lobbying Efforts:Public Citizen...
in April 2008 found that, for the third year in a row, the number of serious disciplinary actions against physicians by state medical boards declined from 2006 to 2007, and called for more oversight of the boards.
The
Centers for Medicare and Medicaid ServicesThe Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
(CMS) publishes an on-line searchable database of performance data on nursing homes.
The regulation is controversial. In 2004, conservative think tank
Cato InstituteThe Cato Institute is a libertarian think tank headquartered in Washington, D.C. It was founded in 1977 by Edward H. Crane, who remains president and CEO, and Charles Koch, chairman of the board and chief executive officer of the conglomerate Koch Industries, Inc., the largest privately held...
published a study which concluded that regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion. The study concluded that the majority of the cost differential arises from
medical malpracticeMedical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error. Standards and...
, U.S. Food and Drug Administration (FDA) regulations, and facilities regulations.
"Certificates of need" for hospitals
In 1978, the federal government required that all states implement Certificate of Need (CON) programs for cardiac care, meaning that hospitals had to apply and receive certificates prior to implementing the program; the intent was to reduce cost by reducing duplicate investments in facilities. It has been observed that these certificates could be used to increase costs through weakened competition. Many states removed the CON programs after the federal requirement expired in 1986, but some states still have these programs. Empirical research looking at the costs in areas where these programs have been discontinued have not found a clear effect on costs, and the CON programs could decrease costs because of reduced facility construction or increase costs due to reduced competition.
Licensing of providers
American Medical AssociationThe American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
(AMA) has lobbied the government to highly limit physician education since 1910, currently at 100,000 doctors per year, which has led to a shortage of doctors and physicians' wages in the U.S. are double those in the Europe, which is a major reason for the more expensive health care.
An even bigger problem may be that the doctors are paid for procedures instead of results.
AMA has also aggressively lobbied for many restrictions that require doctors to carry out operations that might be carried out by cheaper workforce. For example, in 1995, 36 states banned or restricted midwifery even though it delivers equally safe care to that by doctors, according to studies. The regulation lobbied by AMA has decreased the amount and quality of health care, according to the consensus of economist: the restrictions do not add to quality, they decrease the supply of care. Moreover, psychologists, nurses and pharmacologists are not allowed to prescribe medicines. Previously nurses were not even allowed to vaccinate the patients without direct supervision by doctors.
36 states require that health care workers undergo criminal background checks.
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, but 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. 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 MedicineThe Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
, between 1993 and 2003, emergency room visits in the U.S. grew by 26%, while in the same period, the number of emergency departments declined by 425.
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.
Overall system effectiveness compared to other countries
The CIA World Factbook ranked the United States 41st in the world for infant mortality rate and 46th for total life expectancy. A study found that between 1997 and 2003, preventable deaths declined more slowly in the United States than in 18 other industrialized nations.
For example, the United States was listed as 37th for life expectancy and 41st in low birth weight.
The
Organisation for Economic Co-operation and DevelopmentThe Organisation for Economic Co-operation and Development is an international economic organisation of 34 countries founded in 1961 to stimulate economic progress and world trade...
(OECD) found that the United States ranked poorly in terms of
Years of potential life lostYears of potential life lost or potential years of life lost , is an estimate of the average years a person would have lived if he or she had not died prematurely. It is, therefore, a measure of premature mortality. As a method, it is an alternative to death rates that gives more weight to deaths...
(YPLL), a statistical measure of years of life lost under the age of 70 that were amenable to being saved by health care. Among OECD nations for which data are available, the United States ranked third last for the health care of women (after Mexico and Hungary) and fifth last for men (Slovakia and Poland were also worse). See the table and source at
YPLLYears of potential life lost or potential years of life lost , is an estimate of the average years a person would have lived if he or she had not died prematurely. It is, therefore, a measure of premature mortality. As a method, it is an alternative to death rates that gives more weight to deaths...
for details.
Recent studies find growing gaps in life expectancy based on income and geography. In 2008, a government-sponsored study found that life expectancy declined from 1983 to 1999 for women in 180 counties, and for men in 11 counties, with most of the life expectancy declines occurring the Deep South, Appalachia, along the Mississippi River, in the Southern Plains and in Texas. The gap is growing between rich and poor and by educational level, but narrowing between men and women and by race. Another study 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; the authors speculated that risk factors such as smoking, obesity and high blood pressure may lie behind these disparities. In 2011 the
United States National Research CouncilThe National Research Council of the USA is the working arm of the United States National Academies, carrying out most of the studies done in their names.The National Academies include:* National Academy of Sciences...
forecasted that deaths attributed to smoking, on the decline in the US, will drop dramatically, improving life expectancy; it also suggested that 1/5 to 1/3 of the life expectancy difference can be attributed to obesity which is the worst in the world and has been increasing. In an analysis of
breast cancerBreast cancer is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas...
,
colorectal cancerColorectal cancer, commonly known as bowel cancer, is a cancer caused by uncontrolled cell growth , in the colon, rectum, or vermiform appendix. Colorectal cancer is clinically distinct from anal cancer, which affects the anus....
