Health Care emcompasses all public policy issues involved in the provision of medical care. The various institutions that deliver and pay for medical care in the United States are designed for profitability rather than keeping the American public healthy or for overall economic efficiency. Health care in the United States is inferior to that in many other advanced industrial democracies as measured by basic health statistics such as infant mortality rate and as measured by the share of total national GDP in the health care sector. Private health care insurance firms in the United States exhibit a tendency to avoid or shift costs rather than fulfill their obligations.
Flu vaccine crisis
In October 2004, just weeks before the presidential election, it was publicly announced that approximately one half the expected doses of flu vaccine were unavailable due to manufacturing problems at Chiron's facility in Britain. The 2004 flu vaccine shortage led immediately to long lines at hospitals and pharmacies all over the country as senior citizens, people with medical conditions and children waited to get immunized before local supplies ran out.
The shortage focused attention on the Bush administration's role leading up to the shortage and on their management of the flu vaccine stocks after the shortage became apparent. More generally, it reflects a diversion of attention and resources away from Public Health despite the fact that these resources are also vital in protecting the United States from Terrorism in the form of biological attacks, a stated priority of George W. Bush.
See also regarding immunization generally: Immunization Action Coalition
Medicare and Medicaid
Medicare is a federal government program established in 1965 as part of the Social Security program that provides medical care (in exchange for a nominal annual premium) to people eligible for social security benefits (persons age 65 and older, the permanently disabled, and surviving spouses and minor children of deceased workers). It is not means tested. The main types of medical care not covered by Medicare are long term care (i.e. nursing homes), and, historically, prescription drugs. Some Medicare beneficiaries may choose an HMO option which provides additional benefits at the cost of less choice over medical providers like doctors. Congress enacted prescription drug benefit legislation with the support of the American Association of Retired Persons (AARP), despite protests from many members. This provides a confusing array of drug discount cards (and $600 of free drugs for low income seniors) in the phase in period, and greater, but limited, coverage for prescription drugs purchases in later years.
More than 39 million Americans receive Medicare. It is the largest social program in force in terms of expenditures, at the state or federal level, other than Social Security.
Medicaid is a joint state-federal government program, also adopted in 1965 along with Medicare, that provides medical care to selected groups of people on a means tested basis. Generally speaking, it provides care for low-income households with children, including welfare (i.e. TANF) receipients, disabled people (particularly low income disabled people receiving SSI, a social security related means tested program), and persons 65 and over who require long term care. Eligibility standards are more lenient for senior citizens than for other beneficiaries. Many states also go well beyond federal minimum requirements by providing benefits to working class children. Coverage of legal immigrants who have been in the US more than 5 years is a state by state option under the program. Medicaid generally pays doctors less than the prevailing rate for their services and does not allow doctors to require additional payments from their patients. As a result, many providers do not accept new Medicaid patients.
More than 42 million Americans receive Medicaid. In many states, Medicaid is the largest social program after K-12 and Higher Education, in terms of expenditure.
A few interesting facts: 75% of Medicaid beneficiaries are familes with children, but about 70% of expenditures are for the care of the elderly and individuals with disabilities. Long-term care is one of the most expensive items. Lots of helpful statistics and reports are available at the web site of the Kaiser Foundation Commission on Medicaid and the Uninsured, http://www.kff.org/about/kcmu.cfm.
Universal Health Care Plans
Most countries in the developed world provide health care to every citizen as a matter of right. The United States, in contrast, has a substantial proportion of the population, 14% at any one time by one common estimate, that has neither health insurance as part of their Employee Benefits nor eligibility for a government health care program, and around 50% are considered under-insured. Those without any formal health care often turn to emeregency rooms and county hospitals and simply do not pay their bills. See, e.g. here. In part because of this phenomena, the uninsured are typically charged rates for services far in excess of what the insured are billed, to reflect collection risks, and costs are typically shifted, to the extent possible, to more profitable operations in the medical system driving up costs for everyone and encouraging medical systems to try to divorce themselves from the emergency medicine system so that they don't have to help share this public cost.
Free Market Health Care is paradoxical. Healthy people are the highest earners. Healthy people can afford to pay for medical treatment but do not need it. Less healthy people need more treatment but can pay less. The most unfortunate are those born with chronic illnesses or disabilities. Such patients may in the worst cases never in their lives earn the money they need to pay for medical treatment. Universal Health Care is seen as compassionate. It looks after those who through no fault of their own cannot look after themselves.
The United States is known for having care that involves relatively little waiting time (if you have coverage) and high technology practice, at a great expense that not all can afford. Providers from drug companies to hospitals to doctors are all paid far more in the United States than they are for comparable services in countries with single-payer health care systems. The U.S. spends more than 16% of its GDP on health care (the highest percentage in the world among developing countries), yet has worse public health outcomes, such as life expectancy and infant mortality, than many nations that devote far less of their national resources to health care. The U.S. also devotes far more of its health care budget to administrative costs than countries with single-payer systems (30% vs 5%).
