Health care in the United States

Health care in the United States is provided by legal entities. Current estimates put US healthcare spending as GDP, which is the highest in the world.^[1] In the United States, around 85% 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 some of 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 37th by the World Health Organization (WHO) in 2000.^[8]

Health insurance coverage

Most Americans, 59.5%, receive their health insurance coverage through an employer, and about 9% purchase it directly from the market.^[9] Government sources cover 27.3% of the population.^[10] In 2005, there were 46.6 million people in the U.S. (15.9% of the population) who were without healthcare insurance for at least part of that year.(ibid) Many of these may have been in between jobs at low risk of serious illness and therefore choosing to not to purchase it. In fact, approximately one-third of these 46.6 million who did not have health insurance for at least part of the year live in households with an income over $50,000, with half of these having an income of over $75,000.^[11] It is has been estimated that nearly one fifth of the uninsured population is able to afford insurance, almost one quarter is eligible for public coverage, and that the remaining 56% need financial assistance.^[12]

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. The healthcare system is not fully-publicly funded but is a mix of public and private funding. In 2004, private insurance paid for 36% personal health expenditures, private out-of-pocket payments were 15%, while federal, state, and local governments paid 44%.^[13]

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).

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.

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.^[14] However, by 2003, the NIH funded only 28% of medical research funding; funding by private industry increased 102% from 1994 to 2003.^[15] 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.

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. ^[16]

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 Committee on Accreditation of Hospital Organizations, JCAHO.

System inefficiencies and inequities

Inefficiencies

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.^{[citation needed]}

Inequities

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 46.6 million Americans (about 15.9% of the total population) had no health insurance coverage during 2005^[17]. This constituted a rise of about 1.3 million 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.

Health disparities among minorities

Main article: Health disparities

In the United States, health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Hispanics.^[18] 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.^[19] 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.^[20]

Regulatory inefficiencies and inequities

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.

Healthcare regulatory costs

The healthcare industry is likely the most heavily regulated industry in the United States. A Cato Institute study suggests that this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion ^[21]. The majority of the cost differential arises from medical malpractice, FDA regulations, and facilities regulations ^[21]. Part of the cost arises from regulatory requirements that prevent technicians without medical degrees from performing treatment and diagnostic procedures that carry little risk ^[22]. 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 ^[23].

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.

Political issues

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.^[24]

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.^[25]

References

See also

• School health services

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