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Prior to beginning work on this assignment, review your textbook readings covered thus far and the Occupational Outlook Handbook: Healthcare Occupations (Links to an external site.).This assignment is the first part of a comprehensive presentation you will develop on the U. S. health care system. For this assignment, you will provide an overview of the U.S. health care system. Follow the instructions below to complete the assignment.Introduction:Begin your presentation by including a title slide (see specifics below). In the speaker’s notes of this slide, include your introductory information, which will include your degree plan and any health care experience you have had or share your qualifications related to the information you are presenting. If you have no health care experience, you can be creative with professional experience.Next, create an overview slide that describes the required components to be covered within the presentation. Add bulleted points for each of the topics being covered. Briefly describe each bulleted point in the speaker’s notes.Content:The remaining slides will address the content of the presentation and the references. The content will address the following required components:Choose one revolutionary factor from each of the centuries (17th, 18th, 19th, 20th, and 21st) found in your textbook and time line.Describe each revolutionary factor.Discuss how the revolutionary factors changed the health care system.Refer to the time line simulation Global Perspectives: Shifts in Science and Medicine That Changed Healthcare (Links to an external site.) reviewed in Week 1. Chapter 2 in your textbook discusses the evolution of our health care system and is a good resource for this part of the presentation as well.Identify at least one major development from each of the following perspectives: financial, legal, ethical, regulatory, and social (e.g., consumer demand).Discuss how each development transformed the system into what it is For more perspective, you may want to review the time line simulation Global Perspectives: Shifts in Science and Medicine That Changed Healthcare (Links to an external site.).Choose three different stakeholders that have affected the health care system (e.g., health care professionals [physicians, nurses, etc.], clients [patients], health insurance plans [Blue Cross Blue Shield, managed care organizations (MCOs), etc.], federal or state governments, health care professional organizations [American Medical Association (AMA), American Nurses Association (ANA), etc.] and health care accreditation agencies [Centers for Medicare and Medicaid Services (CMS), The Joint Commission, National Committee for Quality Assurance (NCQA), etc.]).Evaluate each stakeholder’s effect on the health care system by discussing their purpose and impact.Include examples of both positive and negative impacts made by your chosen stakeholders (e.g., a negative contribution is when a patient uses the emergency room for nonurgent care).Consider using the PowerPoint Instructions Handout to locate linked resources for properly making a PowerPoint presentation. Also consider these help tools: PowerPoint Best Practices, Don McMillan: Life After Death by PowerPoint (Links to an external site.). Wikimedia Commons (Links to an external site.)can also help you explore creative commons images. You may also want to review What Is CRAAP? A Guide to Evaluating Web Sources (Links to an external site.).Submit your assignment via the classroom to the Waypoint Assignment submission button by Day 6 (Sunday) no later than 11:59 p.m.APA Requirement Details:The U.S. Health Care Presentation: Part 1 AssignmentMust be seven to nine slides in length (not including title and references slides) and formatted according to APA style as outlined in the Ashford Writing Center’s How to Make a PowerPoint Presentation (Links to an external site.).Must include a separate title slide with the following:Title of presentationStudent’s nameCourse name and numberInstructor’s nameDate submittedFor further assistance with the formatting and the title page, refer to APA Formatting for Word 2013 (Links to an external site.).Must utilize academic voice. See the Academic Voice (Links to an external site.) resource for additional guidance.Must use at least two scholarly or credible sources (a least one should be from the Ashford University Library).The Scholarly, Peer-Reviewed, and Other Credible Sources (Links to an external site.) table offers additional guidance on appropriate source types. If you have questions about whether a specific source is appropriate for this assignment, please contact your instructor. Your instructor has the final say about the appropriateness of a specific source for a particular assignment.Must document any information used from sources in APA style as outlined in the Ashford Writing Center’s Citing Within Your Paper (Links to an external site.).Must include a separate reference slide that is formatted according to APA style as outlined in the Ashford Writing Center. See the Formatting Your References List (Links to an external site.) resource in the Ashford Writing Center for specifications.
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Introduction to the U.S. Healthcare System
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Learning Objectives
By the end of this chapter, you should be able to:
1.
2.
3.
4.
5.
Identify the principal factors in the debate over healthcare in the United States.
Summarize healthcare reform policy measures.
Explain how healthcare functions as an industry.
Discuss healthcare delivery models.
Describe cultural and demographic factors that illustrate healthcare delivery and quality in the United States.
Imagine going to the emergency room for what you think is a heart attack and learning that it is just heartburn. In most countries this outcome would represent a huge relief, but
for the 9% of the U.S. population who are uninsured, such an experience could leave a patient with a significant bill and in financial hardship. Even those with insurance are
likely to owe some form of payment for medical services in addition to the monthly premiums necessary to purchase insurance. Why is this the case, and what can be done to
improve the situation? These are central questions surrounding healthcare in the United States.
Other fundamental questions include these: Is healthcare a right or a privilege? Who should pay for healthcare in the United States? The government? Individuals? Employers?
How does a system deliver quality healthcare to everyone? Will the United States move to a system of national healthcare? Has it already? These questions conjure heated
debate in the United States. As a result, the U.S. healthcare system is one of the most contested political, social, and economic issues of our time. This chapter, and this book
more generally, identifies the factors that make the U.S. healthcare system unique and complex relative to other systems worldwide.
This chapter introduces the paradox of the U.S. healthcare system: high costs, poorer than expected health outcomes, and a lack of access for the economically disadvantaged—
yet a system that includes the “highest” standard of medical care in the world. This chapter describes a healthcare puzzle that has plagued policymakers for decades, and it
prepares you to delve into the specifics of the healthcare issues presented in the chapters that follow.
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1.1 Healthcare in the United States: A Long Debate
Rarely does a day pass without a headline that mentions the ever-changing healthcare system in the United States. Although the idea of an organized system that provides
healthcare to its population is a relatively modern invention, the debate surrounding healthcare affordability is not new.
As Chapter 2 (http://content.thuzelearning.com/books/Batnitzky.5231.18.1/sections/sec2.1#sec2.1) describes, before 1920 the United States did not have a healthcare system. In fact,
most people in the United States who required healthcare were treated in their homes, and doctors’ fees were in line with community norms. As medical treatments became more
sophisticated, medical fees exceeded what the general population could afford to pay. Hospitals became centers where people went to regain health, instead of a destination to
die. Along with new technologies came a further increase in costs. Most of these changes took place in the wake of the Great Depression (1929–1941). The solution to rising
costs at the time was the invention of health insurance—a system in which a third-party payer (either private or government) contracted to pay a portion of an individual’s
healthcare costs in exchange for a monthly premium. The first indemnity plans were intended for third-party payers to cover most or all of the costs of a hospital stay. However,
health insurance did not solve the economic problem of healthcare in the United States. In fact, new problems have emerged and old ones remain. Chapter 3
(http://content.thuzelearning.com/books/Batnitzky.5231.18.1/sections/sec3.1#sec3.1) discusses health insurance in greater detail.
Healthcare once meant preventing people from dying. However, as medical technologies changed, so did the definition of healthcare. According to the World Health
Organization (WHO), healthcare now describes “all the activities whose primary purpose is to promote, restore or maintain health” (WHO, 2017). Based on this definition, the
objectives of a healthcare system are three-fold: 1. improving the health of the population; 2. responding to people’s expectations; and 3. providing financial protection against
the costs of ill health (Cockerham, 2010). The success of a healthcare system can be measured by three goals: cost, quality, and access. The challenge of balancing these three
goals is at the crux of the modern U.S. healthcare debate.
Cost
Peter C. Vey/The New Yorker Collection/The Cartoon Bank
“Actually I feel pretty good. One would never guess I was about to get a quarter of a million dollars worth of medical attention.”
