Kenyon College info

Kenyon College info

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Health Reforms in USA

Health Reforms in USA

The Patient Protection and Affordable Care Act (Public Law 111-148) is a health care reform bill that was signed into law in the United States by President Barack Obama on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (passed March 25), the Act is a product of the health care reform agenda of the Democratic 111th Congress and the Obama administration.

The law includes a large number of health-related provisions to take effect over the next four years, including expanding Medicaid eligibility for people making up to 133% of FPL, subsidizing insurance premiums for peoples making up to 400% of FPL ($88,000 for family of 4) so their maximum "out-of-pocket" pay will be from 2% to 9.8% of income for annual premium, providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre-existing conditions, establishing health insurance exchanges, prohibiting insurers from establishing annual spending caps and support for medical research. The costs of these provisions are offset by a variety of taxes, fees, and cost-saving measures, such as new Medicare taxes for high-income brackets, taxes on indoor tanning, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies; there is also a tax penalty for citizens who do not obtain health insurance (unless they are exempt due to low income or other reasons). The Congressional Budget Office estimates that the net effect (including the reconciliation act) will be a reduction in the federal deficit by $143 billion over the first decade.

In May 2011, the state of Vermont became the first state to pass legislation establishing a Single-Payer health care system. The legislation, known as Act 48, establishes health care in the state as a "human right" and lays the responsibility on the state to provide a health care system which best meets the needs of the citizens of Vermont. The state is currently in the studying phase of how best to implement this system.

Health insurance coverage for immigrants

Of the 26.2 million foreign immigrants living in the US in 1998, 62.9% were non-U.S. citizens. In 1997, 34.3% of non-U.S. citizens living in America did not have health insurance coverage opposed to the 14.2% of native-born Americans who do not have health insurance coverage. Among those immigrants who became citizens, 18.5% were uninsured, as opposed to non citizens, who are 43.6% uninsured. In each age and income group, immigrants are less likely to have health insurance. With the recent healthcare changes, many legal immigrants with various immigration statuses now are able qualify for affordable health insurance. Options vary according to the immigrants' age and how long they have been permanent residents.

Health insurance coverage for visitors to the U.S.

Visitors to the U.S. cannot purchase health insurance that is available for U.S. citizens and permanent residents. Most domestic insurance policies purchased overseas cease to be effective inside the U.S., when individuals cross their home country borders during international travel. Currently, it is not mandatory for short-term visitors to U.S. to provide proof of travel medical insurance coverage to obtain a legal visa to enter the U.S. However, considering cost of healthcare for the uninsured in the U.S., many foreigners without residence in the U.S., and visiting the U.S. can benefit by buying a visitors health insurance protection plan that covers emergency expenses such as medical evacuation and treatment for sickness or injuries while in the U.S.

Debate on Health in USA

Debate on Health in USA

Main article: Health care reform in the United States

A poll released in March 2008 by the Harvard School of Public Health and Harris Interactive found that Americans are divided in their views of the U.S. health system, and that there are significant differences by political affiliation. When asked whether the U.S. has the best health care system or if other countries have better systems, 45% said that the U.S. system was best and 39% said that other countries' systems are better. Belief that the U.S. system is best was highest among Republicans (68%), lower among independents (40%), and lowest among Democrats (32%). Over half of Democrats (56%) said they would be more likely to support a presidential candidate who advocates making the U.S. system more like those of other countries; 37% of independents and 19% of Republicans said they would be more likely to support such a candidate. 45% of Republicans said that they would be less likely to support such a candidate, compared to 17% of independents and 7% of Democrats.

A 2004 Institute of Medicine (IOM) report said, "the United States is among the few industrialized nations in the world that does not guarantee access to health care for its population." There is currently an ongoing political debate centering on questions of access, efficiency, quality, and sustainability. Whether a government-mandated system of universal health care should be implemented in the U.S. remains a hotly debated political topic, with Americans divided along party lines in their views of the U.S. health system and what should be done to improve it. Those in favor of universal health care argue that the large number of uninsured Americans creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality. Cato Institute Senior Fellow Alan Reynolds argues that people should be free to opt out of health insurance, citing a study by Economists Craig Perry and Harvey Rosen that found "the lack of health insurance among the self-employed does not affect their health. For virtually every subjective and objective measure of their health status, the self-employed and wage-earners are statistically indistinguishable for each other." Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.

An impediment to implementing any U.S. healthcare reform that does not benefit insurance companies or the private health care industry is the power of insurance company and health care industry lobbyists. Possibly as a consequence of the power of lobbyists, key politicians such as Senator Max Baucus have taken the option of single payer health care off the table entirely. In a June 2009 NBC News/Wall Street Journal survey, 76% said it was either "extremely" or "quite" important to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance."

