Gesundheitsversorgung in den Vereinigten Staaten

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Die Gesundheitsfürsorge in den Vereinigten Staaten wird von vielen verschiedenen Organisationen angeboten. ^[1] Gesundheitsfürsorge Die Anlagen werden größtenteils von Privatunternehmen betrieben und betrieben. 58% der Krankenhäuser in den USA sind gemeinnützig, 21% befinden sich in staatlichem Besitz und 21% sind gewinnorientiert. ^[2] Laut Angaben der Weltgesundheitsorganisation (WHO) gaben die Vereinigten Staaten 9.403 USD pro Kopf für die Gesundheitsfürsorge aus Anteil der Gesundheitsfürsorge an ihrem BIP im Jahr 2014 in Höhe von 17,1%. Die Deckung der Gesundheitsversorgung erfolgt durch eine Kombination aus privater Krankenversicherung und öffentlicher Krankenversicherung (z. B. Medicare, Medicaid). In den Vereinigten Staaten gibt es im Gegensatz zu anderen fortgeschrittenen Industrieländern kein universelles Gesundheitsprogramm. ^[3][4]

Im Jahr 2013 wurden 64% der Gesundheitsausgaben von der Regierung bezahlt ^[5][6] und durch Programme wie Medicare, Medicaid und die Kinder finanziert Krankenversicherungsprogramm und die Veterans Health Administration. Personen unter 65 Jahren erhalten eine Versicherung über den Arbeitgeber ihres oder eines Familienmitglieds, indem sie selbst eine Krankenversicherung abschließen oder sind nicht versichert. Die Krankenversicherung für Angestellte des öffentlichen Sektors wird in erster Linie von der Regierung als Arbeitgeber übernommen. ^[7]

Die Lebenserwartung der Vereinigten Staaten beträgt 78,6 Jahre (75,2 Jahre 1990). Dies ist der 42. Platz unter 224 Nationen und der 22. von 35 Industrieländern in der OECD-Region. 1990 waren es noch keine 20. ^[8][9] In den Jahren 2016 und 2017 sank die Lebenserwartung in den USA erstmals seit 1993. ^[10] Von 17 In den von den National Institutes of Health untersuchten Einkommensländern hatten die Vereinigten Staaten im Jahr 2013 die höchste oder nahezu höchste Prävalenz von Fettleibigkeit, Autounfällen, Säuglingssterblichkeit, Herz- und Lungenerkrankungen, sexuell übertragbaren Infektionen, jugendlichen Schwangerschaften, Verletzungen und Tötungsdelikten. 19659012] Eine Umfrage unter den Gesundheitssystemen von elf entwickelten Ländern aus dem Jahr 2014 ergab, dass das US-amerikanische Gesundheitssystem das teuerste und leistungsstärkste Gesundheitssystem in Bezug auf Zugang zu Gesundheit, Effizienz und Gerechtigkeit ist. ^[12]

Verbotene Kosten sind der Hauptgrund für die Amerikaner haben Probleme beim Zugang zur Gesundheitsversorgung. ^[4] Das Beratungsunternehmen Gallup berichtete, dass die unversicherte Quote für Erwachsene in den USA im ersten Quartal 2015 bei 11,9% lag, was den Rückgang der nicht versicherten Rate bis zum Jahr 2015 fortsetzte Das Gesetz über Patientenschutz und erschwingliche Gesundheitsfürsorge (PPACA). ^[13] Mit über 27 Millionen Menschen ist die Zahl der Personen ohne Krankenversicherungsschutz in den Vereinigten Staaten eines der Hauptanliegen der Befürworter der Gesundheitsreform. Der Mangel an Krankenversicherungen ist abhängig von der Studie mit einer erhöhten Sterblichkeit verbunden, etwa sechzigtausend vermeidbare Todesfälle pro Jahr. ^[14] Eine an der Harvard Medical School durchgeführte Studie der Cambridge Health Alliance zeigte, dass fast 45.000 Todesfälle pro Jahr mit einem Patientenmangel verbunden sind Krankenversicherung. Die Studie ergab auch, dass nicht versicherte, arbeitende Amerikaner ein ungefähr 40% höheres Sterblichkeitsrisiko im Vergleich zu privat versicherten arbeitenden Amerikanern haben. ^[15]

Im Jahr 2010 wurde das Gesetz über den Schutz von Patienten (PPACA) verabschiedet, das wesentliche Änderungen in der Krankenversicherung in Kraft setzte. Der Oberste Gerichtshof bestätigte die Verfassungsmäßigkeit der meisten Gesetze im Juni 2012 und bestätigte im Juni 2015 in allen Bundesstaaten Versicherungssubventionen. ^[16]

Geschichte [ edit

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Statistics [ edit ]

Hospitalizations [ edit ]

Eine Studie der Agency for Healthcare Research and Quality (AHRQ) ergab, dass es in den USA 38,6 Millionen Krankenhausaufenthalte gab 2011 stieg sie um 11% seit 1997. Da die Bevölkerung ebenfalls wuchs, blieb die Krankenhausaufenthaltsrate während dieses Zeitraums stabil bei etwa 1.200 Aufenthalten pro 10.000 Einwohner. ^[17] Die Krankenhausaufenthalte im Jahr 2011 waren durchschnittlich 4,5 Tage lang und kosteten durchschnittlich 10.400 USD pro Aufenthalt Eine Studie der National Institutes of Health berichtet, dass die Die Lebenszeit-Pro-Kopf-Ausgaben bei der Geburt im Jahr 2000 zeigten einen großen Unterschied zwischen den Gesundheitskosten von Frauen (361.192 USD) und Männern (268.679 USD). Ein großer Teil dieses Kostenunterschieds ist auf die kürzere Lebenserwartung von Männern zurückzuführen, aber selbst nach Anpassung an das Alter (unter der Annahme, dass Männer so lange leben wie Frauen), besteht immer noch ein Unterschied von 20% bei den Ausgaben für die lebenslange Gesundheitsfürsorge. ^[19]

Krankenversicherung und Krankenversicherung Zugänglichkeit [ edit ]

Im Gegensatz zu den meisten Industrieländern bietet das US-amerikanische Gesundheitssystem keine Gesundheitsversorgung für die gesamte Bevölkerung des Landes an, ^[20] stattdessen sind die meisten Bürger durch eine Kombination von Privatpersonen abgedeckt Versicherungen und verschiedene Bundes- und Landesprogramme. ^[21] Ab 2017 wurde die Krankenversicherung am häufigsten durch einen an einen Arbeitgeber gebundenen Gruppenplan für 150 Millionen Menschen erworben. ^[22] Weitere wichtige Quellen sind Medicaid (70 Millionen), Medicare, 50 Millionen und mit dem Affordable Care Act (ACA) geschaffene Krankenversicherungsmarktplätze für rund 17 Millionen. ^[22] Eine Studie ergab 2017, dass 73% der Pläne für ACA-Marktplätze über enge Netzwerke verfügten, was den Zugang und die Auswahlmöglichkeiten der Anbieter einschränkte ^[22]