How to provide services that maximize health benefits while minimizing costs is the main question surrounding efficiency. The United States spends more money per person on
healthcare than any other country (Organisation for Economic Co-operation and Development [OECD], 2013a). It is also one of only four countries in the Organisation for
Economic Co-operation and Development (OECD)— an international economic organization comprised of 34 industrialized countries— without universal health coverage, the
other three being Chile, Mexico, and Turkey.
The U.S. per capita health expenditure is $8,608 (The World Bank, 2011), calculated by adding both public and private spending on health services and dividing this number
by the population. This equates to more than two-and-a-half times what most developed nations spend, including relatively rich European countries like France, Sweden, and the
United Kingdom (UK). On a more global scale, it means that U.S. healthcare costs now eat up 17.6% of gross domestic product (GDP) or the total market value of all final
goods and services produced within a country in one year. Figure 1.1 shows the United States’ per capita healthcare costs relative to other countries (OECD, 2013a).
Figure 1.1: Per capita healthcare costs in the United States
The United States spends more money per capita on healthcare than other countries, including several of the relatively wealthy European nations such as Sweden.
Source: Based on data from Organisation for Economic Co-operation and Development (OECD) Health Data, 2013. Retrieved from http://www.oecd.org/els/healthsystems/Health-at-a-Glance-2013.pdf (http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf) .
Despite greater spending on healthcare, the United States has the highest or near-highest prevalence of infant mortality, heart and lung disease, sexually transmitted infections,
adolescent pregnancies, injuries, homicides, and disability among the 17 richest countries in the world (Davis, Schoen, & Stremikis, 2010; National Research Council, 2013;
Save the Children, 2013). These numbers put the United States at the bottom of these countries for overall life expectancy, with U.S. males expected to live almost four fewer
years than those in the top-ranked country. Chapter 11 (http://content.thuzelearning.com/books/Batnitzky.5231.18.1/sections/sec11.2#sec11.2) explores how the U.S. healthcare system
stacks up against international healthcare systems.
So why does the United States spend so much on healthcare yet have such relatively poor health outcomes? Early research suggested that this greater spending could be
attributed to higher incomes, an older population, and a greater supply and utilization of hospitals and doctors (Squires, 2012). A recent study challenged these findings. This
study concluded that the higher health spending is more likely due to higher prices, more readily accessible technology, and even greater obesity in the United States (Cawley &
Meyerhoefer, 2012). These aspects of the U.S. healthcare landscape are further discussed in Chapter 10
(http://content.thuzelearning.com/books/Batnitzky.5231.18.1/sections/sec10.1#sec10.1) . Others argue that the rise in chronic illnesses is the cause of our healthcare crisis, as well as an
ever-expanding elderly population that is projected to live longer, thereby creating an even greater healthcare burden (Blumenthal & Warren, 2011).
One would expect that greater spending on healthcare would result in better health outcomes in the United States. However, this “paradox of efficiency” is still unresolved and
remains at the center of the healthcare debate.
Quality
The effectiveness or quality of a healthcare system can be measured by the efficacy of its treatment relative to its cost. The old adage that “anything is possible in America”
might be applied to the effectiveness of healthcare in the U.S. with one important disclaimer: provided you have the necessary resources. The hyper-specialization of medical
training and the use of the latest technologies and innovations in care have resulted in the U.S. healthcare system being touted as one of the “best” in the world (Emery, 2012). In
fact, despite the poor health outcomes relative to cost, the United States healthcare system is often characterized as notably superior to the far less expensive systems in other
countries, if indicators other than life expectancy and infant mortality are used. For example, people who suffer the three major killers—heart disease, cancer, and strokes—are
more likely to survive in our healthcare system as compared with others (Atlas, 2012).
For those with financial resources to travel and pay for treatment, the United States has historically been and continues to be a much sought-after destination for medical care by
people from around the world (Farrell, Jensen, Kocher, Lovegrove, Mendonca, & Parrish, 2008). A McKinsey & Company report (2008) found that between 60,000 to 85,000
medical tourists per year travel to the United States for the purpose of receiving in-patient medical care. Medical tourism has become an ever-expanding international industry,
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and the United States remains in the top three destinations in terms of quality and range of services provided to international patients (International Medical Travel Journal
[IMTJ], 2013). Ironically, people living in the United States are increasingly traveling to other countries for critical medical procedures due to the high costs of healthcare in the
United States (Johnson, 2008). It is estimated that these “medical tourists” cost U.S. healthcare providers billions of dollars in lost revenue per year (Johnson, 2008).