Advocates for single-payer health care often point to other countries, where national government-funded systems produce better health outcomes at lower cost. Opponents deride this type of system as "socialized medicine", and it has not been one of the favored reform options by Congress or the President in both the Clinton and Obama reform efforts. It has been pointed out that socialized medicine is a system in which the government owns the means of providing medicine. England is an example of socialized system, as, in America, is the Veterans Health Administration. Medicare is an example of a mostly single-payer system, as is France. Both of these systems have private insurers to choose from, but the government is the dominant purchaser.

As an example of how government intervention has had unintended consequences, in 1973, the federal government passed the Health Maintenance Organization Act, which heavily subsidized the HMO business model – a model that was in decline prior to such legislative intervention. The law was intended to create market incentives that would lower health care costs, but HMOs have never achieved their cost-reduction potential.

Piecemeal market-based reform efforts are complex. One study evaluating current popular market-based reform policy packages concluded that if market-oriented reforms are not implemented on a systematic basis with appropriate safeguards, they have the potential to cause more problems than they solve.

According to economist and former U.S. Secretary of Labor, Robert Reich, only a "big, national, public option" can force insurance companies to cooperate, share information, and reduce costs. Scattered, localized, "insurance cooperatives" are too small to do that and are "designed to fail" by the moneyed forces opposing Democratic health care reform. The Patient Protection and Affordable Care Act, signed into law in March 2010, did not include such an option.

Political issues for U.S Govt in Health Feild

Political issues for U.S Govt in Health Feild

Prescription drug prices

The following text needs to be harmonized with text in Prescription drug prices in the United States. (October 2009)

Main article: Prescription drug prices in the United States

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. Per capita, the U.S. spends more on pharmaceuticals than any other country. National expenditures on pharmaceuticals accounted for 12.9% of total health care costs, compared to an OECD average of 17.7% (2003 figures). Some 25% of out-of-pocket spending by individuals is for prescription drugs.

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 in other countries (because many other countries use their bulk-purchasing power to aggressively negotiate drug prices). The U.S. position (consistent with the primary lobbying position of the Pharmaceutical Research and Manufacturers of America) is that the governments of such countries are free riding on the backs of U.S. consumers. Such governments should either deregulate their markets, or raise their domestic taxes in order to fairly compensate U.S. consumers by directly remitting 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, pharmaceutical companies would be able to continue to produce innovative pharmaceuticals while lowering 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 due to the Medicare Prescription Drug, Improvement, and Modernization Act passed in 2003. Democrats have charged that the purpose of this provision is merely to allow the pharmaceutical industry to profiteer off of the Medicare program.

Drug efficiency and safety in USA

Drug efficiency and safety in USA

See also: Regulation of therapeutic goods in the United States

The Food and Drug Administration (FDA) is the primary institution tasked with the safety and effectiveness of human and veterinary drugs. It also is responsible for making sure drug information is accurately and informatively presented to the public. The FDA reviews and approves products and establishes drug labeling, drug standards, and medical device manufacturing standards. It sets performance standards for radiation and ultrasonic equipment.

One of the more contentious issues related to drug safety is immunity from prosecution. In 2004, the FDA reversed a federal policy, arguing that FDA premarket approval overrides most claims for damages under state law for medical devices. In 2008 this was confirmed by the Supreme Court in Riegel v. Medtronic.

On June 30, 2006, an FDA ruling went into effect extending protection from lawsuits to pharmaceutical manufacturers, even if it was found that they submitted fraudulent clinical trial data to the FDA in their quest for approval. This left consumers who experience serious health consequences from drug use with little recourse. In 2007, the House of Representatives expressed opposition to the FDA ruling, but the Senate took no action. On March 4, 2009, an important U.S. Supreme Court decision was handed down. In Wyeth v. Levine, the court asserted that state-level rights of action could not be pre-empted by federal immunity and could provide "appropriate relief for injured consumers." In June 2009, under the Public Readiness and Emergency Preparedness Act, Secretary of Health and Human Services Kathleen Sebelius signed an order extending protection to vaccine makers and federal officials from prosecution during a declared health emergency related to the administration of the swine flu vaccine.

Impact of drug companies

The U.S. is one of two countries in the world that allows direct-to-consumer advertising of prescription drugs. Critics note that drug advertisements cost money which they believe have raised the overall price of drugs.

When health care legislation was being written in 2009, the drug companies were asked to support the legislation in return for not allowing importation of drugs from foreign countries.

Demographic differences in USA

Demographic differences in USA

Main article: Race and health in the United States

Health disparities are well documented in the U.S. in ethnic minorities such as African Americans, Native Americans, and Hispanics. 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. In addition, adult African Americans and Hispanics have approximately twice the risk as whites of developing diabetes and have higher overall obesity rates. Minorities also have higher rates of cardiovascular disease and HIV/AIDS than whites. Caucasian Americans have much lower life expectancy than Asian Americans. A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.