Maßnahmen zur Erreichbarkeit und Erschwinglichkeit, die in nationalen Gesundheitserhebungen nachverfolgt wurden, umfassen: Prozent der versicherten Bevölkerung, eine übliche medizinische Versorgung, jährliche Besuche beim Zahnarzt, Raten vermeidbarer Krankenhauseinweisungen, gemeldete Schwierigkeiten beim Besuch eines Spezialisten, Verzögerung der Behandlung aufgrund von Kosten und Krankenversicherungsschutz. ^[23] Im Jahr 2004 stellte ein OECD-Bericht fest, dass "alle OECD-Länder [except Mexico, Turkey, and the United States] eine allgemeine oder nahezu universelle (mindestens 98,4% versicherte) Deckung ihrer Bevölkerung bis 1990 erreicht hatten". 19659040] Der IOM-Bericht von 2004 stellte auch fest, dass "eine unzureichende Krankenversicherung jedes Jahr in den Vereinigten Staaten etwa 18.000 unnötige Todesfälle verursacht" ^[20]

Das US Census Bureau berichtete, dass 28,5 Millionen Menschen (8,8%) im Jahr 2017 nicht krankenversichert waren , ^[25] weniger als 49,9 Millionen (16,3%) im Jahr 2010. ^[26][27] Zwischen 2004 und 2013 trug ein Trend hoher Unterversicherungsraten und einer Lohnstagnation zu einem Rückgang des Konsums von Gesundheitsleistungen für einkommensschwache Am ericans. ^[28] Dieser Trend wurde nach der Umsetzung der wichtigsten Bestimmungen des Affordable Care Act (ACA) im Jahr 2014 umgekehrt. ^[29]

Ab 2017 hat die Möglichkeit, dass der ACA aufgehoben oder ersetzt werden kann, das Interesse an den Fragen verstärkt darüber, ob und wie sich der Krankenversicherungsschutz auf Gesundheit und Sterblichkeit auswirkt. ^[30] Mehrere Studien haben gezeigt, dass ein Zusammenhang mit der Ausweitung des ACA und Faktoren, die mit besseren gesundheitlichen Ergebnissen verbunden sind, z. B. eine regelmäßige Pflege und die Fähigkeit, sich eine Pflege zu leisten, verbunden sind ^[30] Eine Studie aus dem Jahr 2016 kam zu dem Schluss, dass eine um etwa 60% erhöhte Betreuungsfähigkeit auf die durch das Patientenschutz- und Affordable Care Act erlassenen Bestimmungen zur Medicaid-Erweiterung zurückzuführen ist. ^[31] Darüber hinaus legt eine Analyse der Veränderungen der Sterblichkeit nach der Medicaid-Expansion nahe Medicaid rettet Leben zu einem relativ kosteneffektiveren Satz mit gesellschaftlichen Kosten von 327.000 USD - 867.000 USD pro gerettetes Leben im Vergleich zu anderen öffentlichen Richtlinien h kostete durchschnittlich 7,6 Millionen US-Dollar pro Leben. ^[32]

Eine Studie aus dem Jahr 2009 in fünf Bundesstaaten ergab, dass die Verschuldung von Ärzten 46,2% aller Privatinsolvenzen ausmachte und 62,1% der Insolvenzverwalter 2007 hohe medizinische Kosten geltend machten. ^[33] Die Gesundheitskosten und die Zahl der Nicht- und Unterversicherten sind gestiegen. ^[34] Eine Studie aus dem Jahr 2013 ergab, dass etwa 25% aller Senioren aufgrund von Krankheitskosten Insolvenz anmelden. ^[35]

In der Praxis werden die Nicht-Versicherten oft behandelt, aber die Kosten wird durch Steuern und andere Gebühren gedeckt, die die Kosten verschieben. ^[36] Verzicht auf ärztliche Behandlung aufgrund einer umfassenden Kostenteilung kann letztendlich die Kosten aufgrund nachgelagerter medizinischer Probleme erhöhen; Diese Dynamik spielt möglicherweise im internationalen Ranking der USA eine Rolle, da sie trotz erheblicher Kostenteilung für Patienten die höchsten Ausgaben für das Gesundheitswesen aufweist. ^[29]

Die Versicherten sind unterversichert, so dass sie sich keine angemessene medizinische Versorgung leisten können. Schätzungen aus dem Jahr 2003 zufolge waren 16 Millionen US-amerikanische Erwachsene unterversichert, wodurch diejenigen mit niedrigeren Einkommen unverhältnismäßig stark betroffen waren - 73% der unterversicherten Bevölkerung der Studie hatten ein Jahreseinkommen unter 200% der Armutsgrenze des Bundes. ^[37] Fehlende Versicherung oder höhere Kostenbeteiligung ( Nutzungsentgelte für den versicherten Patienten schaffen Barrieren für den Zugang zur Gesundheitsversorgung: Mit zunehmender Kostenteilungspflicht für Patienten sinkt die Inanspruchnahme der Pflege. ^[29] Bevor der ACA im Jahr 2014 verabschiedet wurde, gaben 39% des unterdurchschnittlichen Einkommens der Amerikaner an, einen Arzt aufsuchen zu müssen für ein medizinisches Problem (während 7% der kanadischen Bevölkerung mit niedrigem Einkommen und 1% der britischen Bürger mit niedrigem Einkommen dasselbe angaben). ^[38]

Gesundheit in den USA im globalen Kontext [ edit ]

Die Vereinigten Staaten befinden sich innerhalb der Region Amerikas oder AMRO (einer Klassifikation der Weltgesundheitsorganisation). Innerhalb von AMRO hatten die USA 2015 die drittniedrigste Kindersterblichkeit unter fünf Jahren (U5MR). ^[39] 2015 betrug die Kindersterblichkeit unter fünf Jahren 6,5 Todesfälle pro 1000 Lebendgeborene, weniger als die Hälfte des regionalen Durchschnitts von 14,7 ^[39] Die USA hatten mit AMRO die zweitniedrigste Müttersterblichkeit, 14 pro 100.000 Lebendgeborene, was weit unter dem regionalen Durchschnitt von 52 liegt. ^[40] Die Lebenserwartung eines im Jahr 2015 in den USA geborenen Kindes beträgt 81,2 (Frauen). oder 76,3 (Männer) Jahre, ^[41] im Vergleich zu 79,9 (Frauen) oder 74 (Männer) Jahren (regionale Schätzungen von AMRO). ^[42] Weltweit beträgt die durchschnittliche Lebenserwartung 73.8 für Frauen und 69.1 für Männer, die 2015 geboren wurden. [19659065] Sterblichkeit und Lebenserwartung der Vereinigten Staaten von 2015 im globalen Kontext


Indictor

USA

Region Amerikas

Globus

Europäische Region

Region Südostasien

Afrikanische Region

Western Pacific Region

Östlicher Mittelmeerraum
Kindersterblichkeit unter fünf Jahren

(Todesfälle pro 1000 Lebendgeburten)

6.5

14.2

40,8

9.6

38,9

76,5

12.9

51,7
Müttersterblichkeitsrate

(Todesfälle pro 100.000 Lebendgeburten)

14

52

216

16

164

542

41

166
Lebenserwartung

(bei Geburt in Jahren)

81.6 (Frauen)

76.9 (Männer)

79.9 (Frauen)

74 (Männer)

73.8 (Frauen)

69.1 (Männer)

80.2 (Frauen)

73.2 (Männer)

70.7 (Frauen)

67.3 (Männer)

61.8 (Frauen)

58.3 (Männer)

78,7 (Frauen)

74.5 (Männer)

70.3 (Frauen)

67.3 (Männer)

Daten stammen aus dem World Health Observatory Data Repository der World Health Organization. ^{[40] [41] [29] [42] [43]}

Der weltweite Durchschnitt der Kindersterblichkeit von Kindern unter fünf Jahren lag im Jahr 2015 bei 42,5 pro 1000 Lebendgeburten. ^[44] Die Kindersterblichkeit von Kindern unter fünf Jahren ist mit 6,5 mehr als 6 mal weniger. ^[39] Der weltweite Durchschnitt der Müttersterblichkeit im Jahr 2015 betrug 216, der Durchschnitt der Vereinigten Staaten von 14 Müttersterben mit 100.000 Lebendgeburten ist mehr als das 15-fache, jedoch hatte Kanada nur halb so viele (7) und Finnland, Griechenland, Island und Polen hatten jeweils nur 3. ^[40] Obwohl 2015 nicht so hoch (14) ^[40] wie 2013 (18,5), verzeichneten die Müttersterblichkeit im Zusammenhang mit der Geburt in letzter Zeit einen Anstieg; 1987 betrug die Sterblichkeitsrate 7,2 pro 100.000. ^[45] Ab 2015 ist die amerikanische Rate in Belgien oder Kanada doppelt so hoch wie die Müttersterblichkeit und in Finnland sowie in einigen anderen westeuropäischen Ländern mehr als verdreifacht. ^[40]

Nach Angaben der Weltgesundheitsorganisation (WHO) ist die Lebenserwartung in den USA bis 2015 die 31. in der Welt (von 183 Ländern). ^[46] Die durchschnittliche Lebenserwartung der USA (beide Geschlechter) liegt bei knapp über 79. [19659] 19659114] Japan steht mit einer durchschnittlichen Lebenserwartung von fast 84 Jahren an erster Stelle. Sierra Leone steht mit einer Lebenserwartung von etwas mehr als 50 Jahren an letzter Stelle. ^[46] Die USA liegen jedoch niedriger (36.), wenn man die gesundheitsangepasste Lebenserwartung (HALE) mit etwas über 69 Jahren in Betracht zieht. ^[46] Eine andere Quelle, die Zentrale Die Intelligence Agency gibt an, dass die Lebenserwartung bei der Geburt in den USA 79,8 beträgt und damit die 42. Position der USA in der Welt ist. Monaco steht an erster Stelle auf dieser Liste von 224 mit einer durchschnittlichen Lebenserwartung von 89,5. Tschad liegt mit 50,2 auf dem letzten Platz. ^[47]

Lebenserwartung von Ländern mit hohem Einkommen im Jahr 2015.

Laut einer Studie des National Research Council 2013 aus dem Jahr 2013 gaben die Vereinigten Staaten an, als seien sie eines von 17 Ländern mit hohem Einkommen Bei Säuglingssterblichkeit, Herz- und Lungenerkrankungen, sexuell übertragbaren Infektionen, Schwangerschaften bei Jugendlichen, Verletzungen, Tötungsdelikten und Behinderungsraten. Zusammen stellen diese Probleme die USA in Bezug auf die Lebenserwartung in Ländern mit hohem Einkommen an die Spitze der Liste. Ab 2007 könnten Männer in den USA fast vier Jahre weniger leben als in der Schweiz, und Frauen in den USA könnten über 5 Jahre weniger leben als Frauen in Japan. ^[11] Frauen, die 2015 in den USA geboren wurden, haben ein Leben Erwartung von 81,6 Jahren und Männer 76,9 Jahre; mehr als 3 Jahre und bis zu 5 Jahre weniger als Menschen, die 2015 in der Schweiz (85,3 F, 81,3 M) oder Japan (86,8 F, 80,5 M) geboren wurden. ^[41]

Todesursachen in den USA edit ]

Die drei häufigsten Todesursachen bei beiden Geschlechtern und allen Altersgruppen in den USA sind seit den 1990er Jahren konsequent kardiovaskuläre Erkrankungen (Platz 1), Neoplasmen (2) und neurologische Erkrankungen (3) geblieben ^[48] Chronische Erkrankung der unteren Atemwege. ^[53] Im Jahr 2015 betrug die Gesamtzahl der Todesfälle durch Herzerkrankungen 633.842, durch Krebs 595.930 und von der chronischen Erkrankung der unteren Atemwege 155.441. ^[49] 2015 267,18 pro 100.000 Todesfälle wurden durch kardiovaskuläre Erkrankungen verursacht, 204,63 durch Neoplasmen und 100,66 durch neurologische Störungen. ^[48] Durchfall, Atemwegserkrankungen und andere häufige Infektionen wurden auf Rang sechs eingestuft, hatten jedoch in den USA mit 31,65 Todesfällen pro 100.000 die höchste Sterblichkeitsrate bei Infektionskrankheiten ^[48] Es gibt Beweise, wie auch immer r, dass ein großer Teil der gesundheitlichen Auswirkungen und der frühen Sterblichkeit auf andere Faktoren als übertragbare oder nicht übertragbare Krankheiten zurückzuführen ist. Nach einer Studie des National Research Council aus dem Jahr 2013 sterben mehr als die Hälfte der Männer, die vor den 50 Jahren sterben, an Mord (19%), Verkehrsunfällen (18%) und anderen Unfällen (16%). Bei Frauen sind die Prozentsätze unterschiedlich. 53% der Frauen sterben vor 50 Jahren an Krankheiten, 38% sterben an Unfällen, Mord und Selbstmord. ^[50]

Providers [ edit

US umfasst individuelles Gesundheitspersonal, Gesundheitseinrichtungen und medizinische Produkte.

Einrichtungen [ edit ]

In den USA befindet sich der Besitz des Gesundheitssystems hauptsächlich in privater Hand, obwohl auch Bundes-, Landes-, Kreis- und Stadtregierungen bestimmte Einrichtungen besitzen.

Ab 2018 gab es in den Vereinigten Staaten 5.534 registrierte Krankenhäuser. Es gab 4.840 Gemeindekrankenhäuser, die als nicht föderale, kurzfristige Allgemeinkrankenhäuser oder Spezialkrankenhäuser definiert werden. ^[51] Der Anteil der gemeinnützigen Krankenhäuser an der Gesamtkapazität der Krankenhäuser ist seit Jahrzehnten relativ stabil (etwa 70%). ^[52] Dort Es gibt auch gewinnorientierte Krankenhäuser in Privatbesitz sowie staatliche Krankenhäuser an einigen Standorten, die sich hauptsächlich im Besitz der Bezirks- und Stadtverwaltungen befinden. Das Hill-Burton-Gesetz wurde 1946 verabschiedet, das Krankenhäuser im Austausch für die Behandlung armer Patienten durch Bundesmittel finanzierte. ^[53]

Vertikales Logo des US-amerikanischen Veterinärministeriums

Es gibt kein landesweites System staatlicher medizinischer Einrichtungen, die der Regierung zur Verfügung stehen Öffentlichkeit, aber es gibt örtliche öffentliche Einrichtungen, die der Öffentlichkeit zugänglich sind. Das US-Verteidigungsministerium betreibt Feldkrankenhäuser sowie permanente Krankenhäuser über das Militärische Gesundheitssystem, um das militärisch finanzierte Personal für das Militär bereitzustellen. ^{[ Zitat benötigt}

Veterans Health Administration betreibt VA-Krankenhäuser, die nur für Veteranen geöffnet sind, obwohl Veteranen, die medizinische Versorgung in Anspruch nehmen, die sie während des Militärdienstes nicht erhalten haben, für Dienstleistungen in Rechnung gestellt werden. Der indische Gesundheitsdienst (IHS) betreibt Einrichtungen, die nur von amerikanischen Ureinwohnern anerkannter Stämme geöffnet sind. Diese Einrichtungen sowie die von IHS finanzierten Stammeseinrichtungen und privat beauftragten Dienstleistungen zur Erhöhung der Systemkapazität und -kapazitäten bieten den Angehörigen eine medizinische Versorgung, die über das hinausgeht, was durch private Versicherungen oder andere staatliche Programme bezahlt werden kann.

Krankenhäuser bieten ambulante Behandlungen in Notaufnahmen und Spezialkliniken an, dienen aber hauptsächlich der stationären Versorgung. Krankenhausnotfallabteilungen und Dringlichkeitszentren sind Quellen für sporadisch problemorientierte Pflege. Operationszentren sind Beispiele für Spezialkliniken. Hospizdienste für todkranke Menschen, von denen erwartet wird, dass sie sechs Monate oder weniger leben, werden in der Regel von Wohltätigkeitsorganisationen und der Regierung subventioniert. Pränatale, familiäre Planung und Dysplasie-Kliniken sind staatlich finanzierte geburtshilfliche und gynäkologische Spezialkliniken und werden in der Regel von Krankenpflegern besetzt , kann auch über Telemedizin von Anbietern wie Teladoc aus der Ferne geliefert werden.

Neben staatlichen und privaten Gesundheitseinrichtungen gibt es in den Vereinigten Staaten auch 355 registrierte kostenlose Kliniken, die begrenzte medizinische Leistungen anbieten. Sie gelten als Teil des sozialen Sicherheitsnetzes für Personen, denen die Krankenversicherung fehlt. Ihre Leistungen können von mehr Akutversorgung (d. H. Geschlechtskrankheiten, Verletzungen, Atemwegserkrankungen) bis hin zu Langzeitpflege (d. H. Zahnmedizin, Beratung) reichen. ^[54] Ein weiterer Bestandteil des Sicherheitsnetzes für die Gesundheitsfürsorge sind staatlich finanzierte Gemeindegesundheitszentren.

Ärzte (MD und DO) [ edit ]

Zu den Ärzten in den USA zählen Ärzte, die vom US-amerikanischen medizinischen Ausbildungssystem ausgebildet wurden, und solche, die internationale medizinische Absolventen durchlaufen haben notwendige Schritte, um eine ärztliche Zulassung zu erwerben, um in einem Staat zu praktizieren. ^{Zitat erforderlich ]} Dies beinhaltet das Durchlaufen der drei Schritte der Medical Licensing Examination (USMLE). Der erste Schritt der USMLE prüft, ob die Medizinstudenten nach dem zweiten medizinischen Jahr die grundlegenden wissenschaftlichen Grundlagen für die Medizin verstehen und auch anwenden können. Die Themen umfassen: Anatomie, Biochemie, Mikrobiologie, Pathologie, Pharmakologie, Physiologie, Verhaltenswissenschaften, Ernährung, Genetik und Altern. In Schritt 2 soll getestet werden, ob Medizinstudenten ihre medizinischen Fähigkeiten und Kenntnisse während des vierten Jahres des Medizinstudiums in der klinischen Praxis anwenden können. Der Schritt 3 wird nach dem ersten Jahr des Wohnsitzes durchgeführt. Es prüft, ob Studenten medizinisches Wissen auf die unbeaufsichtigte Praxis der Medizin anwenden können. ^{[55] unzuverlässige Quelle? ]}

Das American College of Physicians verwendet den Ausdruck als Arzt ]um alle Ärzte zu beschreiben, die ein professionelles Medizinstudium besitzen. In den USA hat die große Mehrheit der Ärzte einen Doktortitel in Doktor of Medicine (MD). ^[56] Diejenigen, die einen Doktortitel in Doktorat für Osteopathie (DO) erworben haben, erhalten eine ähnliche Ausbildung und absolvieren die gleichen MLE-Schritte wie MDs und dürfen dies auch Verwenden Sie den Titel "Arzt".