, and
prostate cancerProstate cancer is a form of cancer that develops in the prostate, a gland in the male reproductive system. Most prostate cancers are slow growing; however, there are cases of aggressive prostate cancers. The cancer cells may metastasize from the prostate to other parts of the body, particularly...
diagnosed during 1990–1994 in 31 countries, the United States had the highest
five-year relative survival rateThe five-year survival rate is a term used in medicine for estimating the prognosis of a particular disease.Analysis performed against the Surveillance, Epidemiology, and End Results database facilitates calculation of Five-year survival rates....
for breast cancer and prostate cancer, although survival was systematically and substantially lower in black U.S. men and women.
The debate about U.S. health care concerns questions of access, efficiency, and quality purchased by the high sums spent. The
World Health OrganizationThe World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
(WHO) in 2000 ranked the U.S. health care system first in responsiveness, but 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study). The WHO study has been criticized by the free market advocate
David GratzerDavid George Gratzer is a physician, columnist, author, Congressional expert witness, and a senior fellow at both the Manhattan Institute and the Montreal Economic Institute...
because "fairness in financial contribution" was used as an assessment factor, marking down countries with high per-capita private or fee-paying health treatment. The WHO study has been criticized, in an article published in
Health Affairs, for its failure to include the satisfaction ratings of the general public. The study found that there was little correlation between the WHO rankings for health systems and the stated satisfaction of citizens using those systems. Some countries, such as Italy and Spain, which were given the highest ratings by WHO were ranked poorly by their citizens while other countries, such as Denmark and Finland, were given low scores by WHO but had the highest percentages of citizens reporting satisfaction with their health care systems. WHO staff, however, say that the WHO analysis does reflect system "responsiveness" and argue that this is a superior measure to consumer satisfaction, which is influenced by expectations.
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%. 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.
System efficiency and equity
Variations in the efficiency of health care delivery can cause variations in outcomes. The
Dartmouth Atlas ProjectThe Dartmouth Institute for Health Policy and Clinical Practice is an organization within Dartmouth College "dedicated to improving health care through education, research, policy reform, leadership improvement, and communication with patients and the public." It was founded in 1988 by John...
, for instance, reported that, for over 20 years, marked variations in how medical resources are distributed and used in the United States were accompanied by marked variations in outcomes.
Value for money
A study of international health care spending levels published in the health policy journal
Health AffairsHealth Affairs is a peer-reviewed healthcare journal established in 1981 by John K. Iglehart. It was described by The Washington Post as "the bible of health policy". Health Affairs is indexed and/or abstracted in PubMed, MEDLINE, EBSCO databases, ProQuest, LexisNexis, Current Contents/Health...
in the year 2000 found that the U.S. spends substantially more on health care than any other country in the Organization for Economic Co-operation and Development (OECD), and that 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. than elsewhere.
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. 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.
In 2008 researchers with the
American Cancer SocietyThe American Cancer Society is the "nationwide community-based voluntary health organization" dedicated, in their own words, "to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and...
found that individuals who lacked private insurance (including those covered by Medicaid) were more likely to be diagnosed with late-stage cancer than those who had such insurance.
Shared costs of the uninsured
The costs of treating the uninsured must often be absorbed by providers as
charity careIn the United States, charity care is health care provided for free or at reduced prices to low income patients. The percentage of doctors providing charity care dropped from 76% in 1996-97 to 68% in 2004-2005. Potential reasons for the decline include changes in physician practice patterns and...
, passed on to the insured via cost shifting and higher health insurance premiums, or paid by taxpayers through higher taxes. However, hospitals and other providers are reimbursed for the cost of providing uncompensated care via a federal matching fund program. Each state enacts legislation governing the reimbursement of funds to providers. In Missouri, for example, providers assessments totaling $800 million are matched — $2 for each assessed $1 — to create a pool of approximately $2 billion. By federal law these funds are transferred to the Missouri Hospital Association for disbursement to hospitals for the costs incurred providing uncompenstated care including Disproportionate Share Payments (to hospitals with high quantities of uninsured patients), Medicaid shortfalls, Medicaid managed care payments to insurance companies and other costs incurred by hospitals. In New Hampshire, by statute, reimbursable uncompensated care costs shall include: charity care costs, any portion of Medicaid patient care costs that are unreimbursed by Medicaid payments, and any portion of bad debt costs that the commissioner determines would meet the criteria under 42 U.S.C. section 1396r-4(g) governing hospital-specific limits on disproportionate share hospital payments under Title XIX of the Social Security Act.
A report published by the
Kaiser Family FoundationThe Henry J. Kaiser Family Foundation , or just Kaiser Family Foundation, is a U.S.-based non-profit, private operating foundation headquartered in Menlo Park, California. It focuses on the major health care issues facing the nation, as well as the U.S. role in global health policy...
in April 2008 found that economic downturns place a significant strain on state
Medicaid Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
and
SCHIPThe State Children's Health Insurance Program – later known more simply as the Children's Health Insurance Program – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children...
