Health care in the United States is provided by many separate legal entities. Current estimations put US health spending at approximately 15% of GDP.
The United States follows a less 'socialist' system of healthcare than most nations; Canada and the United Kingdom, for example, have fully state-funded systems. The accepted system from the point of view of the citizen is to acquire health insurance, typically thousands of dollars per year per capita, and this policy covers all major healthcare requirements. If a citizen lacks such a policy, then they must either pay for treatment, or typically be treated at another, cheaper, or sometimes third-rate hospital, or the county hospital. Various government programs for state aid exist to cover some emergency or more long-term care, and the generally high cost of treatment has led to the concept of doctors completing pro bono work in addition to their more high-paying customers. However, the system has come under criticism for its failure to meet the needs of the uninsured[citation needed].
Who provides it
American health care is provided to patients by a diverse array of entities. There are nonprofit hospitals, which may be operated by county governments, state governments, religious orders, or independent nonprofit organizations. There are for-profit hospitals, which are usually operated by large private corporations. There are many outpatient clinics, which may be operated by any of the above organizations or may be a partnership of health care professionals (essentially a large medical or dental group). Finally, there are some health care professionals who individually, or in a group, practice for personal profit.
Costs of medical supplies (consumables), machines, tools, and pharmaceuticals are usually passed through to the patient or their insurer. The pharmaceutical and medical supply industries have become dominated by powerful private conglomerates like Johnson & Johnson.
Who covers it
The default legal situation has always been that the patient must pay out-of-pocket in full for all services rendered, as with any other service industry; this business model is known as "fee-for-service." But today, fee-for-service applies only to the minority of Americans who are not covered by any kind of insurance, a situation further discussed below.
Most Americans are covered by some kind of cost-spreading mechanism (i.e., insurance) which distributes the risk of illness and the cost of health care among a group of people. This means that each individual or their employer pays predictable monthly premiums, so that when any given individual needs health care, they will have to pay up-front one of the following: (1) nothing (increasingly rare), (2) a minimum part of the total cost (a deductible), or (3) a small part of the cost of every single procedure (a co-payment).
The entity that provides the health care is usually not the same entity that does the task of spreading the cost of it. The exceptions are health maintenance organizations like Kaiser Permanente which run their own hospital and clinic networks to control costs, and a few employers which employ an in-house physician (e.g., Google) or even operate their own outpatient clinics.
Instead, most Americans receive their health insurance coverage through benefits programs provided by employers. Most of the remainder are covered by government insurance programs like Medicare (United States) and Medicaid, and various state and local programs for the poor.
Either way, health care providers must bill a patient's insurer for the cost of services rendered. The billing process is considered by critics, to be inefficient, if not wasteful, for the following reasons:
- The lack of a national identity card forces insurers to impose many bureaucratic procedures like pre-authorization of non-emergency procedures upon both providers and patients to guard against fraud;
- The insurers have a financial interest in denying coverage for any reason, and providers and patients have a financial interest in fighting denials of coverage, and both end up wasting time and money in the process;
- The extreme fragmentation of the entire industry forces all entities to waste a lot of time learning about each other's bureaucratic procedures, because of the low probability that any pair of provider and insurer will regularly encounter each other; and
- Much of the health care industry still operates on inefficient paper documents, because no entity outside the federal government has the market power to impose a single standard for digital transmission of health care information, and the federal government has been unable to create such a standard as of 2005.
The process of selecting the appropriate billing code for each procedure completed has become so intricate that there is an entire industry of clerks devoted to it (complete with its own professional association, the American Academy of Professional Coders).
The coverage gap
Enrollment rules 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.[1] 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."
Since 1986, a controversial federal law, EMTALA [2], has required all American emergency rooms which bill federal healthcare programs to stabilize all incoming patients without regard to their ability to pay. This law was created as 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. 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. Meanwhile, some uninsured people use the emergency rooms as primary-care providers for illnesses such as ear infections and strep throat that could be more cheaply treated elsewhere, and arguably are not emergencies.
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. Some physicians have vociferously questioned the ability of the remaining emergency rooms, particularly in smaller cities, to respond to very large-scale disasters like 9/11.
Although it certainly keeps alive many working-class people who are badly injured, another problem is that 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.
In turn, in many American cities, it is common for mentally ill homeless people to "cycle" through emergency rooms. When admitted, such patients can be suffering from numerous diseases and malnutrition; hospitals clean them up and nurse them back to health, then discharge them to the street at the first legally justifiable opportunity; and then the same patients are back in the ER in three to six months after becoming critically ill again. The hospital sometimes ends up absorbing the full cost of care, since some homeless people are convicted drug addicts, which makes them ineligible for almost all federal and state assistance programs for the poor.
In the end, hospitals spread the cost to the patients who can pay (by raising prices on everything), which only further increases the total cost of health care for everyone. This increase in total cost may also cause additional people to become uninsured as insurance companies pass on the cost.
Finally, the unavailability of free preventive care and the sometimes high cost of paying out-of-pocket means that many working-class persons delay visiting a doctor or an emergency room as long as possible. In turn, such 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). The financial cost of treating those diseases at a late stage is also much higher.
Major 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.
