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In the to all its citizens, but certain Publicly-funded Health Care programs help to provide for the elderly, disabled, children, and the poor, Centers for Medicare & Medicaid Services: Medicare Centers for Medicare & Medicaid Services: Medicaid and federal law ensures public access to emergency services regardless of ability to pay. Centers for Medicare & Medicaid Services: Emergency Medical Treatment & Labor Act In 2001, only the governments of Iceland and Norway spent more per capita on health care.http://earthtrends.wri.org/datatables/index.php?theme=4 U.S. government programs accounted for over 44% of health care expenditures, making the U.S. government the largest insurer in the nation. When public and private spending are added together, the U.S. spends more per capita than any other nation. World Health Organization: Core Health Indicators Americans without health insurance coverage, currently about 16% of the population, or 47 million people, 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. "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''. The debate about U.S. health care concerns questions of access, efficiency, and quality purchased by the high sums spent. The overall performance of the United States health care system was ranked 37th by the , 2007 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% of personal health expenditures, private out-of-pocket payments were 15%, while federal, state, and local governments paid 44%. Health, United States, 2006 . U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. 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). In 1996, Concierge Medicine emerged, where enhanced care and services are provided by primary care physicians for a retainer fee. 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 , September 20, 2005 The research and development for applications is primarily done in commercial research and development labs while the government and universities fund the majority of basic research. Much of this basic research is funded or performed by governmental research institutes such as the NIH and NIMH . HEALTH CARE PAYMENT Most Americans, 59.7%, receive their health insurance coverage through an employer, although this percentage is declining. About 9% purchase it directly from the market. Government sources cover 27% of the population (80.3 million). In 2006, there were 47 million people in the U.S. (15.8% of the population) who were without health insurance for at least part of that year. Among the uninsured, nearly 38 million were employment-age adults (ages 18 to 64), and more than 27 million worked at least part time. About 37% of the uninsured live in households with an income over $50,000. It has been estimated that nearly one fifth of the uninsured population is able to afford insurance, almost one quarter is eligible for public coverage, and that the remaining 56% need financial assistance (8.9% of all Americans).Dubay L, Holahan J and Cook A. The Uninsured and the Affordability of Health Insurance Coverage. ''Health Affairs'' (Web Exclusive), November 2006. {Link without Title} Accessed February 4, 2007. Commercial The "fee-for-service" business model is the default legal situation where the patient must pay out-of-pocket in full for all services rendered, similar to other Service industries. FEHB Glossary. Retrieved May 31, 2006.. 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 single procedure (a Copayment ). Managed Care includes Preferred Provider Organizations , in which insurers negotiate discounted rates with contracted providers, Health Maintenance Organizations such as Kaiser Permanente , which run their own hospital and clinic networks to control costs, and a few employers who employ an in-house physician or even operate their own outpatient clinics. Managed care is controversial, because cost control requires that treatments be authorized by a third party, intervening between doctors and their patients. Managed care frequently denies treatment options considered too costly for their benefits. Managed care is a form of non-price " Rationing " (as distinguished from price rationing); this explicit rationing is frequently criticized as one of the drawbacks of some national health care systems. Public Many individuals not covered by private insurance are covered by government insurance programs such as (SCHIP), a joint-federal state program to insure children in families who earn too much to qualify for Medicaid but cannot afford health insurance.3 SCHIP covered 6.6 million children in 2006,4 but the program is already facing funding shortfalls in many states.5 Role of government in health care market The cost impact of a mixed public-private system is subject to debate. Some commentators and economists observe that government programs bid up health care prices because they lack the financial incentives to bargain with health care providers.6 On the other hand, 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.7 Furthermore, health maintenance organizations were declining before Congress passed the Health Maintenance Organization Act Of 1973 , heavily subsidizing the HMO business model. 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 Commission on Accreditation of Hospital Organizations, JCAHO. SYSTEM INEFFICIENCIES AND INEQUITIES Inefficiencies Increased use of catastrophic care Uninsured Americans are less likely to have regular health care and use preventive services. They are more likely to delay seeking needed care, resulting in more medical crises and emergency hospitalizations, which are more expensive than ongoing treatment for such conditions as diabetes and high blood pressure. 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. National Hospital Ambulatory Care Survey Shared costs of the uninsured The costs of treating the uninsured must often be absorbed by providers as free care, passed on to the insured via cost shifting and higher health insurance premiums, or paid by taxpayers through higher taxes. The Cost of Lack of Health Insurance, American College of Physicans 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.The trade association AHIP , America's Health Insurance Plans, has some 1,300 members. "The Health Care Crisis and What to Do About It" By Paul Krugman, Robin Wells, New York Review of Books, March 23, 2006 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 percent 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. Costs of Health Administration in the U.S. and Canada Woolhandler, et al, NEJM 349(8) Sept. 21, 2003 Inequities Coverage gaps 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 47 million Americans (about 15.8% of the total population) had no health insurance coverage during 2006. Most uninsured Americans are working-class persons whose employers do not provide health insurance, and who earn too much money to qualify for one of the local or state insurance programs for the poor, but do not earn enough to cover the cost of enrollment in a health insurance plan designed for individuals. As health insurance rates rise and the population ages, those seeking to purchase health insurance directly are finding it increasingly difficult to do so, because some insurers are managing their risk by denying directly purchased coverage to individuals who have pre-existing conditions, some of them minor.8 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 {Link without Title} 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. Coverage gaps also occur among the insured population — one study by the Commonwealth Fund published in ''Health Affairs'' estimated that 16 million U.S. adults were underinsured in 2003. The study defined underinsurance as characterized by at least one of the following conditions: annual out-of-pocket medical expenses totaling 10% or more of income, or 5 percent or more among adults with incomes below 200% of the federal poverty level; or health plan deductibles equaling or exceeding 5% of income. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes — 73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level.9 Health disparities among minorities See Also: Health disparities In the , HIV/AIDS , and Infant Mortality than whites.American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004). REGULATORY INEFFICIENCIES AND INEQUITIES Healthcare regulatory costs The healthcare industry is likely the most heavily regulated industry in the United States.10 A Cato Institute study suggests that this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion. The study found that the majority of the cost differential arises from Medical Malpractice , FDA regulations, and facilities regulations. Part of the cost arises from regulatory requirements that prevent technicians without medical degrees from performing treatment and diagnostic procedures that carry little risk.11 Mental illness and the Emergency Medical Treatment and Active Labor Act (EMTALA) 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 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 criteria 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. Since the late 1970's, the community-based care model has been encouraged within the U.S. rather than institutionalization. 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 During the 1990s, the price of Prescription Drugs became a major issue in American politics as the prices of many new drugs increased exponentially, and many citizens discovered that neither the government nor their insurer would cover the cost of such drugs. In absolute currency, the U.S. spends the most on pharmaceuticals per capita in the world. However, national expenditures on pharmaceuticals accounted for only 12.9% of total healthcare costs, compared to an OECD average of 17.7% (2003 figures).12 Some 25% of out-of-pocket spending by individuals is for prescription drugs.http://content.healthaffairs.org/content/vol0/issue2004/images/data/hlthaff.w4.79v1/DC1/Heffler_Feb_Ex5.gif 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). The U.S. position is that the governments of such 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. Approximately one in five drugs that begin testing make it through the full approval process.http://www.allp.com/drug_dev.htm Health care debate See Also: Universal health care The United States along with South Africa are the only examples of industrialized nations without universal coverage. There is currently an ongoing debate on the need to achieve universal coverage as well as the best methods for improving the U.S. health care system. REFERENCES SEE ALSO EXTERNAL LINKS
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