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 2003The Jobs and Growth Tax Relief Reconciliation Act of 2003 , was passed by the United States Congress on May 23, 2003 and signed into law by President George W. Bush on May 28, 2003...
(JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules. The authors conclude that
CongressThe United States Congress is the bicameral legislature of the federal government of the United States, consisting of the Senate and the House of Representatives. The Congress meets in the United States Capitol in Washington, D.C....
should consider similar relief for the current economic downturn.
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
overutilizationOverutilization refers to medical services that are provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overutilization is the predominant factor in its expense...
occurs with other health care services. Unnecessary treatments increase costs and can cause patients unnecessary anxiety. The use of prescription drugs varies significantly by geographic region. The overuse of medical benefits is known as moral hazard -individuals who are insured are then more inclined to consume health care. The way the Health care system tries to eliminate this problem is through cost sharing tactics like co-pays and deductibles. If patients face more of the economic burden they will then only consume health care when it is necessary. According to the RAND health insurance experiment, individuals with higher Coinsurance rates consumed less health care then those with lower rates. The experiment concluded that with less consumption of care there was generally no loss in societal welfare but, for the poorer and sicker groups of people there were definitely negative effects. These patients were forced to forgo necessary preventative care measures in order to save money leading to late diagnosis of easily treated diseases and more expensive procedures later. With less preventative care, the patient is hurt financially with an increase in expensive visits to the ER.The Health Care costs in the U.S will also rise with these procedures as well. More expensive procedures leads to greater costs.
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.
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% of doctors report that their patients "sometimes" or "often" experience long wait times for diagnostic tests.
- Some 20% of doctors report having their patients repeat tests because of an inability to locate the results during a scheduled visit.
According to an article in
The New York TimesThe New York Times is an American daily newspaper founded and continuously published in New York City since 1851. The New York Times has won 106 Pulitzer Prizes, the most of any news organization...
, the relationship between doctors and patients is deteriorating. A study from
Johns Hopkins UniversityThe Johns Hopkins University, commonly referred to as Johns Hopkins, JHU, or simply Hopkins, is a private research university based in Baltimore, Maryland, United States...
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.
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. The use of hospitalists is sometimes mandated by health insurance companies as a cost saving measure which is resented by some primary care physicians.
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. 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.
According to the insurance industry group America's Health Insurance Plans, administrative costs for private health insurance plans have averaged approximately 12% 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.
A 2003 study published by the
Blue Cross and Blue Shield AssociationThe Blue Cross Blue Shield Association is a federation of 39 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 100 million Americans. The history of Blue Cross dates back to 1929, while the history of...
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. 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. 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).
According to a report published by the
CBOThe Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
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. A 2009 study published by the
Blue Cross and Blue Shield AssociationThe Blue Cross Blue Shield Association is a federation of 39 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 100 million Americans. The history of Blue Cross dates back to 1929, while the history of...
found that the average administrative expense cost for all commercial health insurance products was represented 9.18% of premiums in 2008. Administrative costs were 11.12% of premiums for small group products and 16.35% in the individual market.
One study of the billing and insurance-related (BIR) costs borne not only by insurers but also by physicians and hospitals found that BIR among insurers, physicians, and hospitals in California represented 20-22% of privately insured spending in California acute care settings.
Third-party payment problem and consumer-driven insurance
Most Americans pay for medical services largely through insurance, and this can distort the incentives of consumers since the consumer pays only a portion of the ultimate cost. The lack of price information on medical services can also distort incentives. The insurance which pays on behalf of insureds negotiate with medical providers, sometimes using government-established prices such as Medicaid billing rates as a reference point. This reasoning has led for calls to reform the insurance system to create a consumer-driven health care system whereby consumers pay more out-of-pocket. In 2003, the
Medicare Prescription Drug, Improvement, and Modernization ActThe Medicare Prescription Drug, Improvement, and Modernization Act is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history.The MMA was signed by President George W...
was passed, which encourages consumers to have a high-deductible health plan and a
health savings accountA health savings account is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a high-deductible health plan . The funds contributed to an account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account...
.
Overall costs
The cost impact of the existing mixed public-private system is subject to debate. The United States spends more as a percentage of GDP than similar countries, and this can be explained either through higher prices for services or more utilization of these services (for example, due to the United States having a more sickly population), or to a combination of the two. The United States has higher prices than other "rich democracies", and this is a major explanation for its increased costs.
Free-market advocates claim that the health care system is "dysfunctional" because the system of third-party payments from insurers removes the patient as a major participant in the financial and medical choices that affect costs. Because government intervention has expanded insurance availability through programs such as Medicare and Medicaid, this has exacerbated the problem. According to a study paid for by America's Health Insurance Plans (a Washington lobbyist for the health insurance industry) and carried out by PriceWaterhouseCoopers, increased utilization is the primary driver of rising health care costs in the U.S. 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. The study also mentions
cost-shiftingCost-shifting is either an economic situation where one group underpays for a service resulting another group overpaying for a service or where one group pays a smaller share of costs than before resulting in another group paying a larger share of costs than before...
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.
Health care costs rising far faster than inflation have been a major driver for
health care reform in the United StatesHealth care reform in the United States has a long history, of which the most recent results were two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act , signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 , which amended the PPACA and...
.
In March 2010, Massachusetts released a report on the cost drivers which it called "unique in the nation". The report noted that providers and insurers negotiate privately, and therefore the prices can vary between providers and insurers for the same services, and it found that the variation in prices did not vary based on quality of care but rather on market leverage; the report also found that price increases rather than increased utilization explained the spending increases in the past several years.
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 estimated that 45.7 million Americans (15.3% of the total population) had no health insurance coverage in 2007. However, statistics regarding the insured population are difficult to pinpoint for a number of factors, with the Census Bureau writing that "health insurance coverage is likely to be underreported".
http://www.census.gov/prod/2010pubs/p60-238.pdf Further, such statistics do not provide insight into the reason a given person might be uninsured. For example, studies have shown that approximately one third of this 45.7 million person population of uninsured persons is actually eligible for government insurance programmes such as Medicaid/Medicare, but has elected not to enroll. The largest proportion of the population of uninsured Americans is persons earning in excess of $50,000 per annum, with those earning over $75,000 p.a. comprising the fastest-growing segment of the uninsured population. US Citizens who earn too much money to qualify for government assistance with insurance programs but who do not earn enough to purchase a private health insurance plan make up approxmiately 2.7% percent of the total US population (8.2 million of approximately 300 million total population, by 2003 figures).
http://spectator.org/archives/2009/03/20/the-myth-of-the-46-million
Some states (like
CaliforniaCalifornia is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
) do offer insurance coverage for children of low income families, 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
EMTALAThe Emergency Medical Treatment and Active Labor Act is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act . It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to...
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.
Johns Hopkins UniversityThe Johns Hopkins University, commonly referred to as Johns Hopkins, JHU, or simply Hopkins, is a private research university based in Baltimore, Maryland, United States...
professor Vicente Navarro stated in 2003, "the problem does not end here, with the uninsured. An even larger problem is the
underinsuredUnderinsured refers to various degrees of being insured for some real risks and uninsured for others, at the same time.-Health care:Johns Hopkins University professor Vicente Navarro stated in 2003, "the problem does not end here, with the uninsured...
" and "The most credible estimate of the number of people in the United States who have died because of lack of medical care was provided by a study carried out by
Harvard Medical SchoolHarvard Medical School is the graduate medical school of Harvard University. It is located in the Longwood Medical Area of the Mission Hill neighborhood of Boston, Massachusetts....
Professors Himmelstein and Woolhandler (
New England Journal of MedicineThe New England Journal of Medicine is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It describes itself as the oldest continuously published medical journal in the world.-History:...
336, no. 11, 1997). They concluded that almost 100,000 people died in the United States each year because of lack of needed care." Another study by the
Commonwealth FundThe Commonwealth Fund is a private U.S. foundation whose stated purpose is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, especially for society's most vulnerable.-History:...
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% 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. Another study focusing on the effect of being uninsured found that individuals with private insurance were less likely to be diagnosed with late-stage cancer than either the uninsured or Medicaid beneficiaries. 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 while no effect on self-reported health status was observed. The authors concluded that the effect of cost sharing should be carefully monitored.
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. 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.
Mental health
A lack of mental health coverage for Americans bears significant ramifications to the
U.S. economyThe economy of the United States is the world's largest national economy. Its nominal GDP was estimated to be nearly $14.5 trillion in 2010, approximately a quarter of nominal global GDP. The European Union has a larger collective economy, but is not a single nation...
and social system. A report by the
U.S. Surgeon GeneralThe Surgeon General of the United States is the operational head of the Public Health Service Commissioned Corps and thus the leading spokesperson on matters of public health in the federal government...
found that mental illnesses are the second leading cause of
disabilityA disability may be physical, cognitive, mental, sensory, emotional, developmental or some combination of these.Many people would rather be referred to as a person with a disability instead of handicapped...
in the nation and affect 20% of all Americans. 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.
The Paul Wellstone Mental Health and Addiction Equity Act of 2008 mandates that group health plans provide mental health and substance-related disorder benefits that are at least equivalent to benefits offered for medical and surgical procedures. The legislation renews and expands provisions of the
Mental Health Parity Act of 1996The Mental Health Parity Act is legislation signed into United States law on September 26, 1996 that requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance...
. The law requires financial equity for annual and lifetime mental health benefits, and compels parity in treatment limits and expands all equity provisions to addiction services. Up to 2008 insurance companies used loopholes and, though providing financial equity, they often worked around the law by applying unequal co-payments or setting limits on the number of days spent in in-patient or out-patient treatment facilities.
Medical underwriting and the uninsurable
In most states in the U.S., people seeking to purchase health insurance directly must undergo
medical underwritingMedical underwriting is an insurance term referring to the use of medical or health status information in the evaluation of an applicant for coverage . As part of the underwriting process, health information may be used in making two related decisions: whether to offer or deny coverage; and what...
