Foundation of US Health Care System

FOUNDATION OF US HEALTH CARE SYSTEM

The United States is unique in that it is the only industrialized nation that does not have a government sponsored universal health insurance program. In America, only persons covered by insurance are entitled to receive routine and basic health care which is a right to all persons in most other countries. The Patient Protection and Affordable Care Act of 2010 (ACA) expanded access to health care to over 22 million Americans, though it’s future remains uncertain.

The American health care system is made up of delivery providers and settings, the public health domain, and the myriad private insurance companies involved in the financing of health care services.

Image result for patient access and affordability act 2010

Over 16 million health professionals make up the largest workforce in America. There are nearly 6000 hospitals, 16,000 nursing homes, 11,000 home health agencies and hospices,  and nearly 3,000 inpatient mental health facilities. As of 2015, there were 321,420,000 people in the United States. As of 2013, 195 million Americans had private health insurance, 105 had either of the public health insurance coverages (Medicare and Medicaid),

The types of provider organizations generally fall into Managed Care Organizations (MCO). There are over 1000 health insurance companies, 70 Blue Cross/Blue Shield plans, 452 licensed health maintenance organizations (HMO), 925 preferred provider organizations (PPO).The government agencies involved in health care research, delivery and finance range from local health departments to state health departments and laboratories to the National Centers for Disease Control, National Institutes of Health and the Centers for Medicare and Medicaid Services, among many.

Systems of the US Health Care System

MANAGED CARE ORGANIZATIONS (MCOs)

Managed care plans are a type of health insurance. They have contracts with health care providers and medical facilities to provide care for members at reduced costs.

These providers make up the plan’s network. How much of your care the plan will pay for depends on the network’s rules.

Plans that restrict your choices usually cost you less. If you want a flexible plan, it will probably cost more. There are three types of managed care plans:

  • Health Maintenance Organizations (HMO) usually only pay for care within the network. You choose a primary care doctor who coordinates most of your care.
  • Preferred Provider Organizations (PPO) usually pay more if you get care within the network. They still pay part of the cost if you go outside the network.
  • Point of Service (POS) plans let you choose between an HMO or a PPO each time you need care.

Managed care integrates health care to improve efficiency. manages the use of medical services and sets pricing of services/ Managed care is financed by employer or government, less premium and deductible costs to patient (enrollee). MCO contracts with HMO or PPO, depending on plan selected by employer or state plans. An MCO is like an insurance company, managing contracts (health plan) and payments.

MILITARY

The United States military health care system is free of charge to active duty military personnel, member of Public Health Service and NOAA (National Oceanographic and Atmospheric Association). The system combines public health and medical care to provide preventive and treatment services. Family members of active duty or retired career military are covered by Tricare, through Department of Defense financing.

Image result for veterans administration

  • The Veterans Administration (VA) health care system is available to retirees and disabled veterans.  It is the largest and oldest health care organization in America with 5.5 million participants

SPECIAL POPULATIONS

In the United States vulnerable populations such as the elderly, the poor and disabled are covered for health care under “safety net’ programs such as Medicare and Medicaid.

  • The Bureau of Primary Health Care (BPHC) in the Department of Health and Human Services (DHHS) provides support to migrant and seasonal farm workers, homeless persons, public housing residents and school age children.
  • Medicare covers all citizens age 65 and older regardless of income, disabled and persons with end-stage renal disease.
  • Medicaid covers low-income individuals and persons with disabilities.
  • CHIP – the 1997 Children’s Health Insurance Program, preceded the ACA coverage for children in uninsured families.
  • ***In 2017, the U.S. Congress, Senate and President are continuing to debate the viability of these health care programs.
INTEGRATED DELIVERY SYSTEMS (IDS)

Integrated delivery systems refer to health networks linking hospitals, physicians and insurers. Their focus is on quality improvement and cost controls. Integrated delivery systems typically include one or more hospitals; outpatient clinics and ambulatory surgical centers; physician group practices; long-term care facilities; home health and hospice services; and, one or more MCOs. Specialized services often participate in local IDS, including rural mobile delivery systems, women’s health care, cancer centers and rehabilitation clinics. The sharing of resources can help to avoid duplication of services and fill in gaps of services in rural communities.

LONG TERM CARE DELIVERY

Long term care are the services and supports necessary to meet health or personal care needs over an extended period of time. Long term care involves medical and nonmedical care provided to chronically ill and persons with disabilities including a range of services and supports needed for custodial care. Non-skilled service or care, such as help with bathing, dressing, eating, getting in and out of bed or chair, moving around, and using the bathroom. needs. Most long-term care is not medical care, but rather assistance with the basic personal tasks of everyday life, sometimes called Activities of Daily Living (ADLs). Basic actions that independently functioning individuals perform on a daily basis:, such as:

    • Housework
    • Managing money
    • Taking medication
    • Preparing and cleaning up after meals
    • Shopping for groceries or clothes
    • Using the telephone or other communication devices
    • Caring for pets
    • Responding to emergency alerts such as fire alarms

Long-term care can be provided in a patient’s home, assisted living facilities, and nursing homes. Medicare does not cover long term care; Medicaid covers limited LTC services to an eligible patient

PUBLIC HEALTH SYSTEM

The United States Public Health System (PHS) monitors health status in the community. Public health departments provide diagnostic and investigative services targeting health problems and hazards in the community. The PHS provides health information and education to the community, policy to support community and its residents and works to enforce and regulate health and safety laws. In concert with local integrated delivery systems, the PHS helps to provide access to health care. The PHS is the state system responsible for quality standards in health care and regulate licensure and competence of health care professionals and monitor quality of care of health services. At the national and state level, the public health system helps to control the spread of illness and death by conducting epidemiologic research in the study of disease.

US HEALTH CARE SYSTEM IN CRISIS

Unlike all other health care systems in the developed world, the US health care system is complex in that there is little integration and no centralized agency to oversee care in financing. America is the only nation without a national health care system.

Rising costs In the past few decades have been technology driven due the high cost of diagnostic testing and treatments, and sometimes, unnecessary interventions.

Unlike nations with lower cost national health services, the U.S. system is focused on acute care rather than prevention. The inequality of access to care and extremely high costs in comparison to other systems has resulted in mediocre outcomes. The U.S. trails behind other countries in quality of care, as well as patient outcomes.

While lawmakers argue for a free-market system, the current quasi-market system affords very little options available.

Image result for us healthcare system

Government subsidies are available to health providers in the private sector, but the private sector causes gaps in health care such as environmental protection, research and training, and care of vulnerable populations. The concept of market justice (profit motivated, based on ability to pay) vs social justice (well being of the community) is the crux of the controversy, leading lawmakers to a stalemate in the “repeal and replace” platform of the 2017 presidential campaign. The balance of power (special interest groups and lobbyists representing for profit medical product, health services and pharmaceutical companies) presents the greatest challenge to cost containment.

America’s health care system will be covered with particular attention to quality of care, which depends on accountability, access based on insurance coverage rather than medical need, and medical practice based on legal risk (malpractice insurance).

WORLD’S 25 BEST HEALTH CARE SYSTEMS

https://www.youtube.com/watch?time_continue=1&v=pbMOp1qzBMc

Review the video and identify three countries systems for research and discussion. Present these systems in your introduction to your Resource Compendium .

YOU’LL NEED TO PAUSE TO READ CAPTIONS!

WHERE DOES THE UNITED STATES FIT IN?

assignment instructions