Turning to other countries for healthcare services is reminiscent of the longstanding trend of Americans purchasing prescription drugs abroad because of the prohibitive costs of
pharmaceuticals, despite safety warnings from the FDA (Harris, 2003). However, this practice was sanctioned recently by the state of Maine after the state negotiated a contract
with a Canadian pharmaceutical broker to provide prescription drugs legally to more than 13,000 state employees (Levitz, 2013).
The effectiveness of the U.S. healthcare system is increasingly being challenged by opportunities to seek healthcare services and products available abroad. Furthermore, a
healthcare system cannot be considered truly effective if the outputs (i.e., poor health outcomes) do not match the inputs (i.e., high spending costs). In addition, medical
technology and innovation are available only to those who can afford them.
Access
Regarding medical ethics (see Chapter 9), a healthcare system must be equitable and protect the patient’s rights. Therefore, to measure equity in a healthcare system, it must be
determined if healthcare services are evenly distributed among the population. In other words, who has access to it must be determined.
The U.S. healthcare system is based upon an anti-collectivist system where the user is expected to pay at the point of use or buy into private health insurance. This type of
structure is in direct contrast to systems in other developed nations where health services are funded by income from taxes or compulsory insurance, otherwise known as
socialist or collectivist systems. (Chapter 11 discusses different health systems used internationally.)
The structure of an anti-collectivist healthcare system is inherently inequitable because it excludes those unable to pay at the point of service or those without medical insurance.
Furthermore, medical insurance in the United States is most often tied to full-time employment. Thus, unemployed, part-time, and self-employed individuals historically have
found it hard to obtain insurance. Advocates of health reform often point to the evidence of the number of uninsured to demonstrate the lack of equity in the healthcare system as
illustrated in Table 1.1 (Chandler, 2006).
Table 1.1: Uninsured rates by age, race/ethnicity, and household income
Percent of the total population
Percent of the uninsured1
Age
Race/ethnicity
Household income
Under 19
19–25
26–34
35–44
45–64
65 and older
White, Non-Hispanic
Black
Asian
Hispanic (any race)
Less than $25,000
$25,000–$49,999
$50,000–$74,999
$75,000 or more
25.4%
9.7%
12.0%
12.9%
26.5%
13.4%
64.3%
13.1%
5.3%
17.3%
19.0%
23.3%
18.5%
39.2%
15.7%
17.0%
21.1%
17.3%
27.5%
1.4%
45.3%
16.1%
5.6%
33.0%
30.7%
31.8%
18.1%
19.3%
Uninsured rate2
9.7%
27.7%
27.5%
21.0%
16.3%
1.7%
11.1%
19.5%
16.8%
30.1%
25.4%
21.5%
15.4%
7.8%
1Percent
of uninsured is the number of uninsured people in the specified category divided by the total uninsured population. For Race/Ethnicity, it is the percent of those that
reported Race/Ethnicity in one of the four categories.
2Uninsured rate is the number of uninsured people in the specified category divided by the total number of people in that specific category.