Although some people argue that the U.S. should regulate drug prices like nearly all other countries, 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 so many other countries regulate drug prices). This is essentially an instance of the free rider problem in economics. 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.
The counterargument is that the corporations commonly known as Big Pharma are among the most profitable in the world, and their executives and shareholders are already earning astronomical returns; the standard rebuttal is that those corporations and their investors take enormous financial risks in developing any given drug, and as with any capitalist enterprise, they should be allowed to capture enormous profit in exchange for accepting the risk of enormous losses. Less than 1 in 10 make it through the full approval process, and if a drug is proven to be unsafe later, then the manufacturer can be subject to massive legal liability (e.g., fen-phen).
Many also feel that because the US government pays for large amounts of research in the form of grants and subsidies that it has a right to expect that research to be used for the greater good.
Universal health care
As for remedying the problem of the lack of coverage, some physicians and analysts support the concept of tax-payer subsidies for the health care system as has been done in most industrialized countries. However, such proposals have fell flat, largely due to opposition from other physicians and analysts, libertarians, conservatives, and the corporations who manufacture most drugs and run most hospitals.
A major problem with tax-payer subsidies is that the quality of American physicians at present appears to be partially dependent on their salaries, which compensate them for their working hours, education and training (approximately 10 years from when they make the decision as a college undergraduate), and education debt.
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. During the SARS crisis, some American healthcare analysts argued that the inadequate responses of several foreign healthcare systems (especially Canada) was partially caused by the tendency of the best and brightest students in such countries to be attracted to higher-paying fields like business or law. Similar comparative analyses have been performed on various other public health disasters.
It remains to be seen whether industrialized nations will follow the U.S. system of requiring the fees for services rendered to be paid by those receiving such services, or whether the U.S. will follow those counties in the rest of the world which have chosen tax-payer subsidized healthcare.
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. 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. The argument is that deportation to their home countries would be a death sentence, because their home countries' healthcare systems are either incompetent or underfunded. In early 2005, one highly publicized case involved a young girl named Rachel Andrews, whose parents fought deportation to the U.K. on the grounds that U.K. 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 U.K.
Some see the current system as a compromise: it guarantees excellent care for the 100 million who have money to pay for good insurance, reasonable care for the 150 million who have average insurance or government insurance, and emergency care for the 40 million who don't have any insurance[citation needed].
Health disparities
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 10 % higher than among whites[citation needed]. 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[citation needed].
See also
Notes
^ Kate Traynor, "More Americans than ever lack health insurance," American Journal of Health-System Pharmacy 62, no. 24 (15 December 2005), 2583-2591.
External links and references
- Let’s Stop Being Nutty About the Mentally Ill "It is important to realize the magnitude of this experiment. In 1955 state psychiatric hospitals housed 558,239 seriously mentally ill persons. If the same proportion of Americans were hospitalized today, when the U.S. population is much larger, these hospitals would contain some 900,000 seriously mentally ill individuals. In fact the actual number is less than 70,000, meaning that the net deinstitutionalization amounts to some 830,000 people—more than the population of Boston, Baltimore, or San Francisco."
- Washington Post "The District's treatment of a homeless Haitian immigrant who was held illegally at St. Elizabeths Hospital for nearly three months was "callously cruel and indifferent," a D.C. Superior Court judge said yesterday."
- California Treatment Advocacy Coalition Recommendations "The current system for providing involuntary treatment is incompatible with newer scientific knowledge regarding the fluctuating degrees of cognitive and mentation deficits caused by brain dysfunction in mental illness. Moreover, piecemeal additions to the statutes addressing involuntary treatment, as well as common practice misinterpretation of the statute over the past thirty years, have made the system cumbersome and adversarial"
- Money and Health care in America " I am a family physician who provides care to homeless families in San Francisco through the Homeless Families program based at Tom Waddell Health Center. Given the extraordinary breadth and depth of the proposed cuts in mental health, substance abuse, and homeless outreach services, I feel the need to register my strong conviction that these cuts will have a severe impact on many San Francisco residents. These deleterious effects will be most concentrated among the people with the least ability to deal with them and will perpetuate the circumstances that drive people into homelessness. As you know, medical and mental illness as well as substance abuse are major causes of homelessness. Cutting necessary services will not result in cost savings and will cause increased suffering. Please consider cutting services and tax breaks to the wealthy and healthy who can take care of themselves rather than removing the final safety network for people in desperate need."
- New York Supreme Court testimony "Federal disability benefits under the Supplemental Security Income (SSI) program or the Social Security Disability Insurance (SSDI) program provide both cash support and, in nearly all states, immediate and automatic coverage under Medicaid (or in the case of SSDI, automatic coverage under Medicare). In New York, which supplements the federal payment, the maximum monthly SSI benefit is $580. Technical Assistance Collaborative, Inc. & Consortium for Citizens with Disabilities Housing Task Force, Priced Out in 1998: The Housing Crisis for People With Disabilities 43 (1999). SSI and SSDI are cash benefits that can be used to secure housing, and may be the critical difference between stability and homelessness for a person with mental disabilities. Medicaid coverage is critical for successful re-entry following a jail or prison term. Thus, individuals who are on Medicaid when they enter a City Jail should be able to leave with their Medicaid re-established, so as to immediately access services."
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