Health care in the United States
From Wikipedia, the free encyclopedia
Health care in the United States is provided by many separate legal entities. Current estimates put US healthcare spending at approximately 15% of GDP, which is the highest in the world.[1] In the United States, the vast majority of citizens have health insurance, either through their employer or purchased individually.[2] The federal government does not guarantee universal health care to all its citizens, but certain publicly-funded health care programs help to provide for the elderly, disabled, and the poor[3][4] and federal law ensures public access to emergency services regardless of ability to pay.[5] Those without health insurance coverage are expected to pay privately for medical services. Health insurance is expensive and medical bills are overwhelmingly the most common reason for personal bankruptcy in the United States.[6]
A 2004 survey released by the National Center for Health Statistics estimated that approximately 70% of Americans were in "excellent" or "very good" health. [7] The overall performance of the United States health care system was ranked 15th by the World Health Organization (WHO) in 1997.[8]
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[edit] Health care providers
American health care is provided by a diverse array of individuals and legal entities. Individuals offer inpatient and outpatient services for commercial, charitable, or governmental entities.
[edit] Services
"Ambulatory care" refers to health care outside the hospital; most health care in the United States occurs in the outpatient setting. "Home health care services" are generally nursing enterprises, but are usually ordered by physicians. Private sector outpatient medical care is provided by personal primary care physicians (specialists in internal medicine, family medicine, and pediatric medicine), subspecialty physicians (gastroenterologists, cardiologists, or pediatric endocrinologists are examples) or non-physicians (including nurse practitioners and physician assistants).
[edit] Facilities
There are for-profit hospitals, which are usually operated by large private corporations and there are nonprofit hospitals, which may be operated by county governments, state governments, religious orders, or independent nonprofit organizations. Hospitals provide some outpatient care in their emergency rooms and specialty clinics, but primarily they exist to provide inpatient care. Hospital emergency departments and urgent care centers are sources of sporadic problem-focused care. "surgicenters" are examples of specialty clinics. Hospice services for the terminally ill who are expected to live six months or less are most commonly subsidized by charities and government. Prenatal, family planning, and "dysplasia" clinics are government-funded obstetric and gynecologic specialty clinics respectively, and are usually staffed by nurse practitioners.
[edit] Medical products, research and development
Companies provide medical products such as pharmaceuticals and medical devices. The nation spends a substantial amount on medical research, mostly privately-funded. As of 2000, non-profit private organizations (such as the Howard Hughes Medical Institute) funded 7%, private industry funded 57%, and the tax-funded National Institutes of Health funded 36% of medical research in the U.S.[9] The research and development for applications is primarily done in commercial R&D labs while the government and universities fund the majority of basic research.[citation needed] Much of this basic research is funded or performed by governmental research institutes such as the NIH and NIMH.
[edit] Medicaid
It has been reported that the number of physicians accepting Medicaid has decreased in recent years due to relatively high administrative costs and low reimbursements. [10]
[edit] Health care regulation and oversight
There are government institutes such as the Centers for Disease Control and Prevention that identify threats to public health. In addition there are regulatory bodies such as the FDA that identify and approve drugs for medical use and sale. Many healthcare organizations also voluntarily submit to inspection and certification by the Joint Committe on Accreditation of Hospital Organizations, JCAHO.
[edit] System inefficiencies and inequities
[edit] Inefficiencies
[edit] Catastrophic care vs. free preventative care
Many working-class persons are more vulnerable to catastrophic diseases that could have been much more easily treated if identified early through regular checkups (like cancer and heart disease).[citation needed] The financial cost of treating those diseases at a late stage is also much higher.
[edit] Inequities
[edit] The coverage gap
Enrollment rules in private and governmental programs result in millions of Americans going without health care coverage, including children. The most recent data available from the U.S. Census Bureau indicates that 45.8 million Americans (about 15% of the total population) had no health insurance coverage during 2004[11]. This constituted a rise of about 850,000 from the previous year. Most uninsured Americans are working-class persons between the ages of 2 and 65 whose employers do not provide health insurance, and who earn too much money to qualify for one of the local or state insurance programs for the poor, but do not earn enough to cover the cost of enrollment in a health insurance plan designed for individuals. Some states (like California) do offer limited insurance coverage for working-class children, but not for adults; other states do not offer such coverage at all, and so, both parent and child are caught in the notorious coverage "gap." Although EMTALA [1] 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 certainly does nothing about the difficulties in the American mental health system.
[edit] Health disparities among minorities
In the United States, health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Hispanics[citation needed]. When compared to whites,these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes. Among the disease-specific examples of racial and ethnic disparities in the United States is the cancer incidence rate among African Americans, which is 25% higher than among whites [2]. In addition, adult blacks and Hispanics have approximately twice the risk as whites of developing diabetes. Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites [3][4].
[edit] Regulatory inefficiencies and inequities
[edit] Mental illness and the Emergency Medical Treatment and Active Labor Act (EMTALA)(1986)
Mentally ill patients present a challenge for emergency departments and hospitals. In accordance with the Emergency Medical Treatment and Active Labor Act, mentally ill patients are evaluated for emergency medical conditions. Once mentally ill patients are found to be medically stable, regional mental health agencies are contacted to evaluate patients. Patients are evaluated as to whether they are a danger to themselves or others. If mentally ill patients are found to be a danger to themselves or others, they 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, which then requires a court order. Since the late 1970's, the community based care model has been encouraged within the United States rather than institutionalization.
