Chapter 1: Introduction to US Health Care PDF

Access Provided by: Understanding Health Policy: A Clinical Approach, 9th Edition Chapter 1: Introduction: The Strengths and Weaknesses of US Health Care INTRODUCTION Louise Brown was an accountant with a 25­year history of diabetes. Her physician taught her to monitor her glucose at home, an...

Access Provided by: Understanding Health Policy: A Clinical Approach, 9th Edition Chapter 1: Introduction: The Strengths and Weaknesses of US Health Care INTRODUCTION Louise Brown was an accountant with a 25­year history of diabetes. Her physician taught her to monitor her glucose at home, and her health coach helped her follow a healthy diet. Her diabetes was brought under good control. Diabetic retinopathy was discovered at yearly eye examinations, and periodic laser treatments of her retina prevented loss of vision. Ms. Brown lived to the age of 92, a success story of the US health care system. Angela Martini grew up in a low­income urban neighborhood with underfunded schools, became pregnant as a teenager, and has been on public assistance while caring for her four children. Her Medicaid coverage pays for yearly preventive care visits with her family physician at no cost to Angela. A mammogram ordered by her physician detected a suspicious lesion, found to be cancer on biopsy. She was referred to a surgical breast specialist, underwent a mastectomy, was treated with a hormonal medication, and has been healthy for the past 15 years. For people with private or public insurance who have access to health care services, the melding of high­quality primary and preventive care with appropriate specialty treatment can produce the best medical care in the world. The United States is blessed with thousands of well­trained physicians, nurses, pharmacists, and other caregivers who compassionately and skillfully provide health services to patients who seek their assistance. This is the face of the health care system in which we can take pride. Success stories, however, are only part of the reality of health care in the United States. Some persons receive too little care because they are uninsured or inadequately insured. Others are subjected to unnecessary treatments. James Jackson was recently unemployed but unable to qualify for Medicaid because his state did not expand Medicaid under the 2010 Patient Protection and Affordable Care Act. At age 34, he developed abdominal pain but did not seek care for 10 days because he had no insurance and feared the cost of treatment. He began to vomit, became weak, and was finally taken to an emergency room by his cousin. The physician diagnosed a perforated ulcer with peritonitis and septic shock. The illness had gone on too long; Mr. Jackson died on the operating table. Had he received prompt medical attention, his illness would likely have been cured. Betty Yee was a 68­year­old woman with angina, high blood pressure, and diabetes. Her total bill for medications, only partly covered by Medicare, came to $150 per month. She was unable to afford the medications, her blood pressure went out of control, and she suffered a stroke. Ms. Yee’s final lonely years were spent in a nursing home; she was paralyzed on her right side and unable to speak. Consuelo Gonzalez had moderate pain in her back relieved by over­the­counter acetaminophen. She went to an orthopedic surgeon who ordered an MRI, which showed a small disc protrusion. The doctor recommended surgery, after which Ms. Gonzalez’ pain became much worse. She consulted a general internist who told her that the MRI abnormality was not serious, that the surgery had been unnecessary, and that physical therapy might help. After a year of physical therapy, the pain partially subsided. SPENDING TOO MUCH AND GETTING TOO LITTLE The United States is spending too much money on health care and getting too little health. Health care spending per person is far higher than in other high­income countries. Yet the United States is the only one of those countries that does not have universal health coverage. The United States has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, and the highest maternal and infant mortality among high income nations—health statistics comparable to much less economically developed nations. Racial and ethnic inequities abound in the United States; for example, average life expectancy in 2019 for Black Americans and American Indians or Alaska Natives was 4 and 7 years lower, respectively, than for White Americans (Commonwealth Fund, 2023). The mirror image of these deficiencies is that many Americans, like Consuelo Gonzalez, receive too much health care and end up in worse health. Studies suggest that perhaps one­fourth of hospital days, one­fourth of procedures, and two­fifths of medications are unnecessary (Brook, 1989). Waste is estimated to account for 25% of total US health care spending (Shrank et al., 2019). Downloaded 2025­1­20 12:57 P Your IP is THE ChapterPUBLIC’S 1: Introduction:VIEW OF THE The Strengths HEALTHofCARE and Weaknesses SYSTEM US Health Care, Page 1 / 3 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Health care in the United States encompasses a wide spectrum, ranging from the highest­quality, most compassionate treatment of those with complex illnesses, to the turning away of the very ill because of lack of ability to pay; from well­designed protocols for prevention of illness to White Americans (Commonwealth Fund, 2023). The mirror image of these deficiencies is that many Americans, like Consuelo Gonzalez, receive too much health care and end up in worse health. Access Provided by: Studies suggest that perhaps one­fourth of hospital days, one­fourth of procedures, and two­fifths of medications are unnecessary (Brook, 1989). Waste is estimated to account for 25% of total US health care spending (Shrank et al., 2019). THE PUBLIC’S VIEW OF THE HEALTH CARE SYSTEM Health care in the United States encompasses a wide spectrum, ranging from the highest­quality, most compassionate treatment of those with complex illnesses, to the turning away of the very ill because of lack of ability to pay; from