Medizinische Produkte, Forschung und Entwicklung [ edit ]

Wie in den meisten anderen Ländern wird die Herstellung und Herstellung von Arzneimitteln und medizinischen Geräten von privaten Unternehmen durchgeführt. Die Forschung und Entwicklung von Medizinprodukten und Pharmazeutika wird durch öffentliche und private Finanzierungsquellen unterstützt. Im Jahr 2003 beliefen sich die Ausgaben für Forschung und Entwicklung auf etwa 95 Milliarden US-Dollar, wobei 40 Milliarden US-Dollar aus öffentlichen Quellen und 55 Milliarden US-Dollar aus privaten Quellen stammten. ^[57][58] Diese Investitionen in die medizinische Forschung haben die Vereinigten Staaten, gemessen in den USA, zum Marktführer in der medizinischen Innovation gemacht Einnahmen oder die Zahl der neu eingeführten Medikamente und Geräte. ^[59][60] Die Forschungs- und Entwicklungsausgaben der Pharmaunternehmen in den USA beliefen sich 2016 auf rund 59 Milliarden Dollar. ^[61] Auf die USA entfielen 2006 drei Viertel des Jahres die weltweiten Einnahmen aus der Biotechnologie und 82% der weltweiten FuE-Ausgaben in der Biotechnologie. ^[59][60] Die hohen Kosten patentierter Arzneimittel in den USA haben nach Ansicht mehrerer internationaler Pharmakonzerne zu erheblichen Neuinvestitionen in solche Forschung und Entwicklung geführt. ^[59][60][62] auch als Obamacare oder ACA bekannt, wird die Industrie zwingen, Arzneimittel zu einem günstigeren Preis zu verkaufen. ^[63] Aufgrund dessen ist es möglich, b Es werden Kürzungen bei der Erforschung und Entwicklung der menschlichen Gesundheit und Medizin in Amerika vorgenommen. ^[63]

Beschäftigung von Gesundheitsdienstleistern in den Vereinigten Staaten [ edit

Eine große demografische Verschiebung in den Vereinigten Staaten Das "medizinische Boomer" wird unter Druck gesetzt, als "Babyboomer" das Rentenalter erreichen. ^[64] Der demographische Wandel zu einer älteren Bevölkerung wird voraussichtlich die medizinischen Ausgaben in Nordamerika um mindestens 5% erhöhen, ^[65] Regierung (durch Medicare und andere soziale Dienste), Versicherungsgesellschaften und individuelle Sparkonten werden es schwer haben, das Geld zu absorbieren. Die Ausgaben für Gesundheitsdienstleistungen für Menschen über 45 Jahre sind 8,3-mal so hoch wie die unter 45-Jährigen. ^[66] Schließlich steigt die Nachfrage nach Gesundheitsdienstleistungen der älteren Bevölkerung trotz der knappen Budgets und des Personalabbaus rasch an. Alle diese Faktoren üben einen Druck auf Löhne und Arbeitsbedingungen aus, ^[67] wobei die Mehrheit der Gesundheitsberufe zwischen 2009 und 2011 Gehaltskürzungen verzeichnete. ^[68]

Alternative medicine [ ]

Outside Im Standard des Gesundheitssystems suchen immer mehr Menschen nach alternativen Behandlungsmöglichkeiten. Diese Behandlungen werden als Therapien definiert, die im Allgemeinen weder in der medizinischen Fakultät angeboten noch in Krankenhäusern angeboten werden. Dazu gehören Kräuter, Massagen, Energieheilung, Homöopathie und vieles mehr. Eine nationale Umfrage ergab, dass der Einsatz von mindestens einer alternativen Therapie von 1990 bis 1997 von 33,8% auf 42,1% angestiegen ist. ^[69] Neueren Studien zufolge stimmten etwa 40% der Erwachsenen im Jahr 2007 einer Form der Komplementärmedizin und der Alternativmedizin zu im letzten Jahr. Ihre Gründe für die Suche nach diesen alternativen Ansätzen waren das Verbessern ihres Wohlbefindens, die Teilnahme an einer Transformationserfahrung, eine bessere Kontrolle über die eigene Gesundheit oder die Suche nach einem besseren Weg, um durch chronische Krankheiten verursachte Symptome zu lindern. Sie zielen darauf ab, nicht nur körperliche Krankheiten zu behandeln, sondern auch die zugrunde liegenden ernährungsphysiologischen, sozialen, emotionalen und spirituellen Ursachen zu behandeln. ^[70] Die meisten Benutzer zahlen für diese Leistungen aus eigener Tasche, da die meisten Dienstleistungen durch die Versicherung teilweise oder gar nicht abgedeckt werden. Die Gesamtkosten für das Taschengeld beliefen sich 1997 auf etwa 27,0 Milliarden US-Dollar. ^[69]

Ausgaben [ edit

U.S. Gesundheitskosten pro Kopf 2000–2011

US. Die Gesundheitskosten übersteigen die Kosten anderer Länder, bezogen auf die Größe der Wirtschaft oder das BIP.

Die USA geben einen höheren BIP-Anteil aus als vergleichbare Länder, was entweder durch höhere Preise für Dienstleistungen selbst, höhere Kosten zu erklären ist Verwalten Sie das System, oder nutzen Sie diese Dienste mehr oder kombinieren Sie diese Elemente. ^[71] Die Kosten für die Gesundheitsfürsorge, die weit über die Inflationsrate steigen, waren ein wichtiger Motor für die Gesundheitsreform in den Vereinigten Staaten. Ab 2016 gaben die USA 3,3 Billionen USD (17,9% des BIP) oder 10.438 USD pro Person aus. Zu den Hauptkategorien gehörten 32% für Krankenhausbehandlungen, 20% für Ärzte und klinische Dienste und 10% für verschreibungspflichtige Arzneimittel. ^[72] Im Vergleich dazu gab das Vereinigte Königreich 3.749 USD pro Person aus. ^[73]

In 2018 kam eine Analyse zu dem Schluss, dass Preise und Verwaltungskosten im Wesentlichen die Ursache für die hohen Kosten waren, einschließlich der Preise für Arbeitskräfte, Arzneimittel und Diagnostika. ^[74] Die Kombination von hohen Preisen und hohem Volumen kann besondere Kosten verursachen. In den USA umfassen High-Margin-Verfahren mit hohem Volumen Angioplastien, Kaiserschnitte, Kniegelenksersatz sowie CT- und MRI-Scans. ^[75]

Die gesamten US-Krankenhauskosten beliefen sich 2011 auf 387,3 Milliarden US-Dollar - a Anstieg um 63% seit 1997 (inflationsbereinigt). Die Kosten pro Aufenthalt stiegen seit 1997 um 47% und betrugen im Jahr 2011 durchschnittlich 10.000 USD. ^[17] Ab 2008 machten die öffentlichen Ausgaben zwischen 45% und 56% der US-Gesundheitsausgaben aus. ^[76] Chirurgische Versorgung, Verletzung, mütterliche und neonatale Krankenhäuser Die Besuchskosten stiegen von 2003 bis 2011 um mehr als 2% pro Jahr. Während die durchschnittlichen Krankenhausentlassungen stabil blieben, stiegen die Krankenhauskosten von 9.100 US-Dollar im Jahr 2003 auf 10.600 US-Dollar im Jahr 2011 und waren bis 2013 voraussichtlich 11.000 US-Dollar. ^[77]

Laut der Weltgesundheitsorganisation (WHO) ), die Gesamtausgaben für das Gesundheitswesen in den USA betrugen im Jahr 2011 18% des BIP und waren damit die höchsten der Welt. ^[78] Die Abteilung für Gesundheits- und Sozialdienste erwartet, dass der Gesundheitsanteil des BIP seinen historischen Aufwärtstrend fortsetzt und 19% erreicht. des US-BIP bis 2017. ^[79][80] Von jedem Dollar, der in den USA für die Gesundheitsfürsorge ausgegeben wird, gehen 31% in Krankenhäuser, 21% in ärztliche Dienste / klinische Dienste, 10% in Arzneimittel, 4% in der Zahnheilkunde und 6% in der Krankenpflege Haushalte und 3% für die häusliche Pflege, 3% für andere Einzelhandelsprodukte, 3% für öffentliche Gesundheitsaktivitäten, 7% für Verwaltungskosten, 7% für Investitionen und 6% für sonstige professionelle Dienstleistungen (Physiotherapeuten, Optometriker usw.) ^[81]

Verwaltung der Gesundheitsfürsorge consti 30 Prozent der Gesundheitskosten in den USA. ^[82]

Befürworter des freien Marktes behaupten, dass das Gesundheitssystem "dysfunktional" sei, weil das System der Zahlungen von Dritten von den Versicherern als entlassen werde ein wichtiger Teilnehmer an den finanziellen und medizinischen Entscheidungen, die die Kosten beeinflussen. Das Cato Institute behauptet, dass das Problem durch die staatliche Intervention durch Programme wie Medicare und Medicaid verstärkt wurde. ^[83] Laut einer Studie, die von Amerikas Krankenversicherungsplänen (einem Washingtoner Lobbyisten für die Krankenversicherungsindustrie) bezahlt wurde. Die von PriceWaterhouseCoopers durchgeführte Steigerung der Inanspruchnahme ist die Hauptursache für die steigenden Gesundheitskosten in den USA. ^[84] Die Studie nennt zahlreiche Ursachen für eine verstärkte Nutzung, darunter steigende Konsumnachfrage, neue Behandlungen, intensivere Diagnosetests, Lebensstilfaktoren und Bewegung auf breitere Zugangspläne und höherpreisige Technologien. ^[84] In der Studie wird auch die Verlagerung von Kosten von staatlichen Programmen auf private Zahler erwähnt. Niedrige Erstattungssätze für Medicare und Medicaid haben den Druck auf die Kosten für Krankenhäuser und Ärzte erhöht, die für die gleichen Leistungen höhere Kosten für Privatpersonen zahlen, was letztendlich die Krankenversicherungssätze beeinflusst. ^[85] Im März 2010 veröffentlichte Massachusetts einen Bericht über die Kostentreiber, die es als "einzigartig in der Nation" bezeichnete. ^[86] Der Bericht stellte fest, dass Anbieter und Versicherer privat verhandeln und daher die Preise zwischen Anbietern und Versicherern für dieselben Dienstleistungen variieren können Es stellte fest, dass die Preisschwankungen sich nicht nach der Qualität der Pflege, sondern nach der Hebelwirkung des Marktes unterschieden. Der Bericht stellte auch fest, dass Preiserhöhungen anstelle von zunehmender Nutzung die Ausgabenerhöhungen in den letzten Jahren erklären. ^[86]

Regulierung und Aufsicht [ edit ]

Beteiligte Organisationen und Institutionen edit ]

Das Gesundheitswesen unterliegt einer umfassenden Regulierung auf Bundes- und Länderebene, von denen viele "zufällig" entstanden. ^[87] Im Rahmen dieses Systems tritt die Bundesregierung im Rahmen des McCarran-Ferguson Acts die Hauptverantwortung an die Staaten ab. Zu den wesentlichen Vorschriften gehören die Zulassung von Gesundheitsdienstleistern auf staatlicher Ebene sowie die Prüfung und Zulassung von Arzneimitteln und medizinischen Geräten durch die US-amerikanische Food and Drug Administration (FDA) sowie Labortests. Diese Vorschriften sollen die Verbraucher vor ineffektiver oder betrügerischer Gesundheitsversorgung schützen. Darüber hinaus regulieren Staaten den Krankenversicherungsmarkt, und sie haben oft Gesetze, nach denen die Krankenversicherungen bestimmte Verfahren abdecken müssen ^[88] obwohl staatliche Mandate im Allgemeinen nicht für die von Groß angebotenen selbstfinanzierten Krankenversicherungspläne gelten Arbeitgeber, die nach dem Vorkaufsrecht des Employee Retirement Income Security Act von staatlichen Gesetzen befreit sind.

Im Jahr 2010 wurde das Gesetz über Patientenschutz und erschwingliche Gesundheitsfürsorge (PPACA) von Präsident Barack Obama unterzeichnet und enthält verschiedene neue Bestimmungen. Eine der wichtigsten ist ein Krankenversicherungsauftrag, bei dem alle Bürger eine Krankenversicherung abschließen müssen. Obwohl dies keine Regulierung an sich ist, hat die Bundesregierung auch einen erheblichen Einfluss auf den Gesundheitsmarkt, da sie Zahlungen an Medicare und Medicaid anbietet, die in einigen Fällen als Bezugspunkt für die Verhandlungen zwischen Ärzten und Versicherungen herangezogen werden. ^[87]

Auf Bundesebene beaufsichtigt das US-Ministerium für Gesundheit und menschliche Dienste die verschiedenen Bundesbehörden, die im Gesundheitswesen tätig sind. Die Gesundheitsbehörden sind Teil des US-amerikanischen Gesundheitsdienstes und umfassen die Food and Drug Administration, die die Sicherheit von Lebensmitteln, die Wirksamkeit von Medikamenten und medizinischen Produkten bescheinigt, und die Centers for Disease Prevention, die Krankheiten, vorzeitigen Tod und Behinderung verhindert , die Behörde für Forschung und Qualität im Gesundheitswesen, das Register für toxische Substanzen und Krankheiten, das gefährliche Freisetzungen toxischer Substanzen regelt, und die National Institutes of Health, die medizinische Forschung betreiben. ^{[ erforderliche Zitat ]}