. Insurance companies seeking to mitigate the problem of
adverse selectionAdverse selection, anti-selection, or negative selection is a term used in economics, insurance, statistics, and risk management. It refers to a market process in which "bad" results occur when buyers and sellers have asymmetric information : the "bad" products or services are more likely to be...
and manage their risk pools screen applicants for pre-existing conditions. Insurers reject many 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. An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.
Proponents of medical underwriting argue that it ensures that individual health insurance premiums are kept as low as possible. Critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from obtaining health insurance.
One large industry survey found that 13% 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% for those under 18 to just under one-third for those aged 60 to 64. Among those who were offered coverage, the study found that 76% received offers at standard premium rates, and 22% were offered higher rates. 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. 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. Some states have outlawed medical underwriting as a prerequisite for individually purchased health coverage. These states tend to have the highest premiums for individual health insurance.
Demographic differences
In the
United StatesThe United States of America is a federal constitutional republic comprising fifty states and a federal district...
, health disparities are well documented in ethnic minorities such as African Americans,
Native AmericansNative Americans in the United States are the indigenous peoples in North America within the boundaries of the present-day continental United States, parts of Alaska, and the island state of Hawaii. They are composed of numerous, distinct tribes, states, and ethnic groups, many of which survive as...
, and Hispanics. When compared to
whitesWhite Americans are people of the United States who are considered or consider themselves White. The United States Census Bureau defines White people as those "having origins in any of the original peoples of Europe, the Middle East, or North Africa...
, 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. In addition, adult African Americans and Hispanics have approximately twice the risk as whites of developing diabetes. Minorities also have higher rates of
cardiovascular diseaseHeart disease or cardiovascular disease are the class of diseases that involve the heart or blood vessels . While the term technically refers to any disease that affects the cardiovascular system , it is usually used to refer to those related to atherosclerosis...
and HIV/AIDS than whites. Caucasian Americans have much lower life expectancy than Asian Americans. A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.
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). Seniors comprise 13% of the population but take 1/3 of all prescription drugs. The average senior fills 38 prescriptions annually.
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. According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care. For example, minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic people. In other cases, inequalities in health care reflect a
systemic biasSystemic bias is the inherent tendency of a process to favor particular outcomes. The term is a neologism that generally refers to human systems; the analogous problem in non-human systems is often called systematic bias, and leads to systematic error in measurements or estimates.-Bias in...
in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of
racism in scienceScientific racism is the use of scientific techniques and hypotheses to sanction the belief in racial superiority or racism.This is not the same as using scientific findings and the scientific method to investigate differences among the humans and argue that there are races...
and medicine shows that people and institutions behave according to the ethos of their times. Nancy Krieger wrote that racism underlies unexplained inequities in health care, including treatment for heart disease, renal failure, bladder cancer, and pneumonia. 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. One recent study has found that when minority and white patients use the same hospital, they are given the same standard of care.
Drug efficacy and safety
The Food and Drug Administration (FDA) is the primary institution tasked with the safety and effectiveness of human and veterinary drugs. It also is responsible for making sure drug information is accurately and informatively presented to the public. The FDA reviews and approves products and establishes drug labeling, drug standards, and medical device manufacturing standards. It sets performance standards for radiation and ultrasonic equipment.
One of the more contentious issues related to drug safety is immunity from prosecution. In 2004, the FDA reversed a federal policy, arguing that FDA premarket approval overrides most claims for damages under state law for medical devices. In 2008 this was confirmed by the Supreme Court in Riegel v. Medtronic.
On 30 June 2006, an FDA ruling went into effect extending protection from lawsuits to pharmaceutical manufacturers, even if it was found that they submitted fraudulent clinical trial data to the FDA in their quest for approval. This left consumers who experience serious health consequences from drug use with little recourse. In 2007, opposition was raised in the Congressional House to the FDA ruling, but the Senate upheld the status quo. On 4 March 2009, an important U.S. Supreme Court decision was handed down. In
Wyeth v. LevineWyeth v. Levine, 555 U.S. 555 , is a United States Supreme Court case holding that Federal regulatory approval of a medication does not shield the manufacturer from liability under state law.-Vermont jury trial:...
, the court asserted that state-level rights of action could not be pre-empted by federal immunity and could provide "appropriate relief for injured consumers." In June 2009, under the
Public Readiness and Emergency Preparedness ActThe Public Readiness and Emergency Preparedness Act , passed by the United States Congress and signed into law by President of the United States George W. Bush in December, 2005, is a controversial tort liability shield intended to protect vaccine manufacturers from financial risk in the event of a...
, Secretary of Health and Human Services
Kathleen SebeliusKathleen Sebelius is an American politician currently serving as the 21st Secretary of Health and Human Services. She was the second female Governor of Kansas from 2003 to 2009, the Democratic respondent to the 2008 State of the Union address, and chair-emerita of the Democratic Governors...
signed an order extending protection to vaccine makers and federal officials from prosecution during a declared health emergency related to the administration of the swine flu vaccine.