Public spending is highly correlated with age; average per capita public spending for seniors was more than five times that for children ($6,921 versus $1,225). Average public spending for non-Hispanic blacks ($2,973) was slightly higher than that for whites ($2,675), while spending for Hispanics ($1,967) was significantly lower than the population average ($2,612). Total public spending is also strongly correlated with self-reported health status ($13,770 for those reporting "poor" health versus $1,279 for those reporting "excellent" health). Seniors comprise 13% of the population but take 1/3 of all prescription drugs. The average senior fills 38 prescriptions annually. A new study has also found that older men and women in the South are more often prescribed antibiotics than older Americans elsewhere, even though there is no evidence that the South has higher rates of diseases requiring antibiotics.

There is considerable research into inequalities in health care. In some cases these inequalities are caused by income disparities that result in lack of health insurance and other barriers to receiving services. According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care. For example, minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic people. In other cases, inequalities in health care reflect a systemic bias in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of racism in science and medicine shows that people and institutions behave according to the ethos of their times. Nancy Krieger wrote that racism underlies unexplained inequities in health care, including treatment for heart disease, renal failure, bladder cancer, and pneumonia. Raj Bhopal writes that these inequalities have been documented in numerous studies. The consistent and repeated findings were that black Americans received less health care than white Americans – particularly when the care involved expensive new technology. One recent study has found that when minority and white patients use the same hospital, they are given the same standard of care.

Mental health

Mental health

See also: Emotional mental health in the United States and Mentally ill prisoners in the United States

A lack of mental health coverage for Americans bears significant ramifications to the U.S. economy and social system. A report by the U.S. Surgeon General found that mental illnesses are the second leading cause of disability in the nation and affect 20% of all Americans. It is estimated that less than half of all people with mental illnesses receive treatment (or specifically, an ongoing, much needed, and managed care; where medication alone, cannot easily remove mental conditions) due to factors such as stigma and lack of access to care.

The Paul Well stone Mental Health and Addiction Equity Act of 2008 mandates that group health plans provide mental health and substance-related disorder benefits that are at least equivalent to benefits offered for medical and surgical procedures. The legislation renews and expands provisions of the Mental Health Parity Act of 1996. The law requires financial equity for annual and lifetime mental health benefits, and compels parity in treatment limits and expands all equity provisions to addiction services. Insurance companies and third-party disability administrators (most notably, Sedgwick CMS) used loopholes and, though providing financial equity, they often worked around the law by applying unequal co-payments or setting limits on the number of days spent in inpatient or outpatient treatment facilities.

Medical underwriting and the un insurable

In most states in the U.S., people seeking to purchase health insurance directly must undergo medical underwriting. Insurance companies seeking to mitigate the problem of adverse selection and manage their risk pools screen applicants for pre-existing conditions. Insurers reject many applicants or quote increased rates for those with pre-existing conditions. Diseases that can make an individual un insurable include serious conditions, such as arthritis, cancer, and heart disease, but also such common ailments as acne, being 20 pounds over or under weight, and old sports injuries. An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.

Proponents of medical underwriting argue that it ensures that individual health insurance premiums are kept as low as possible. Critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from obtaining health insurance.

One large industry survey found that 13% of applicants for individual health insurance who went through medical underwriting were denied coverage in 2004. Declination rates increased significantly with age, rising from 5% for those under 18 to just under one-third for those aged 60 to 64. Among those who were offered coverage, the study found that 76% received offers at standard premium rates, and 22% were offered higher rates. The frequency of increased premiums also increased with age, so for applicants over 40, roughly half were affected by medical underwriting, either in the form of denial or increased premiums. In contrast, almost 90% of applicants in their 20s were offered coverage, and three-quarters of those were offered standard rates. Seventy percent of applicants age 60–64 were offered coverage, but almost half the time (40%) it was at an increased premium. The study did not address how many applicants who were offered coverage at increased rates chose to decline the policy. A study conducted by the Commonwealth Fund in 2001 found that, among those aged 19 to 64 who sought individual health insurance during the previous three years, the majority found it un affordable, and less than a third ended up purchasing insurance. This study did not distinguish between consumers who were quoted increased rates due to medical underwriting and those who qualified for standard or preferred premiums. Some states have outlawed medical underwriting as a prerequisite for individually purchased health coverage. These states tend to have the highest premiums for individual health insurance.

Health insurance coverage in the United States

Shared costs of the uninsured

Main article: Health insurance coverage in the United States

The costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost shifting and higher health insurance premiums, or paid by taxpayers through higher taxes. However, hospitals and other providers are reimbursed for the cost of providing uncompensated care via a federal matching fund program. Each state enacts legislation governing the reimbursement of funds to providers. In Missouri, for example, providers assessments totaling $800 million are matched – $2 for each assessed $1 – to create a pool of approximately $2 billion. By federal law these funds are transferred to the Missouri Hospital Association for disbursement to hospitals for the costs incurred providing uncompenstated care including Disproportionate Share Payments (to hospitals with high quantities of uninsured patients), Medicaid shortfalls, Medicaid managed care payments to insurance companies and other costs incurred by hospitals. In New Hampshire, by statute, reimbursable uncompensated care costs shall include: charity care costs, any portion of Medicaid patient care costs that are unreimbursed by Medicaid payments, and any portion of bad debt costs that the commissioner determines would meet the criteria under 42 U.S.C. section 1396r-4(g) governing hospital-specific limits on disproportionate share hospital payments under Title XIX of the Social Security Act.

A report published by the Kaiser Family Foundation in April 2008 found that economic downturns place a significant strain on state Medicaid and SCHIP programs. The authors estimated that a 1% increase in the unemployment rate would increase Medicaid and SCHIP enrollment by 1 million, and increase the number uninsured by 1.1 million. State spending on Medicaid and SCHIP would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion). This increased spending would occur at the same time state government revenues were declining. During the last downturn, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules. The authors conclude that Congress should consider similar relief for the current economic downturn.

Variations in provider practices

The treatment given to a patient can vary significantly depending on which health care providers they use. Research suggests that some cost-effective treatments are not used as often as they should be, while over utilization occurs with other health care services. Unnecessary treatments increase costs and can cause patients unnecessary anxiety. The use of prescription drugs varies significantly by geographic region. The overuse of medical benefits is known as moral hazard – individuals who are insured are then more inclined to consume health care. The way the Health care system tries to eliminate this problem is through cost sharing tactics like co-pays and deductibles. If patients face more of the economic burden they will then only consume health care when it is necessary. According to the RAND health insurance experiment, individuals with higher Coinsurance rates consumed less health care than those with lower rates. The experiment concluded that with less consumption of care there was generally no loss in societal welfare but, for the poorer and sicker groups of people there were definitely negative effects. These patients were forced to forgo necessary preventative care measures in order to save money leading to late diagnosis of easily treated diseases and more expensive procedures later. With less preventative care, the patient is hurt financially with an increase in expensive visits to the ER.The Health Care costs in the U.S will also rise with these procedures as well. More expensive procedures lead to greater costs.

One study has found significant geographic variations in Medicare spending for patients in the last two years of life. These spending levels are associated with the amount of hospital capacity available in each area. Higher spending did not result in patients living longer.

Care coordination

Primary care doctors are often the point of entry for most patients needing care, but in the fragmented health care system of the U.S., many patients and their providers experience problems with care coordination. For example, a Harris Interactive survey of California physicians found that:

• Four of every ten physicians report that their patients have had problems with coordination of their care in the last 12 months.
• More than 60% of doctors report that their patients "sometimes" or "often" experience long wait times for diagnostic tests.
• Some 20% of doctors report having their patients repeat tests because of an inability to locate the results during a scheduled visit.

According to an article in The New York Times, the relationship between doctors and patients is deteriorating. A study from Johns Hopkins University found that roughly one in four patients believe their doctors have exposed them to unnecessary risks, and anecdotal evidence such as self-help books and web postings suggest increasing patient frustration. Possible factors behind the deteriorating doctor/patient relationship include the current system for training physicians and differences in how doctors and patients view the practice of medicine. Doctors may focus on diagnosis and treatment, while patients may be more interested in wellness and being listened to by their doctors.

Many primary care physicians no longer see their patients while they are in the hospital. Instead, hospitalists are used, which fragments care because hospitalists usually have had no previous relationship with the patient they are treating and do not have a personal knowledge of the patient's medical history. The use of hospitalists is sometimes mandated by health insurance companies as a cost-saving measure which is resented by some primary care physicians.

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. 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% 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.

According to the insurance industry group America's Health Insurance Plans, administrative costs for private health insurance plans have averaged approximately 12% of premiums over the last 40 years. There has been a shift in the type and distribution of administrative expenses over that period. The cost of adjudicating claims has fallen, while insurers are spending more on other administrative activities, such as medical management, nurse help lines, and negotiating discounted fees with health care providers.

A 2003 study published by the Blue Cross and Blue Shield Association (BCBSA) also found that health insurer administrative costs were approximately 11% to 12% of premiums, with Blue Cross and Blue Shield plans reporting slightly lower administrative costs, on average, than commercial insurers. For the period 1998 through 2003, average insurer administrative costs declined from 12.9% to 11.6% of premiums. The largest increases in administrative costs were in customer service and information technology, and the largest decreases were in provider services and contracting and in general administration. The McKinsey Global Institute estimated that excess spending on "health administration and insurance" accounted for as much as 21% of the estimated total excess spending ($477 billion in 2003).