State governments maintain state health departments, and local governments (counties and municipalities) often have their own health departments, usually branches of the state health department. Regulations of a state board may have executive and police strength to enforce state health laws. In some states, all members of state boards must be health care professionals. Members of state boards may be assigned by the governor or elected by the state committee. Members of local boards may be elected by the mayor council. The McCarran–Ferguson Act, which cedes regulation to the states, does not itself regulate insurance, nor does it mandate that states regulate insurance. "Acts of Congress" that do not expressly purport to regulate the "business of insurance" will not preempt state laws or regulations that regulate the "business of insurance." The Act also provides that federal anti-trust laws will not apply to the "business of insurance" as long as the state regulates in that area, but federal anti-trust laws will apply in cases of boycott, coercion, and intimidation. By contrast, most other federal laws will not apply to insurance whether the states regulate in that area or not.^{[citation needed]}

Self-policing of providers by providers is a major part of oversight. Many health care organizations also voluntarily submit to inspection and certification by the Joint Commission on Accreditation of Hospital Organizations, JCAHO. Providers also undergo testing to obtain board certification attesting to their skills. A report issued by Public Citizen in April 2008 found that, for the third year in a row, the number of serious disciplinary actions against physicians by state medical boards declined from 2006 to 2007, and called for more oversight of the boards.^[89]

The federal Centers for Medicare and Medicaid Services (CMS) publishes an on-line searchable database of performance data on nursing homes.^[90]

In 2004, libertarian think tank Cato Institute published a study which concluded that regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion.^[91] The study concluded that the majority of the cost differential arises from medical malpractice, FDA regulations, and facilities regulations.^[91]

"Certificates of need" for hospitals[edit]

In 1978, the federal government required that all states implement Certificate of Need (CON) programs for cardiac care, meaning that hospitals had to apply and receive certificates prior to implementing the program; the intent was to reduce cost by reducing duplicate investments in facilities.^[92] It has been observed that these certificates could be used to increase costs through weakened competition.^[87] Many states removed the CON programs after the federal requirement expired in 1986, but some states still have these programs.^[92] Empirical research looking at the costs in areas where these programs have been discontinued have not found a clear effect on costs, and the CON programs could decrease costs because of reduced facility construction or increase costs due to reduced competition.^[92]

Licensing of providers[edit]

The American Medical Association (AMA) has lobbied the government to highly limit physician education since 1910, currently at 100,000 doctors per year,^[93] which has led to a shortage of doctors.^[94]

An even bigger problem may be that the doctors are paid for procedures instead of results.^[95]

The AMA has also aggressively lobbied for many restrictions that require doctors to carry out operations that might be carried out by cheaper workforce. For example, in 1995, 36 states banned or restricted midwifery even though it delivers equally safe care to that by doctors.^[96] The regulation lobbied by the AMA has decreased the amount and quality of health care, according to the consensus of economist: the restrictions do not add to quality, they decrease the supply of care.^[93] Moreover, psychologists, nurses and pharmacists are not allowed to prescribe medicines.^{[clarification needed]} Previously nurses were not even allowed to vaccinate the patients without direct supervision by doctors.

36 states require that health care workers undergo criminal background checks.^[97]

Emergency Medical Treatment and Active Labor Act (EMTALA)[edit]

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.^[98] 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.^[99]

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[edit]

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."^[100] Private companies such as Grand Rounds also release quality information and offer services to employers and plans to map quality within their networks.^[101]

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 behaviour or improves care."^{[102][needs update]}

Overall system effectiveness[edit]

Measures of effectiveness[edit]

The US health care delivery system unevenly provides medical care of varying quality to its population.^[103] 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,^[104] the Government Performance and Results Act, Healthy People 2020, and the National Strategies for Quality and Prevention.^[105][106]

Waiting times[edit]

Waiting times in American health care are usually short, but are not usually 0 for non-urgent care at least. Also, a minority of American patients wait longer than is perceived. In a 2010 Commonwealth Fund survey, most Americans self-reported waiting less than four weeks for their most recent specialist appointment and less than one month for elective surgery. However, about 30% of patients reported waiting longer than one month for elective surgery, and about 20% longer than four weeks for their most recent specialist appointment.^[107] These percentages were smaller than in France, the U.K., New Zealand and Canada, but not better than Germany and Switzerland (although waits shorter than four weeks/one month may not be equally long across these three countries). The number of respondents may not be enough to be fully representative. In a study in 1994 comparing Ontario to three regions of the U.S., self-reported mean wait times to see an orthopedic surgeon were two weeks in those parts of the U.S., and four weeks in Canada. Mean waits for the knee or hip surgery were self-reported as three weeks in those parts of the U.S. and eight weeks in Ontario.^{[citation needed]} However, current waits in both countries' regions may have changed since then (certainly in Canada waiting times went up later).^{[citation needed]}

It is unclear how many of the American patients waiting longer have to. Some may be by choice, because they wish to go to a well-known specialist or clinic that many people wish to attend, and are willing to wait to do so. Waiting times may also vary by region. One experiment reported that uninsured patients experienced longer waits;^{[citation needed]} patients with poor insurance coverage probably face a disproportionate number of long waits.

American health care tends to rely on rationing by exclusion (uninsured and underinsured), out-of-pocket costs for the insured, fixed payments per case to hospitals (resulting in very short stays), and contracts that manage demand instead.^{[citation needed]}

Population health: quality, prevention, vulnerable populations[edit]

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.^[108]


• The underutilization of preventative measures, rates of preventable illness and prevalence of chronic disease suggest that the US healthcare system does not sufficiently promote wellness.^[105] Over the past decade rates of teen pregnancy and low birth rates have come down significantly, but not disappeared.^[109] Rates of obesity, heart disease (high blood pressure, controlled high cholesterol), and type 2 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."^[110]


• 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.^[111] Minorities are more likely to suffer from serious illnesses (e.g., type 2 diabetes, heart disease and colon cancer) and less likely to have access to quality health care, including preventative services.^[112] Efforts are underway to close the gap and to provide a more equitable system of care.

Innovation: workforce, healthcare IT, R&D[edit]

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.^[113]

Compared to other countries[edit]

Life expectancy compared to healthcare spending from 1970 to 2008, in the US and the next 19 most wealthy countries by total GDP.^[114]

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 Organisation for Economic Co-operation and Development.^[115][116]

As of 2017, the U.S. stands 43rd in the world with a life expectancy of 80.00 years.^[117] The CIA World Factbook ranked the United States 170th worst (out of 225) – meaning 55th best – in the world for infant mortality rate (5.80/1,000 live births).^[118] Americans also undergo cancer screenings at significantly higher rates than people in other developed countries, and access MRI and CT scans at the highest rate of any OECD nation.^[119]

A study found that between 1997 and 2003, preventable deaths declined more slowly in the United States than in 18 other industrialized nations.^[120] 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.^[121]

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).