[edit] Healthcare regulatory costs
The healthcare industry is likely the most heavily regulated industry in the United States. A Cato Institute study by suggests that this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion [12]. The majority of the cost differential arises from medical malpractice, FDA regulations, and facilities regulations [12]. Part of the cost arises from regulatory requirements that prevent technicians without medical degrees from performing treatment and diagnostic procedures that carry little risk [13]. In addition to regulatory costs, commentators and economists observe that government programs bid up healthcare prices because they lack the financial incentives to bargain with healthcare providers [14].
[edit] Inequities
EMTALA is an unfunded mandate; the federal government and the state governments have never fully compensated both public and private hospitals for the full cost of such emergency charity care. As a result, innumerable private hospitals have gone out of business since 1986. Others have raised prices on those that can pay to avoid going out of business. The hospitals do attempt to bill uninsured patients directly under the fee-for-service model, but most such people cannot pay their hospital fees, and escape into bankruptcy when hospitals seek legal process against them.
[edit] Political issues
[edit] Universal health care
In 2006, San Francisco mayor Gavin Newsom announced plans for a citywide universal health care system that has yet to be approved by the city's Board of Supervisors.[15]
In contrast, in nearly all other major industrialized countries, higher education institutions are tax-payer subsidized and thus their physicians do not have to obtain loans to finance their educations. However, physicians in such countries have lower maximum income potential, due to the subsidization by tax-payers of healthcare systems. Similar comparative analyses have been performed on various other public health disasters.
There have also been occasional reports of incidents in which illegal immigrants from various countries (including the United Kingdom and Mexico) deliberately enter the United States to seek treatment of extremely severe or rare illnesses [citation needed]. When Immigration and Customs Enforcement sought to deport such persons for illegal entry or for overstaying their visas, the immigrants would throw themselves on the mercy of the American people. In early 2005, one highly publicized case involved a young girl named Rachel Andrews, whose parents fought deportation to the UK on the grounds that UK doctors did not know how to treat her rare sleep disorders properly and that the life-saving drug she needed (Provigil) was not approved for pediatric use in the UK [citation needed].
[edit] Prescription drug coverage
Since the 1990s, the price of prescription drugs became a major issue in American politics as the prices of many new life-saving drugs has increased exponentially and many citizens discovered that neither the government nor their insurer would cover the cost of such drugs. Currently, approximately 13% of US health care spending goes to pay for pharmaceuticals, though 25% of out-of-pocket spending by individuals is for prescription drugs.[16]
The U.S. government has taken the position (through the Office of the United States Trade Representative) that U.S. drug prices are rising because U.S. consumers are effectively subsidizing costs which drug companies cannot recover from consumers anywhere else (because many other countries use their bulk-purchasing power to aggressively negotiate drug prices).[citation needed] The U.S. position is that the governments of those countries should either deregulate their markets or directly remit 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, those companies would be able to lower prices for U.S. consumers. Currently, the U.S., as a purchaser of pharmaceuticals, negotiates some drug prices but is forbidden by law from negotiating drug prices for the Medicare program.[citation needed]
Approximately one in five drugs that begin testing make it through the full approval process.[17]
[edit] References
- ^ "The World Health Report 2006 - Working together for health."
- ^ "Income, Poverty, and Health Insurance Coverage in the United States: 2004." U.S. Census Bureau. Issued August 2005.
- ^ Centers for Medicare & Medicaid Services: Medicare
- ^ Centers for Medicare & Medicaid Services: Medicaid
- ^ Centers for Medicare & Medicaid Services: Emergency Medical Treatment & Labor Act
- ^ "Illness And Injury As Contributors To Bankruptcy", by David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler, published at Health Affairs journal in 2005, Accessed 10 May 2006.
- ^ Adams PF, Barnes PM. "Summary health statistics for the U.S. population: National Health Interview Survey, 2004." Vital Health Stat 10. 2006 Aug;(229):1-104. PMID 16918080.
- ^ "Overall health system attainment in all Member States, WHO index, estimates for 1997" World Health Organization, World Health Report 2000, Accessed Nov 27, 2006.
- ^ http://hsc.utoledo.edu/research/nih_research_benefits.pdf The Benefits of Medical Research and the Role of the NIH]
- ^ Cunningham P, May J. "Medicaid patients increasingly concentrated among physicians." Track Rep. 2006 Aug;(16):1-5. PMID 16918046.
- ^ "Income, Poverty, and Health Insurance Coverage in the United States: 2004." U.S. Census Bureau. Issued August 2005.
- ^ a b Christopher J. Conover (4-10-2004). "Health Care Regulation: A $169 Billion Hidden Tax". Cato Policy Analysis 527: 1-32.
- ^ Sue A. Blevins (15-12-1995). "The Medical Monopoly: Protecting Consumers Or Limiting Competition?". Cato Policy Analysis 246.
- ^ Ronald Bailey. Mandatory Health Insurance Now! It will save private medicine -- and spur medical innovation.. Reason Magazine. Retrieved on 2006-06-21.
- ^ http://www.time.com/time/nation/article/0,8599,1207599,00.html
- ^ http://content.healthaffairs.org/content/vol0/issue2004/images/data/hlthaff.w4.79v1/DC1/Heffler_Feb_Ex5.gif
- ^ http://www.allp.com/drug_dev.htm
[edit] See also
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