According to a report published by the CBO in 2008, administrative costs for private insurance represent approximately 12% of premiums. Variations in administrative costs between private plans are largely attributable to economies of scale. Coverage for large employers has the lowest administrative costs. The percentage of premium attributable to administration increases for smaller firms, and is highest for individually purchased coverage. A 2009 study published by BCBSA found that the average administrative expense cost for all commercial health insurance products was represented 9.18% of premiums in 2008. Administrative costs were 11.12% of premiums for small group products and 16.35% in the individual market.

One study of the billing and insurance-related (BIR) costs borne not only by insurers but also by physicians and hospitals found that BIR among insurers, physicians, and hospitals in California represented 20–22% of privately insured spending in California acute care settings.

Third-party payment problem and consumer-driven insurance

Most Americans pay for medical services largely through insurance, and this can distort the incentives of consumers since the consumer pays only a portion of the ultimate cost directly. The lack of price information on medical services can also distort incentives. The insurance which pays on behalf of insureds negotiate with medical providers, sometimes using government-established prices such as Medicaid billing rates as a reference point. This reasoning has led for calls to reform the insurance system to create a consumer-driven health care system whereby consumers pay more out-of-pocket. In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act was passed, which encourages consumers to have a high-deductible health plan and a health savings account.

Overall costs

U.S. Healthcare Costs as a Percentage of GDP 2000–2011

U.S. Healthcare Costs per Capita 2000–2011

The U.S. spends more as a percentage of GDP than similar countries, and this can be explained either through higher prices for services themselves, higher costs to administer the system, or more utilization of these services, or to a combination of these elements.

Free-market advocates claim that the health care system is "dysfunctional" because the system of third-party payments from insurers removes the patient as a major participant in the financial and medical choices that affect costs. The Cato Institute claims that because government intervention has expanded insurance availability through programs such as Medicare and Medicaid, this has exacerbated the problem. According to a study paid for by America's Health Insurance Plans (a Washington lobbyist for the health insurance industry) and carried out by Price Water house Coopers, increased utilization is the primary driver of rising health care costs in the U.S. The study cites numerous causes of increased utilization, including rising consumer demand, new treatments, more intensive diagnostic testing, lifestyle factors, the movement to broader-access plans, and higher-priced technologies. The study also mentions cost-shifting from government programs to private payers. 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.

Health care costs rising far faster than inflation have been a major driver for health care reform in the United States. Surgical, injury, and maternal and neonatal health hospital visit costs increased by more than 2% each year from 2003-2011. Further, while average hospital discharges remained stable, hospital costs rost from $9,100 in 2003 to $10,600 in 2011, and were projected to be $11,000 by 2013.

In March 2010, Massachusetts released a report on the cost drivers which it called "unique in the nation". The report noted that providers and insurers negotiate privately, and therefore the prices can vary between providers and insurers for the same services, and it found that the variation in prices did not vary based on quality of care but rather on market leverage; the report also found that price increases rather than increased utilization explained the spending increases in the past several years.

Equity

Coverage

Enrollment rules in private and governmental programs result in millions of Americans going without health care coverage, including children. The U.S. Census Bureau estimated that 45.7 million Americans (15.3% of the total population) had no health insurance coverage in 2007. However, statistics regarding the insured population are difficult to pinpoint for a number of factors, with the Census Bureau writing that "health insurance coverage is likely to be under reported". Further, such statistics do not provide insight into the reason a given person might be uninsured. Studies have shown that approximately one third of this 45.7 million person population of uninsured persons is actually eligible for government insurance programs such as Medicaid/Medicare, but has elected not to enroll. The largest proportion of the population of uninsured Americans is persons earning in excess of $50,000 per annum, with those earning over $75,000 p.a. comprising the fastest-growing segment of the uninsured population. U.S. Citizens who earn too much money to qualify for government assistance with insurance programs but who do not earn enough to purchase a private health insurance plan make up approximately 2.7% percent of the total US population (8.2 million of approximately 300 million total population, by 2003 figures).

States like California offer insurance coverage for children of low income families, but not for adults; other states do not offer such coverage at all: both parent and child are caught in the notorious coverage "gap." Although EMTALA 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 does nothing about the difficulties in the American mental health system.