Impact of drug companies
The United States is one of two countries in the world that allows
direct-to-consumer advertisingDirect-to-consumer advertising usually refers to the marketing of pharmaceutical products but can apply in other areas as well. This form of advertising is directed toward patients, rather than healthcare professionals. The Food and Drug Administration holds responsibility of regulating DTC...
of prescription drugs. Critics note that drug ads costs money which they believe have raised the overall price of drugs.
When health care legislation was being written in 2009, the drug companies were asked to support the legislation in return for not allowing importation of drugs from foreign countries.
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. Per capita, the U.S. spends more on pharmaceuticals than any other country. National expenditures on pharmaceuticals accounted for 12.9% of total health care costs, compared to an OECD average of 17.7% (2003 figures). Some 25% of out-of-pocket spending by individuals is for prescription drugs.
The U.S. government has taken the position (through the
Office of the United States Trade RepresentativeThe Office of the United States Trade Representative is the United States government agency responsible for developing and recommending United States trade policy to the president of the United States, conducting trade negotiations at bilateral and multilateral levels, and coordinating trade...
) 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). 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 ridingIn economics, collective bargaining, psychology, and political science, a free rider is someone who consumes a resource without paying for it, or pays less than the full cost. The free rider problem is the question of how to limit 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
MedicareMedicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
program due to the
Medicare Prescription Drug, Improvement, and Modernization ActThe Medicare Prescription Drug, Improvement, and Modernization Act is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history.The MMA was signed by President George W...
passed in 2003. 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.
Health care debate
A poll released in March 2008 by the
Harvard School of Public HealthThe Harvard School of Public Health is one of the professional graduate schools of Harvard University, located in the Longwood Area of the Boston, Massachusetts neighborhood of Mission Hill, which is next to Harvard Medical School. HSPH is considered a significant school focusing on health in the...
and
Harris InteractiveHarris Interactive , headquartered in New York, New York, is a custom market research firm, known for the Harris Poll. Harris works in a wide range of industries...
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.
According to the
Institute of MedicineThe Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
of the
National Academy of SciencesThe National Academy of Sciences is a corporation in the United States whose members serve pro bono as "advisers to the nation on science, engineering, and medicine." As a national academy, new members of the organization are elected annually by current members, based on their distinguished and...
, the United States is the only wealthy, industrialized nation that does not ensure universal coverage. 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
partyA political party is a political organization that typically seeks to influence government policy, usually by nominating their own candidates and trying to seat them in political office. Parties participate in electoral campaigns, educational outreach or protest actions...
lines in their views of the U.S. health system and what should be done to improve it. Those in favor of
universal health careUniversal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...
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.
Cato InstituteThe Cato Institute is a libertarian think tank headquartered in Washington, D.C. It was founded in 1977 by Edward H. Crane, who remains president and CEO, and Charles Koch, chairman of the board and chief executive officer of the conglomerate Koch Industries, Inc., the largest privately held...
Senior Fellow Alan Reynolds argues that people should be free to opt out of health insurance, citing a study by Economists Craig Perry and Harvey Rosen that found "the lack of health insurance among the self-employed does not affect their health. For virtually every subjective and objective measure of their health status, the self-employed and wage-earners are statistically indistinguishable for each other." Both sides of the
political spectrumA political spectrum is a way of modeling different political positions by placing them upon one or more geometric axes symbolizing independent political dimensions....
have also looked to more philosophical arguments, debating whether people have a fundamental
rightHuman rights are "commonly understood as inalienable fundamental rights to which a person is inherently entitled simply because she or he is a human being." Human rights are thus conceived as universal and egalitarian . These rights may exist as natural rights or as legal rights, in both national...
to have health care provided to them by their government.
An impediment to implementing any US healthcare reform that does not benefit insurance companies or the private health care industry is the power of insurance company and health care industry lobbyists. Possibly as a consequence of the power of lobbyists, key politicians such as Senator
Max BaucusMax Sieben Baucus is the senior United States Senator from Montana and a member of the Democratic Party. First elected to the Senate in 1978, as of 2010 he is the longest-serving Senator from Montana, and the fifth longest-serving U.S...
have taken the option of single payer health care off the table entirely. In a June 2009
NBC NewsNBC News is the news division of American television network NBC. It first started broadcasting in February 21, 1940. NBC Nightly News has aired from Studio 3B, located on floors 3 of the NBC Studios is the headquarters of the GE Building forms the centerpiece of 30th Rockefeller Center it is...
/Wall Street Journal survey, 76% said it was either "extremely" or "quite" important to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance."
Advocates for
single-payer health careSingle-payer health care is medical care funded from a single insurance pool, run by the state. Under a single-payer system, universal health care for an entire population can be financed from a pool to which many parties employees, employers, and the state have contributed...
often point to other countries, where national government-funded systems produce better health outcomes at lower cost. Opponents deride this type of system as "
socialized medicineSocialized medicine is a term used to describe a system for providing medical and hospital care for all at a nominal cost by means of government regulation of health services and subsidies derived from taxation. It is used primarily and usually pejoratively in United States political debates...
", and it has not been one of the favored reform options by Congress or the President in both the Clinton and Obama reform efforts.