Source: United States Census Bureau, Income Poverty and Health Insurance Coverage in the United States: 2011. Retrieved from
http://www.census.gov/newsroom/releases/archives/income_wealth/cb12-172.html (http://www.census.gov/newsroom/releases/archives/income_wealth/cb12-172.html) ; and
United States Department of Health and Human Services, Overview of the Uninsured in the United States Population: A Summary of the 2012 Current Population Survey
Report [ASPE Issue Brief]. Retrieved from http://aspe.hhs.gov/health/reports/2012/uninsuredintheus/ib.shtml#_#_ftn2
(http://aspe.hhs.gov/health/reports/2012/uninsuredintheus/ib.shtml#_#_ftn2)
In addition to the unequal level of health coverage of individuals (i.e., insurance), inequities persist in the distribution of and access to health services based in part on geography
(Gatrell & Elliott, 2009). A truly equitable healthcare system evenly distributes services for each person. In geographical terms, this most often translates into establishing
centers of care where there is the greatest need. Given that the highest population density is in urban America, it is no coincidence that the greatest concentration of healthcare
facilities is found in America’s cities. However, the number of physicians is often not commensurate with the percentage of population. For instance, about 10% of all physicians
practice in rural America, yet nearly one-fourth of the population lives in these areas. As a result, rural communities have less access to healthcare than their urban counterparts,
not only because of a dearth of providers, but also because rural residents are less likely to have employer-provided healthcare coverage or prescription drug coverage. Also,
people who live in rural areas have less access to private health coverage than their urban counterparts because fewer employers in rural areas offer health insurance to their
workers, and more workers are self-employed, as depicted in Figure 1.2 (Center on Budget and Policy Priorities [CBPP], 2013). As a result, Medicaid plays an important role in
the payment of healthcare for much of the rural population (CBPP, 2013). These numbers do not necessarily mean that urbanites have adequate access to healthcare. Indeed, in
the urban context, there are sufficient numbers of healthcare providers, but the cost of healthcare proves the barrier to access. Rural residents though—especially poor ones—
often face a double barrier to healthcare services.
Figure 1.2: Health coverage for nonelderly adults in rural America, 2012
In 2012, the rate of health coverage for adults in rural America was 59%, and 41% of nonelderly adults were not covered at all.
Source: Center on Budget and Policy Priorities (2013, June 7). Rural America will benefit from Medicaid expansion. Retrieved from http://www.cbpp.org/files/Fact-SheetRural-America.pdf (http://www.cbpp.org/files/Fact-Sheet-Rural-America.pdf) .
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1.2 Healthcare Reform Efforts
The highly decentralized and fragmented healthcare system has been faced with two main challenges: cutting costs and improving health results. Although there is a long history
of healthcare reform in the United States, the most recent—and successful—initiatives to pass reform began during the 2008 presidential election with then-Senators Barack
Obama and John McCain. Reform initiatives continue to this day.
Health Reform Legislation: Affordable Care Act of 2010
The Patient Protection and Affordable Care Act (PPACA)—often referred to as the Affordable Care Act (ACA) or “Obamacare”—is a U.S. federal statute signed into law by
President Barack Obama in 2010. This law represents the most significant attempt at healthcare overhaul in U.S. history since the enactment of Medicare and Medicaid in 1965.
The 2010 law was, and remains, highly contested. In fact, whether it violated the U.S. Constitution or not was questioned in a federal court case brought to the United States
Supreme Court in 2012. The court upheld the constitutionality of most of the ACA on June 28, 2012. Since then, there have been numerous attempts to overhaul or repeal this
piece of legislation.
The passage of the ACA, along with the Healthcare and Education Reconciliation Act, which also passed in 2010, was intended to increase access to medical care by making
health insurance more affordable and by reducing the overall costs of healthcare for both the individual and the government. The law was written to accomplish this through a
variety of initiatives, including mandates, subsidies, and tax credits. The major rollout of these provisions occurred in October 2013.
Patient Protection
J. David Ake/Associated Press
Under the Affordable Care and Patient Protection Act, individuals cannot be denied healthcare coverage due to a pre-existing condition.
The ACA was written with the primary goal of protecting a patient’s right to quality healthcare. A variety of provisions and mandates within the ACA were designed to provide
new benefits that ensure quality healthcare at an affordable cost to all Americans. First, an individual mandate was implemented, requiring adults to have health insurance or pay
a fine. Second, an employer mandate made it compulsory for firms with 50 or more employees to offer coverage or pay a fine. Third, the ACA required that each state establish a
health insurance exchange or accept a federally established exchange in which individuals and small businesses can buy coverage. Fourth was a provision calling for the
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