Coverage gaps also occur among the insured population. Johns Hopkins University professor Vicente Navarro stated in 2003, "the problem does not end here, with the uninsured. An even larger problem is the under insured" and "The most credible estimate of the number of people in the United States who have died because of lack of medical care was provided by a study carried out by Harvard Medical School Professors Himmelstein and Wool handler. They concluded that almost 100,000 people died in the U.S. yearly because of lack of needed care." Another study by the Commonwealth Fund published in Health Affairs estimated that 16 million U.S. adults were under insured in 2003. The study defined under insurance as characterized by at least one of the following conditions: annual out-of-pocket medical expenses totaling 10% or more of income, or 5% or more among adults with incomes below 200% of the federal poverty level; or health plan deductibles equaling or exceeding 5% of income. The under insured 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 under insurance disproportionately affects those with lower incomes — 73% of the under insured in the study population had annual incomes below 200% of the federal poverty level. Another study focusing on the effect of being uninsured found that individuals with private insurance were less likely to be diagnosed with late-stage cancer than either the uninsured or Medicaid beneficiaries. A study examining the effects of health insurance cost-sharing more generally found that chronically ill patients with higher co-payments sought less care for both minor and serious symptoms while no effect on self-reported health status was observed. The authors concluded that the effect of cost sharing should be carefully monitored.

Coverage gaps and affordability also surfaced in a 2007 international comparison by the Commonwealth Fund. Among adults surveyed in the U.S., 37% reported that they had foregone needed medical care in the previous year because of cost; either skipping medications, avoiding seeing a doctor when sick, or avoiding other recommended care. The rate was higher — 42% — among those with chronic conditions. The study reported that these rates were well above those found in the other six countries surveyed: Australia, Canada, Germany, the Netherlands, New Zealand, and the UK. The study also found that 19% of U.S. adults surveyed reported serious problems paying medical bills, more than double the rate in the next highest country.

Emergency Medical Treatment and Active Labor Act (EMTALA)

Emergency Medical Treatment and Active Labor Act (EMTALA)

Main article: Emergency Medical Treatment and Active Labor Act

EMTALA, enacted by the federal government in 1986, requires that hospital emergency departments treat emergency conditions of all patients regardless of their ability to pay and is considered a critical element in the "safety net" for the uninsured, but established no direct payment mechanism for such care. Indirect payments and reimbursements through federal and state government programs have never fully compensated public and private hospitals for the full cost of care mandated by EMTALA. More than half of all emergency care in the U.S. now goes uncompensated. According to some analyses, EMTALA is an unfunded mandate that has contributed to financial pressures on hospitals in the last 20 years, causing them to consolidate and close facilities, and contributing to emergency room overcrowding. According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26%, while in the same period, the number of emergency departments declined by 425.

Mentally ill patients present a unique challenge for emergency departments and hospitals. In accordance with EMTALA, 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 criterion 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.

Quality assurance

See also: Hospital Quality Incentive Demonstration

Health care quality assurance consists of the "activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps."

One innovation in encouraging quality of health care is the public reporting of the performance of hospitals, health professionals or providers, and healthcare organizations. However, there is "no consistent evidence that the public release of performance data changes consumer behavior or improves care."

Overall system effectiveness

Measures of effectiveness

The US health care delivery system unevenly provides medical care of varying quality to its population. In a highly effective health care system, individuals would receive reliable care that meets their needs and is based on the best scientific knowledge available. In order to monitor and evaluate system effectiveness, researchers and policy makers track system measures and trends over time. The US Department of Health and Human Services(HHS) populates a publicly available dashboard called, the Health System Measurement Project (healthmeasures.aspe.hhs.gov), to ensure a robust monitoring system. The dashboard captures the access, quality and cost of care; overall population health; and health system dynamics (e.g., workforce, innovation, health information technology). Included measures align with other system performance measuring activities including the HHS Strategic Plan, the Government Performance and Results Act, Healthy People 2020, and the National Strategies for Quality and Prevention.

Access to care: Cost, affordability, coverage

The US health system does not provide health care to the country's entire population. Individuals acquire health insurance to offset health care spending. However, lack of adequate health insurance persists and is a known barrier to accessing the healthcare system and receiving appropriate and timely care. Measures of accessibility and affordability tracked by national health surveys include: having a usual source of medical care, visiting the dentist yearly, rates of preventable hospitalizations, reported difficulty seeing a specialist, delaying care due to cost, and rates of health insurance coverage.

• As a country, rising health care costs have raised concerns among the public and private sector alike. Between 2000 and 2011, health care expenditures nearly doubled, growing from $1.2 trillion to $2.3 trillion [CDC Health, United States, 2013]. Evidence suggests the rate of growth has slowed in recent years. Other measures of cost captured by national surveys include: health insurance premiums, high out of pocket costs (e.g., deductibles, co payments), and national health expenditures including individual, employer, and government expenditures.

Population health: Quality, prevention, vulnerable populations

The health of the population is also viewed as a measure of the overall effectiveness of the healthcare system. The extent to which the population lives longer healthier lives signals an effective system.