It has been pointed out that
socialized medicineSocialized medicine is a term used to describe a system for providing medical and hospital care for all at a nominal cost by means of government regulation of health services and subsidies derived from taxation. It is used primarily and usually pejoratively in United States political debates...
is a system in which the government owns the means of providing medicine. Britain is an example of socialized system, as, in America, is the
Veterans Health AdministrationThe Veterans Health Administration is the component of the United States Department of Veterans Affairs led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VA outpatient clinics,...
. Medicare is an example of a mostly single-payer system, as is France. Both of these systems have private insurers to choose from, but the government is the dominant purchaser.
As an example of how government intervention has had
unintended consequenceIn the social sciences, unintended consequences are outcomes that are not the outcomes intended by a purposeful action. The concept has long existed but was named and popularised in the 20th century by American sociologist Robert K. Merton...
s, in 1973, the federal government passed the
Health Maintenance Organization ActThe Health Maintenance Organization Act of 1973 , also known as the HMO Act of 1973, 42 U.S.C. § 300e, is a law passed by the Congress of the United States that resulted from discussions Paul Ellwood had with what is today the Department of Health and Human Services...
, 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.
PiecemealÀ la carte is a French language loan phrase meaning "according to the menu", and used in* A reference to a menu of items priced and ordered separately, i.e. the usual operation of restaurants * To order an item from the menu on its own, e.g...
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.
According to economist and former US Secretary of Labor,
Robert ReichRobert Bernard Reich is an American political economist, professor, author, and political commentator. He served in the administrations of Presidents Gerald Ford and Jimmy Carter and was Secretary of Labor under President Bill Clinton from 1993 to 1997....
, only a "big, national, public option" can force insurance companies to cooperate, share information, and reduce costs. Scattered, localized, "insurance cooperatives" are too small to do that and are "designed to fail" by the moneyed forces opposing Democratic health care reform. The
Patient Protection and Affordable Care ActThe Patient Protection and Affordable Care Act is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law is the principal health care reform legislation of the 111th United States Congress...
, signed into law in March, 2010, did not include such an option.
Health Care Reform
The
Patient Protection and Affordable Care ActThe Patient Protection and Affordable Care Act is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law is the principal health care reform legislation of the 111th United States Congress...
(Public Law 111-148) is a health care reform bill that was signed into law in the
United StatesThe United States of America is a federal constitutional republic comprising fifty states and a federal district...
by
PresidentThe President of the United States of America is the head of state and head of government of the United States. The president leads the executive branch of the federal government and is the commander-in-chief of the United States Armed Forces....
Barack ObamaBarack Hussein Obama II is the 44th and current President of the United States. He is the first African American to hold the office. Obama previously served as a United States Senator from Illinois, from January 2005 until he resigned following his victory in the 2008 presidential election.Born in...
on March 23, 2010. Along with the
Health Care and Education Reconciliation Act of 2010The Health Care and Education Reconciliation Act of 2010 is a law that was enacted by the 111th United States Congress, by means of the reconciliation process, in order to amend the Patient Protection and Affordable Care Act...
(passed March 25), the Act is a product of the
health care reformHealth care reform in the United States has a long history, of which the most recent results were two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act , signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 , which amended the PPACA and...
agenda of the
DemocraticThe Democratic Party is one of two major contemporary political parties in the United States, along with the Republican Party. The party's socially liberal and progressive platform is largely considered center-left in the U.S. political spectrum. The party has the lengthiest record of continuous...
111th Congress and the Obama administration.
The law includes a large number of health-related provisions to take effect over the next four years, including expanding
Medicaid Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
eligibility for people making up to 133% of FPL, subsidizing insurance premiums for peoples making up to 400% of FPL ($88,000 for family of 4) so their maximum "out-of-pocket" pay will be from 2% to 9.8% of income for annual premium, providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre-existing conditions, establishing
health insurance exchangeA health insurance exchange is a set of state-regulated and standardized health care plans in the United States, from which individuals may purchase health insurance that is eligible for Federal subsidies...
s, prohibiting insurers from establishing annual spending caps and support for medical research. The costs of these provisions are offset by a variety of taxes, fees, and cost-saving measures, such as new Medicare taxes for high-income
bracketsTax brackets are the divisions at which tax rates change in a progressive tax system . Essentially, they are the cutoff values for taxable income — income past a certain point will be taxed at a higher rate.-Example:Imagine that there are three tax brackets: 10%, 20%, and 30%...
, taxes on indoor tanning, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies; there is also a tax penalty for citizens who do not obtain health insurance (unless they are exempt due to low income or other reasons). The
Congressional Budget OfficeThe Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
estimates that the net effect (including the reconciliation act) will be a reduction in the federal deficit by $143 billion over the first decade.
Health Insurance Coverage of Immigrants
Of the 26.2 million foreign immigrants living in the US in 1998, 62.9% were non-citizens. In 1997, 34.3% of non-citizens living in America did not have health insurance coverage opposed to the 14.2% of native-born Americans who do not have health insurance coverage. Among those immigrants who became citizens, 18.5% were uninsured as opposed to non citizens who are 43.6% uninsured. In each age and income group, immigrants are less likely to have health insurance.