A variety of proposals exist to address this situation.
One proposal, commonly viewed as the most revolutionary, would be a single-payer system, similar to that of Canada and many European nations, in which a government (or government subcontracted) agency directly pays health care providers for services and citizens receive medical care. Funding comes from taxation similar to how Medicare is currently funded, although the tax would be larger since it covers everyone from cradle to grave. Savings from reduced insurance paperwork would make more funds available for benefits and bargaining leverage for prescription drugs and durable medical goods. This is also similar to the model now used in the Medicare system, but differs in that in a single-payer system the government would have much more bargaining power with providers than it does now as an important payment source of providers, but not the only source of payment. Dennis Kucinich has favored such a plan for the United States in his Presidential campaign. Critics of single-payer systems argue that they lead to longer waiting periods for non-emergency care, underinvestment in health care technology, and weak incentives for the brightest professionals to enter the health care system, although little evidence exists to support these last two arguments.
An alternative group of proposals seeks to secure universal health care with a patchwork of approaches based on the current health care system. Typically such plans use carrots, like tax credits and access to reasonably priced government employee health plans to small businesses, and sticks, like taxes on employers that don't provide health insurance or health insurance mandates for certain classes of workers, to increasing the scope of private health insurance from employers, while expanding government programs, like Medicaid, to cover more uninsured people and benefits not previously covered, like prescription drugs. John Kerry has favored this sort of approach in his Presidential campaign. It has the advantage of being less disruptive and leaving systems that work for private people with health insurance in place, but does very little to reduce administrative costs or to provide a means to engage in meaningful collective bargaining with providers to cut the amount of private profit in the health care system, nor is there any guarantee of universal coverage.
Malpractice Litigation As A Source of Rising Health Care Costs
Exactly to what degree the American malpractice system affects health care costs is controversial. A number of studies have produced mixed conclusions over the percieved and real financial implact, the fairness of the process for plaintiffs and defendants, the effectiveness of various "tort reform" laws in states, and the various motivations of insurance carriers, lawyers, patients, and physicians in the process. What is not in dispute is that there exists disatisfaction with process from many perspectives and that there is room for improvement in the way these cases are adjucated.
Health insurance costs and the costs of health care services rose dramatically in the 1990s, and the process for adjucating medical malpractice lawsuits in the United States has been criticised for providing an expensive, adversarial, unpredictable, and inefficient settlement system. The cost of medical malpractice litigation in the United States has steadily increased at almost 12% percent annually since 1975.<ref> Towers Perrin, Tillinghast, U.S. Tort Costs and Cross-Border Perspectives: 2005 Update, (New York, NY: Towers Perrin, March 2006) </ref>, and an estimated 60% of malpractice lawsuit expenses are now consumed by administrative, or transaction, costs (eg, lawyer fees, expert witness charges, court costs), as compared with 25% to 30% for systems such as workers' compensation. Jury Verdict Research, a database of plaintiff and defense verdicts, says awards in medical liability cases increased 43 percent in 1999, from $700,000 to $1,000,000.
Both insurance companies and Physicians have argued that excessive verdicts in medical malpractice lawsuits are in part responsible for the increasing medical malpractice insurance rates. These groups point to examples where rate increases are causing doctors to go out of business or have moved to states where more favorable tort systems exist. <ref>Medical Malpractice Insurance Roundtable: Doctors Prescribe Remedies for Crisis. The Business Journal, Jun 11, 2004, accessed August 3, 2006.</ref>
A 2003 report from the General Accounting Office identified multiple reasons for these rate increases, one of which one was indeed costs associated with malpractice lawsuits.<ref>GAO-03-702 Medical Malpractice Insurance: Multiple Factors Have Contributed to Increased Premium Rates General Accounting Office, June 2003, accessed August 3, 2006.</ref> The average increase in malpractice premiums in that same year ranged from 15 to 30 percent in most states, depending on the location and medical specialty. These drastic increases in malpractice insurance rates have resulted in doctors striking in West Virginia, the temporary closings of hospital services (e.g., the trauma care center at the University of Nevada Medical Center), the reduction or elimination of physicians performing high-risk services, and the early retirement of some physicians to pursue other fields.
In May 2006, the study "Claims, Errors, and Compensation Payments in Medical Malpractice Litigation" was released by the Harvard School of Public Health. This study concluded that in most cases the successful claimants were entitled to compensation, but at least 40% of all claims reviewed were groundless and nearly 15% of the money paid out in settlements or verdicts was involving cases felt to be groundless as well.<ref> Claims, Errors, and Compensation Payments in Medical Malpractice Litigation, New England Journal of Medicine,May 11, 2006.</ref>, <ref> Medical Malpractice Study, Disproving Frivolous Myth, Jeffrey B. Bloom, Gair, Gair, Conason, Steigman & Mackauf, The National Law Journal, July 3, 2006 </ref>
Malpractice expenses make up just 0.5% of U.S. health care costs. Even in states like Colorado where tort reform and a variety of other changes in the market place have caused malpractice insurance premiums to fall 60% in real dollars between 1988 and the present, where tort trials are less common and where inflation adjusted awards have fallen, health care expenditures have doubled (or even increased moreso) in the past decade.States with medical malpractice damage caps actually see more malpractice insurance premium increases than states without them, and the impact of large non-economic damage awards on premiums is less than 1% of the amount paid according to insurance industry sources. Utah, for example, which has strict caps on non-economic damage awards ($250,000) in medical malpractice cases, had the second highest increase in malpractice insurance premiums since 1991. According to 2003 study by insurance industry analysis firm Weiss Ratings Inc.:
- Insurers in states with caps raised their premiums at a significantly faster pace than those in states without caps - 48 percent compared with 36 percent.
- Despite the imposition of caps, insurers in nearly nine of 10 states continued to raise rates, while insurers in states without caps were actually more likely to hold or cut their premiums.
- In states with caps, insurers are more likely to charge premiums exceeding the national median than those in states without caps.
A number of groups are actively involved in the issue of tort reform with regards to the medical malpractice system. For example, Common Good has proposed creating specialized medical courts (similar to existing administrative tax or workmen's comp court proceedings) where medically-trained judges would evaluate cases and subsequently render precedent-setting decisions. Proponents believe that giving up jury trials and scheduling noneconomic damages such as pain and suffering would lead to more people being compensated, and to their receiving their money sooner. While this proposal has been criticised by some lawyers and consumer activists as depriving Americans of their right to a trial by jury, a number of groups have supported this proposal, including he AMA, and the American College of Surgeons, the National Law Journal, Forbes magazine, and the USA Today and Wall Street Journal editorial pages.<ref>National Law Journal, 'Health courts' offer cure USA Today, July 4, 2005, accessed Aug. 3, 2006; and Health Courts Endorsed in Wall Street Journal by Betsy McCaughey The Wall Street Journal, August 24, 2005, accessed Aug. 2, 2006.</ref> Other tort reform proposals, some of which have been enacted in various states, include placing limits on noneconomic damages and collecting lawsuit claim data from malpractice insurance companies and courts in order to assess any connection between malpractice settlements and premium rates.<ref> Medical Malpractice Tort Reform, National Conference of State Legislatures, May 1, 2006, accessed Aug. 3, 2006.</ref>Other tort reform proposals, some of which have been enacted in various states, include placing limits on noneconomic damages and collecting lawsuit claim data from malpractice insurance companies and courts in order to assess any connection between malpractice settlements and premium rates.<ref> Medical Malpractice Tort Reform, National Conference of State Legislatures, May 1, 2006, accessed Aug. 3, 2006.</ref>
See also related Dkos Diaries such as Process Changes.
References will be visible on Wikipedia pages, but the template doesn't work on dkosopedia yet.
The high cost of health care in the United States is particular an issue in the area of prescription drugs, where consumers see Canadians whose government has negotiated for lower prices with drug companies, pay less than consumers in the United States.
The high prices drug companies are able to charge are largely a product of the patent that a drug company receives on new drugs. Thus, drug prices are highly responsive to changes in patent law. Drug companies have historically argued that strong patent protections are necessary to finance research and development, but this argument is limited in application. While drug companies do spend a larger percentage of their income on research and development than many companies, much of the basic research that makes commercially useful drugs possible is financed by the federal government and public state universities. Yet, the drug companies often use this government research free of charge. Also, drug companies also devote huge amounts of money to profits for their shareholders and marketing expenses. And, the market model does little or nothing to promote drug research for rare diseases.
Also, it isn't entirely clear that the existing model of having drugs research done by drug companies on their own account is the best approach to financing drug research. Government health care programs pay for a large part of all drug sales, and with a new prescription drug benefit in the Medicare program, this will be increasingly the case in the future. If government is going to be the main consumer of prescription drugs, it may make sense for the government to do the research itself (or hire drug companies to do research on behalf of the government) in the areas it deems to be a priority, and then contract with drug companies to produce the finished product at a much lower profit margin. This way, the government doesn't have to pay for a huge markup on the R&D costs that have to be incurred by someone.
Other Health Articles
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- Health Regulations Changes on GW Bush Administration
- HPV vaccine is opposed by the religious right
- Announcing Flu Wiki
Just a Bump in the Beltway, The Next Hurrah and Effect Measure blogs announce the launch of a new experiment in collaborative problem solving in public health, The Flu Wiki.
Come kick the tires, add your state or province, or country in this collaborative public health project to track pandemic flu preparations.
--DemFromCT 13:22, 28 Jun 2005 (PDT)
Professional Nursing Issues:
- Key Demographics
- Invisible Profession
- Practice Groups for Nursing
- Bases of Power
- Education: The War
--Universalhealth 14:14, 11 December 2006 (PST)