• While life expectancy is one measure, HHS uses a composite health measure that estimates not only the average length of life, but also, the part of life expectancy that is expected to be "in good or better health, as well as free of activity limitations." Between 1997 and 2010, the number of expected high quality life years increased from 61.1 to 63.2 years for newborns.
• The under utilization of preventative measures, rates of preventable illness and prevalence of chronic disease suggest that the US healthcare system does not sufficiently promote wellness. Over the past decade rates of teen pregnancy and low birth rates have come down significantly, but not disappeared. Rates of obesity, heart disease (high blood pressure, controlled high cholesterol), and diabetes are areas of major concern. While chronic disease and multiple co-morbidities became increasingly common among a population of elderly Americans who were living longer, the public health system has also found itself fending off a rise of chronically ill younger generation. According to the US Surgeon General "The prevalence of obesity in the U.S. more than doubled (from 15% to 34%) among adults and more than tripled (from 5% to 17%) among children and adolescents from 1980 to 2008."
• A concern for the health system is that the health gains do not accrue equally to the entire population. In the United States, disparities in health care and health outcomes are widespread. Minorities are more likely to suffer from serious illnesses (e.g., diabetes, heart disease and colon cancer) and less likely to have access to quality health care, including preventative services. Efforts are underway to close the gap and to provide a more equitable system of care.

Innovation: Workforce, healthcare IT, R&D

Finally, the United States tracks investment in the healthcare system in terms of a skilled healthcare workforce, meaningful use of healthcare IT, and R&D output. This aspect of the healthcare system performance dashboard is important to consider when evaluating cost of care in America. That is because in much of the policy debate around the high cost of US healthcare, proponents of highly specialized and cutting edge technologies point to innovation as a marker of an effective health care system.

Compared to other countries

Life expectancy compared to healthcare spending from 1970 to 2008, in the US and the next 19 most wealthy countries by total GDP.

A 2014 study by the private American foundation The Commonwealth Fund found that although the U.S. health care system is the most expensive in the world, it ranks last on most dimensions of performance when compared with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom. The study found that the United States failed to achieve better outcomes than other countries, and is last or near last in terms of access, efficiency and equity. Study date came from international surveys of patients and primary care physicians, as well as information on health care outcomes from The Commonwealth Fund, the World Health Organization, and the Organization for Economic Cooperation and Development.

The U.S. stands 50th in the world with a life expectancy of 78.49. The CIA World Factbook ranked the United States 174th worst (out of 222) – meaning 48th best – in the world for infant mortality rate (5.98/1,000 live births).

A study found that between 1997 and 2003, preventable deaths declined more slowly in the United States than in 18 other industrialized nations. A 2008 study found that 101,000 people a year die in the U.S. that would not if the health care system were as effective as that of France, Japan, or Australia.

The Organisation for Economic Co-operation and Development (OECD) found that the U.S. ranked poorly in terms of years of potential life lost (YPLL), a statistical measure of years of life lost under the age of 70 that were amenable to being saved by health care. Among OECD nations for which data are available, the United States ranked third last for the health care of women (after Mexico and Hungary) and fifth last for men (Slovakia and Poland also ranked worse).

Further information: Years of potential life lost

Recent studies find growing gaps in life expectancy based on income and geography. In 2008, a government-sponsored study found that life expectancy declined from 1983 to 1999 for women in 180 counties, and for men in 11 counties, with most of the life expectancy declines occurring in the Deep South, Appalachia, along the Mississippi River, in the Southern Plains and in Texas. The difference is as high as three years for men, six years for women. The gap is growing between rich and poor and by educational level, but narrowing between men and women and by race. Another study found that the mortality gap between the well-educated and the poorly educated widened significantly between 1993 and 2001 for adults ages 25 through 64; the authors speculated that risk factors such as smoking, obesity and high blood pressure may lie behind these disparities. In 2011 the U.S. National Research Council forecasted that deaths attributed to smoking, on the decline in the US, will drop dramatically, improving life expectancy; it also suggested that one-fifth to one-third of the life expectancy difference can be attributed to obesity which is the worst in the world and has been increasing. In an analysis of breast cancer, colorectal cancer, and prostate cancer diagnosed during 1990–1994 in 31 countries, the U.S. had the highest five-year relative survival rate for breast cancer and prostate cancer, although survival was systematically and substantially lower in black U.S. men and women.