well­designed protocols for prevention of illness to inappropriate high­risk surgical procedures performed on uninformed patients. While the past decades have witnessed major upheavals in health care, one fundamental truth remains: the United States has the least universal, most costly health care system in the industrialized world. Many people view the high costs of care, the lack of universal access, and pervasive health inequities as indicators of serious failings in the health care system. A 2022 Gallup poll found that only 38% of people in the United States had confidence in the health care system; 78% worry about the availability and affordability of health care. WHAT TO EXPECT FROM THIS BOOK To correct the weaknesses of the health care system while building on its strengths, it is necessary to understand how the system works. To promote that understanding, the book is organized into 5 sections: Financing and Payment; Equity and Resource Allocation; the Organization of Health Care; Cost, Quality, and Value; and the Political Economy of Health Care. Section One describes how money moves in the health care system. Why do we start by focusing on money? Although money is largely a means to the end of delivering health services to meet the needs of the public, much of health policymaking focuses on financing and payment as key levers for influencing health system performance. Chapters 2 and 3 discuss private and public models of health insurance, the growing problem of underinsurance (high out­of­pocket costs for many people who have health insurance), and how insurance coverage affects access to care. Chapter 4 focuses on how money moves from health insurance plans to the people and organizations delivering care and the different ways of paying health care providers. Section Two picks up on the theme of health access by providing a conceptual framework for understanding health equity. Chapter 5 examines health and health care inequities based on race­ethnicity, gender, sexual orientation, and other factors, and how systemic and interpersonal racism and other forms of oppression of marginalized groups contribute to these inequities. Chapter 6 adds the framework of medical ethics for understanding social justice in health care, including issues of resource allocation. Section Three turns to the organization of health care. Chapter 7 provides a conceptual overview, grouping services and providers into primary, secondary, and tertiary care sectors. Chapter 8 then reviews the history of different organizational models in the United States from the independent physician offices and community hospitals of the twentieth century to the large vertically and horizontally integrated delivery systems prevalent in the twenty­first century. Central to the organization of care is the people working in the health care system, the topic of Chapter 9. Section Three closes by shining a light on an often­neglected component of the health care system: long­term care for people living with disabilities who need ongoing assistance in activities of daily living. Section Four covers cost, quality, and value. Value in health care is defined as the quality of care achieved for a given cost. This framework is used in Chapter 11 to describe how controlling costs may be painful to patients’ health, or painless, depending on whether the approach increases value. Specific cost control mechanisms are reviewed in Chapter 12 and quality improvement strategies are discussed in Chapter 13. Prevention and public health interventions are often high­value approaches; these are covered in Chapter 14. Section Five addresses the political economy of health care. We begin by describing the ways in which four other nations (Germany, Canada, the United Kingdom, and Japan) approach health care financing, payment, and organization and the lessons of these models for the United States. We then review more than 100 years of efforts in the United States to achieve universal health coverage, leading up to enactment of the Affordable Care Act in 2010. The section closes with a critical examination of the business of US health care in an era in which investor­owned, for­profit enterprises are consolidating into huge conglomerates with tremendous economic power in the US health care market. To improve health policy, one must first understand the basic concepts, terms, and workings of health care. To chart a better future for health care in the United States, one must understand the health system’s current performance, how we got to where we are, and the forces driving this ever­ evolving story. Better understanding is the goal of this book. REFERENCES Downloaded 2025­1­20 12:57 P Your IP is Brook RH. Chapter 1: Practice guidelines Introduction: and practicing The Strengths medicine. JAMA. and Weaknesses of US1989;262:3027–3030. Health Care, [PubMed: 2810647] Page 2 / 3 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Commonwealth Fund. U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. Issue Brief, January 31, 2023. https://www.commonwealthfund.org/publications/issue­briefs/2023/jan/us­health­care­global­perspective­2022. To improve health policy, one must first understand the basic concepts, terms, and workings of health care. To chart a better future for health care in the United States, one must understand the health system’s current performance, how we got to where we are, and the forces driving this ever­ evolving story. Better understanding is the goal of this book. Access Provided by: REFERENCES Brook RH. Practice guidelines and practicing medicine. JAMA. 1989;262:3027–3030. [PubMed: 2810647] Commonwealth Fund. U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. Issue Brief, January 31, 2023. https://www.commonwealthfund.org/publications/issue­briefs/2023/jan/us­health­care­global­perspective­2022. Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system. JAMA. 2019;322:1501–1509. [PubMed: 31589283] Downloaded 2025­1­20 12:57 P Your IP is Chapter 1: Introduction: The Strengths and Weaknesses of US Health Care, Page 3 / 3 ©2025 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility