ESSENTIALS OF THE U.S.HEALTHCARE SYSTEM 3RD EDITION PDF
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This article provides an overview of the U. Prepared for a nation comparative study for the Organization for Economic Cooperation and Development OECDthe article summarizes descriptive u.s.healthcar on the financing, utilization, access, and supply of U. This article was prepared for a country comparative analysis of health system reforms in the s in Organization for Economic Cooperation and Development OECD countries. This article pulls together basic structural information, reviews trends in the growth of health system costs and indicators, discusses the major health system reforms of the s, and summarizes the proposed changes currently being debated.
As a part of this OECD project, a comparative study of all 15 countries is currently being written u.s.healthcre will be published by OECD, along with the individual country papers early next year.
The United States spends more on health care services than does any other nation—on average, more than twice as much per person as the other OECD countries Schieber, Poullier, and Greenwald, These expenditures are 3gd by a complex mixture of public payers Federal, Essentiaals, and local governmentas well as private insurance and individual payments: There is no single nationwide system of health insurance.
The United States primarily relies on employers to voluntarily provide health insurance coverage to their employees and dependents; government programs are confined to the elderly, the disabled, and some of the poor. These private and public health insurance programs all differ with respect to benefits covered, sources of financing, and payments to medical care providers. There is little coordination between private and public programs: Some people have both public and private insurance while others have neither.
Nevertheless, persons without health insurance are not entirely without health care. Health services are provided by a loosely structured delivery u.s.healthcafe organized at the local level. Hospitals can open or close according to community resources, preferences, and the dictates of an open market for hospital services. Also, physicians are free to establish systej practice where they choose.
There is no health planning at the Federal level, and State planning efforts vary from none to stringent review of hospital and nursing home construction projects.
In areas without sufficient u.s.hezlthcare providers e.
Municipal and county public health departments provide limited primary care services through public health clinics and regulate sanitation, water supply, and environmental hazards.
Most hospitals are owned by private non-profit institutions; the remainder are owned by governments or private for-profit corporations. Physicians, the vast majority of whom are in private practice and paid on an FFS basis, see their patients in their offices, and admit them to hospitals where they can continue to serve them. About two-fifths of physicians are in solo practice. Although there is a long-term trend toward the formation of more and larger group practices, the proportion of solo practices is shrinking only at a very slow rate Marder et al.
A relatively small number of physicians is not in the FFS sector but is employed by the government, corporations, managed care networks, or hospitals. In recent years, health reform in the United States has focused on controlling rapidly rising health costs and increasing financial access to health care. A variety of cost-control strategies have been attempted at the Federal, State, and local levels of government and by private payers. Despite these efforts, health care costs continue to escalate.
The resulting pressure on public, private, and individual budgets keeps the issue of control of health care costs high on the public agenda.
The vast majority of the population, about 74 percent, is covered by oc health insurance Figure 1. Those under 65 years of age and their dependents ov private health insurance either through their employers 61 percent of the population or by direct purchase of non-group health insurance 13 percent of the population.
A small proportion of the population, 13 percent, has multiple health insurance coverage 2 e. Bureau of the Census, b. Not all firms offer health insurance. In fact the majority of the uninsured 75 percent are employees or their dependents Short, Monheit, and Beauregard, There are more than 1, private health insurance companies providing health insurance policies with different i.s.healthcare structures, premiums, and rules for paying the insured or medical care providers.
These companies are regulated by State insurance commissioners; the Federal Government does not generally regulate insurance companies. States sometimes specify that certain, often narrowly defined, benefits or providers e. States may also regulate insurance premium increases and other aspects of the insurance industry. Although evition health insurance is voluntary, it is encouraged by tax policy.
Employer-paid contributions to employee health costs are basically a substitute for cash wages. This substitution has increased in recent years. Health benefits rose from 2. When employers pay wages in the form of health benefits, they are subject neither to the personal income tax nor to the Social Security tax.
Department of the Treasury, Individuals with relatively high medical expenses, more than 7. The majority of those with private health insurance are covered for inpatient hospital services and physician services; the breadth and depth of coverage of other services vary. Industries with strong unions e.
On the other hand, service industries e. The amount of patient cost sharing also varies. For example, as many as 55 million Americans with private health insurance are underinsured, that is, they do not have a limit on their out-of-pocket health expenses and are at risk of being impoverished should they experience a costly, major illness Farley, Home care is covered in most insurance plans after a hospitalization for an acute episode of illness in order to allow recovery in a less costly setting.
Home care and long-term care for chronic conditions and frailty related to aging are not generally covered by public or private insurance. Most long-term care and home care are purchased out-of-pocket or provided informally by family and friends.
In the last few years, some private health insurers have been marketing long-term care policies, primarily to upper income individuals who can afford the premiums. Medicare is a uniform national health insurance program for the aged and disabled.
Administered by the Federal Government, it is the single largest health insurer in the country, covering about 13 percent of the population, including virtually all the elderly 65 years of age or over 31 million peopleand certain persons with disabilities or kidney failure 3 million people Board of Trustees of the Federal Hospital Insurance Trust Fund, The program is financed by a combination of payroll taxes, general Federal revenues, and premiums.
It is comprised of two parts: Coverage under Part A is earned through payment of a payroll tax during one’s working years; coverage under Part B is voluntarily obtained through payment of a premium once eligibility for Medicare is established through receipt of retirement or disability benefits under the Social Security income assistance program.
Welcome to Essentials of the U.S. Health Care System
Medicare is an inter-generational transfer program primarily funded by taxes from working people to provide services to aged beneficiaries. However, this financing approach is not actuarially sound: Expenses are increasing faster than revenues, leading to a projected trust fund bankruptcy early in the next century Boards of Trustees of the Federal Hospital Insurance Trust Fund, As the population ages, there will be fewer pf supporting each beneficiary.
There were 5 workers for each beneficiary inthere will be 3 workers per beneficiary essentjalsand 1. House of Representatives, Coverage under Part A includes inpatient hospital care, very limited nursing home services, and some home health services.
The Part A payroll tax is paid by virtually all employed individuals. The payroll tax is 1. Coverage under Part B includes physician and other ambulatory services, durable medical equipment e. Systfm is oriented towards acute care, and such services as long-term nursing home care, routine eye care, and outpatient prescription drugs are not covered. Moreover, Medicare patients must also pay coinsurance and deductibles: These account for an average of 17 percent of the services covered by Medicare, and consume an average of 6 percent of their per capita income U.
Medicare covers less than one-half of the total medical care expenses of the elderly Waldo et al. To pay for Medicare coinsurance and deductibles and, in some cases, uncovered benefits, about 68 percent of Essentiaals beneficiaries have private supplemental health plans, provided by former employers or self-purchased, and an additional 9 percent have Medicaid U.
Bureau of the Census, a. Despite all of these sources of health insurance, the elderly spend an increasing share of their after-tax income on health expenses, up from 7. Medicaid is a health insurance program for certain groups of the poor. It covers preventive, acute, and long-term care services for 25 million people, or 10 percent of the population.
Medicaid is jointly financed by Federal and State governments. The Federal Government matches State Medicaid outlays at rates which vary by State personal-income levels: The Federal share of esentials expenditures ranges from 50 to 83 percent, with the poorer States receiving a higher match from the Federal Government.
Medicaid is administered by the States under broad Federal guidelines governing the scope of services, ezsentials level of payments to providers, and population groups eligible for coverage. In order to be eligible for Medicaid, a person must be poor as well as aged, blind, disabled, pregnant, or the parent of a dependent child. Mothers and dependent children comprise about 68 percent of Medicaid exsentials, the elderly 13 percent, the blind and disabled 15 percent, and others 4 percent.
States further define eligibility levels e. Consequently, about 60 percent of the poor below the Federal poverty line are excluded from Medicaid Swartz and Lipson, Childless, non-disabled adults under 65 years of age, no matter how poor or how high their medical expenses, are not eligible, nor are individuals essrntials assets above State-defined levels. On the other systfm, because Medicaid is the only public program that finances long-term nursing u.s.healghcare care, a significant number of middle-class elderly have become eligible for Medicaid-covered nursing home care by intentionally transferring assets to their children and exhausting their income on nursing home expenses Burwell, About 43 percent of Medicaid expenditures are spent on skilled nursing facilities and intermediate care facilities Ruther et essenyials.
The uninsured receive fewer health services systek insured individuals with comparable health status Freeman et al.
A layman’s guide to the U.S. health care system
Services for the uninsured are provided through a variety of sources, the amount and scope of which vary by community. Federal, State, and local governments support public health clinics and hospitals with a primary mission of providing care to the indigent.
In some cases they pay private providers to care for the indigent as well. Public health expenditures support preventive health measures such as vaccinations, cancer screening programs, and well-child care. The services are often available to all, although a fee which varies according to income may be charged. Providers sometimes subsidize the costs of services to uninsured individuals from operating margins.
Charity care and bad debt represented 5 percent of hospital expenses in Prospective Payment Assessment Commission, Estimates of physician charity care are difficult to make because, unlike hospitals, physicians do not submit detailed cost reports to the Federal Government.
However, as insurers and employers try to control their own costs, the ability of hospitals and other providers to cross-subsidize care for the uninsured, by cost-shifting to insurers and employers, may decrease.