The debate about U.S. health care concerns questions of access, efficiency, and quality purchased by the high sums spent. The World Health Organization (WHO) in 2000 ranked the U.S. health care system first in responsiveness, but 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study). The WHO study has been criticized by the free market advocate David Gratzer because "fairness in financial contribution" was used as an assessment factor, marking down countries with high per-capita private or fee-paying health treatment. The WHO study has been criticized, in an article published in Health Affairs, for its failure to include the satisfaction ratings of the general public. The study found that there was little correlation between the WHO rankings for health systems and the stated satisfaction of citizens using those systems. Countries such as Italy and Spain, which were given the highest ratings by WHO were ranked poorly by their citizens while other countries, such as Denmark and Finland, were given low scores by WHO but had the highest percentages of citizens reporting satisfaction with their health care systems. WHO staff, however, say that the WHO analysis does reflect system "responsiveness" and argue that this is a superior measure to consumer satisfaction, which is influenced by expectations. Furthermore, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes is complex and not well defined.

A report released in April 2008 by the Foundation for Child Development, which studied the period from 1994 through 2006, found mixed results for the health of children in the U.S. Mortality rates for children ages 1 through 4 dropped by a third, and the percentage of children with elevated blood lead levels dropped by 84%. The percentage of mothers who smoked during pregnancy also declined. On the other hand, both obesity and the percentage of low-birth weight babies increased. The authors note that the increase in babies born with low birth weights can be attributed to women delaying childbearing and the increased use of fertility drugs.

In a sample of 13 developed countries the USA was third in its population weighted usage of medication in 14 classes in both 2009 and 2013. The drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. The study noted considerable difficulties in cross border comparison of medication use.

System efficiency and equity

Variations in the efficiency of health care delivery can cause variations in outcomes. The Dartmouth Atlas Project, for instance, reported that, for over 20 years, marked variations in how medical resources are distributed and used in the United States were accompanied by marked variations in outcomes. The willingness of physicians to work in an area varies with the income of the area and the amenities it offers, a situation aggravated by a general shortage of doctors in the United States, particularly those who offer primary care. The Affordable Care Act, if implemented, will produce an additional demand for services which the existing stable of primary care doctors will be unable to fill, particularly in economically depressed areas. Training additional physicians would require some years.

Lean manufacturing techniques such as value stream mapping can help identify and subsequently mitigate waste associated with costs of healthcare. Other product engineering tools such as FMEA and Fish Bone Diagrams have been used to improve efficiencies in healthcare delivery.

Efficiency

Preventable deaths

In 2010, coronary artery disease, lung cancer, stroke, chronic obstructive pulmonary diseases, and traffic accidents caused the most years of life lost in the US. Low back pain,depression, musculoskeletal disorders, neck pain, and anxiety caused the most years lost to disability. The most deleterious risk factors were poor diet, tobacco smoking, obesity,high blood pressure, high blood sugar, physical inactivity, and alcohol use. Alzheimer's disease, drug abuse, kidney disease and cancer, and falls caused the most additional years of life lost over their age-adjusted 1990 per-capita rates.

Between 1990 and 2010, among the 34 countries in the OECD, the US dropped from 18th to 27th in age-standardized death rate. The US dropped from 23rd to 28th for age-standardized years of life lost. It dropped from 20th to 27th in life expectancy at birth. It dropped from 14th to 26th for healthy life expectancy.

According to a 2009 study conducted at Harvard Medical School by co-founders of Physicians for a National Health Program, a pro-single payer lobbying group, and published by the American Journal of Public Health, lack of health coverage is associated with nearly 45,000 excess preventable deaths annually. Since then, as the number of uninsured has risen from about 46 million in 2009 to 48.6 million in 2012, the number of preventable deaths due to lack of insurance has grown to about 48,000 per year. The group's methodology has been criticized by economist John C. Goodman for not looking at cause of death or tracking insurance status changes over time, including the time of death.

A 2009 study by former Clinton policy adviser Richard Kronick published in the journal Health Services Research found no increased mortality from being uninsured after certain risk factors were controlled for.

Value for money

A study of international health care spending levels published in the health policy journal Health Affairs in the year 2000 found that the United States spends substantially more on health care than any other country in the Organization for Economic Co-operation and Development (OECD), and that the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study conclude that the prices paid for health care services are much higher in the U.S. than elsewhere. While the 19 next most wealthy countries by GDP all pay less than half what the U.S. does for health care, they have all gained about six years of life expectancy more than the U.S. since 1970.

Delays in seeking care and increased use of emergency care

Uninsured Americans are less likely to have regular health care and use preventive services. They are more likely to delay seeking care, resulting in more medical crises, which are more expensive than ongoing treatment for such conditions as diabetes and high blood pressure. A 2007 study published in JAMA concluded that uninsured people were less likely than the insured to receive any medical care after an accidental injury or the onset of a new chronic condition. The uninsured with an injury were also twice as likely as those with insurance to have received none of the recommended follow-up care, and a similar pattern held for those with a new chronic condition. 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.

In 2008 researchers with the American Cancer Society found that individuals who lacked private insurance (including those covered by Medicaid) were more likely to be diagnosed with late-stage cancer than those who had such insurance.