See also
- Canadian and American health care systems compared
Comparison of the health care systems in Canada and the United States are often made by government, public health and public policy analysts. The two countries had similar health care systems before Canada reformed its system in the 1960s and 1970s. The United States spends much more money on...
- Centers for Disease Control and Prevention timeline
- Key person insurance
Corporate-owned life insurance , also known as dead peasant life insurance or janitors insurance, is life insurance on employees' lives that is owned by the employer, with benefits payable to the employer...
- Health care compared - tabular comparisons of the US, Canada, and other countries not shown above.
- Health care industry
- Health care politics
Health policy can be defined as the "decisions, plans, and actions that are undertaken to achieve specific health care goals within a society." According to the World Health Organization, an explicit health policy can achieve several things: it defines a vision for the future; it outlines...
- Health care systems (including comparisons)
- Health insurance cooperative
A health insurance cooperative is a cooperative entity that has the goal of providing health insurance and is also owned by the people that the organization insures...
- HIV/AIDS in the United States
[[File:New HIV Cases 22 States 2006 CDC.svg|thumb|300px|Estimated Number of New HIV Cases—22 States 2006...
- List of healthcare accreditation organizations in the United States
- List of countries by health care expenditures
- Medical cannabis in the United States
In the United States, there are important legal differences between medical cannabis at the federal and state levels. At the federal level, cannabis per se has been made criminal by implementation of the Controlled Substances Act but as of 2009, new federal guidelines have been enacted. According...
- Medical centers in the United States
Medical centers in the United States are conglomerations of health-care facilities including hospitals and research facilities that also either include or are closely affiliated with a medical school...
- Medical debt
Medical debt refers to debt incurred by individuals due to health care costs and related expenses.Medical debt is different from other forms of debt, because it is usually incurred accidentally or faultlessly...
- Medicare Rights Center
The Medicare Rights Center is a national, 501 nonprofit consumer service organization with offices in New York City and Washington, DC...
- Medicare Sustainable Growth Rate
The Medicare Sustainable Growth Rate is a method currently used by the Centers for Medicare and Medicaid Services in the United States to control spending by Medicare on physician services...
- Military Health System
The Military Health System is the enterprise within the United States Department of Defense responsible for providing health care to active duty and retired U.S. Military personnel and their dependents...
- School health services
School health services are services from medical, teaching and other professionals applied in or out of school to improve the health and well-being of children and in some cases whole families...
- United States National Health Care Act
- Universal Health Care Foundation of Connecticut
Universal Health Care Foundation of Connecticut is an independent, nonprofit organization with offices in Meriden, Connecticut. The foundation supports the mission of its parent organization, CHART...
- Water fluoridation in the United States
As with some other countries water fluoridation in the United States is a contentious issue. As of May 2000, 42 of the 50 largest U.S. cities had water fluoridation....
Further reading
- Christensen, Clayton Hwang MD, Jason, Grossman MD, Jerome, The Innovator's Prescription, McGraw Hill, 2009. ISBN 978-0-07-159208-6
- Gutkind, Lee
Lee Gutkind is an American writer.Gurkind is the founder of the literary magazine Creative Nonfiction and the author or editor of over a dozen books. He started the first ever MFA program in creative nonfiction at the University of Pittsburgh in Pittsburgh...
, One Children's Place: Inside a Children's Hospital, Penguin, 1992. ISBN 978-0452266872
- Gutkind, Lee
Lee Gutkind is an American writer.Gurkind is the founder of the literary magazine Creative Nonfiction and the author or editor of over a dozen books. He started the first ever MFA program in creative nonfiction at the University of Pittsburgh in Pittsburgh...
, Stuck in Time: The Tragedy of Childhood Mental Illness, Henry Holt & Company, 1994. ISBN 0-8050-1469-1
- Mahar, Maggie, Money-Driven Medicine: The Real Reason Health Care Costs So Much, Harper/Collins, 2006. ISBN 978-0-06-076533-0
- Starr, Paul
Paul Starr is a Pulitzer Prize-winning professor of sociology and public affairs at Princeton University. He is also the co-editor and co-founder of The American Prospect, a notable liberal magazine which was created in 1990...
, The Social Transformation of American MedicineThe Social Transformation of American Medicine is a book written by Paul Starr and published by Basic Books in 1982. It won the 1984 Pulitzer Prize for General Non-Fiction as well as the Bancroft Prize.Capers Jones wrote,...
, Basic Books, 1982. ISBN 0-465-07934-2
- President Obama REMARKS BY THE PRESIDENT TO A JOINT SESSION OF CONGRESS ON HEALTH CARE September 9, 2009
External links
- National Center for Health Statistics from Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
(CDC)
- National Health Expenditure Data (U.S.) from United States Department of Health and Human Services
The United States Department of Health and Human Services is a Cabinet department of the United States government with the goal of protecting the health of all Americans and providing essential human services. Its motto is "Improving the health, safety, and well-being of America"...
(CMS)
- United States profile from the World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
*
- FamiliesUSA contains links to numerous studies and literature about various aspects of health care in the US].