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.^[122] 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.^[123] 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.^[124] 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.^[125]

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).^[126][127] 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.^[128] The WHO study has been criticized, in an article published in Health Affairsfor its failure to include the satisfaction ratings of the general public.^[129] The study found that there was little correlation between the WHO rankings for health systems and the stated satisfaction of citizens using those systems.^[129] 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.^[129] 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.^[130] Furthermore, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes is complex and not well defined.^[131]

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.^[132][133]

In a sample of 13 developed countries the US 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.^[134]

System efficiency and equity[edit]

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.^[135] 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.^[136]

Lean manufacturing techniques such as value stream mapping can help identify and subsequently mitigate waste associated with costs of healthcare.^[137] Other product engineering tools such as FMEA and Fish Bone Diagrams have been used to improve efficiencies in healthcare delivery.^[138]

Efficiency[edit]

Preventable deaths[edit]

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.^[9]

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.^[9]

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 Healthlack of health coverage is associated with nearly 45,000 excess preventable deaths annually.^[139][140] Since then, as the number of uninsured has risen from about 46 million in 2009 to 49 million in 2012, the number of preventable deaths due to lack of insurance has grown to about 48,000 per year.^[141] 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.^[142]

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.^[143]

Value for money[edit]

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 Organisation 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.^[144] 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.^[114]

Delays in seeking care and increased use of emergency care[edit]

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.^[145] 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.^[146]

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.^[147]

Variations in provider practices[edit]

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 overutilization occurs with other health care services. Unnecessary treatments increase costs and can cause patients unnecessary anxiety.^[148] The use of prescription drugs varies significantly by geographic region.^[149] 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 they perceive it to be 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 US will also rise with these procedures as well. More expensive procedures lead to greater costs.^[150][151]

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.^[152][153]

Care coordination[edit]

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.^[154]

According to an article in The New York Timesthe relationship between doctors and patients is deteriorating.^[155] 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.^[155]

Many primary care physicians no longer see their patients while they are in the hospital; instead, hospitalists are used.^[156] The use of hospitalists is sometimes mandated by health insurance companies as a cost-saving measure which is resented by some primary care physicians.^[157]

Administrative costs[edit]

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.^[158] The trade association America's Health Insurance Plans, has some 1,300 members. 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.^[159]

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.^[160]

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.^[161] For the period 1998 through 2003, average insurer administrative costs declined from 13% to 12% 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.^[162] 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).^[163]

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.^[164] A 2009 study published by BCBSA found that the average administrative expense cost for all commercial health insurance products was represented 9.2% of premiums in 2008.^[165] Administrative costs were 11.1% of premiums for small group products and 16.4% in the individual market.^[165]

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.^[166]

Third-party payment problem and consumer-driven insurance[edit]

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.^[87] The lack of price information on medical services can also distort incentives.^[87] 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.^[87] 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.^[167] 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.

Equity[edit]

Coverage[edit]

U.S. health insurance coverage by source in 2016. CBO estimated ACA/Obamacare was responsible for 23 million persons covered via exchanges and Medicaid expansion.^[168]

Enrollment rules in private and governmental programs result in millions of Americans going without health care coverage, including children. A 2016 breakdown of the uninsured revealed that many did not enroll into programs, with 46% citing high costs as a barrier.^[169]

Medicaid, which is available for those under certain income levels, does not guarantee access as physicians may elect to not accept Medicaid patients due to slow reimbursement, complex regulations, too much paperwork, and the necessity for extra staff to process the excess paperwork.^[170]

The lack of coverage results in death due to lack of needed care^[171]

Mental health[edit]

Mental illness affects one out of six adults in the United States. That is about 44.7 million people, as of 2016.^[172] In 2006, mental disorders were ranked one of the top five most costly medical conditions, which expenditures of $57.5 billion.^[173] 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.^[174] 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.^[175]

The Paul Wellstone 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.^[176][177]

Medical underwriting and the uninsurable[edit]

Prior to the Patient Protection and Affordable Care Act, medical underwriting was common, but after the law came into effect in 2014 it became effectively prohibited.^[178]

Demographic differences[edit]

Health disparities are well documented in the U.S. in ethnic minorities such as African Americans, Native Americans, and Hispanics.^[179] 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.^[180] In addition, adult African Americans and Hispanics have approximately twice the risk as whites of developing diabetes and have higher overall obesity rates.^[181] Minorities also have higher rates of cardiovascular disease and HIV/AIDS than whites.^[180] In the U.S., Asian Americans live the longest (87.1 years), followed by Latinos (83.3 years), whites (78.9 years), Native Americans (76.9 years), and African Americans (75.4 years).^[182] A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.^[183]

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).^[76] Seniors comprise 13% of the population but take 1/3 of all prescription drugs. The average senior fills 38 prescriptions annually.^[184] 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.^[185]

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.^[186] According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care.^[187] 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.^[188] Nancy Krieger wrote that racism underlies unexplained inequities in health care, including treatment for heart disease,^[189] renal failure,^[190] bladder cancer,^[191] and pneumonia.^[192]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.^[193] One recent study has found that when minority and white patients use the same hospital, they are given the same standard of care.^[194][195]

Prescription drug issues[edit]

Drug efficiency and safety[edit]

The Food and Drug Administration (FDA)^[196] 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.^[197]

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."^[198] 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.^[199][200]

Prescription drug prices[edit]

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, although expenditures on pharmaceuticals accounts for a smaller share (13%) of total health care costs compared to an OECD average of 18% (2003 figures).^[201] Some 25% of out-of-pocket spending by individuals is for prescription drugs.^[202]

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).^[203] 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.^[204]

Impact of drug companies[edit]

The U.S., along with New Zealand, make up the only countries in the world that allows direct-to-consumer advertising of prescription drugs. In 2015, the American Medical Association called for the banning of direct-to-consumer advertising because it is linked with increased drug prices.^[205] Still, other evidence cites that there are some benefits to direct-to-consumer advertising, such as encouraging patients to see the doctor, diagnosis of rare diseases, and the removal of stigma associated with the disease.^[206]

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.^[207]

Healthcare reform debate[edit]

In 2008, prior to the major healthcare reform in 2010, Americans were divided in their views of the U.S. health system; 45% said that the U.S. system was best and 39% said that other countries' systems are better.^[208][209]

Much of the historical debate around healthcare reform centered around single-payer health care, and particularly pointing to the hidden costs of treating the uninsured^[210] while free-market advocates point to freedom of choice in purchasing health insurance^{[211][212][213]} and unintended consequences of government intervention, citing the Health Maintenance Organization Act of 1973.^[214] Ultimately, a single-payer health care, sometimes called "socialized medicine",^[215][216] was not adopted in the final Patient Protection and Affordable Care Act.

Patient Protection and Affordable Care Act (2010)[edit]

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. The law includes a large number of health-related provisions, most of which took effect in 2014, including expanding Medicaid eligibility for people making up to 133% of FPL,^[217] subsidizing insurance premiums for individuals and families making up to 400% of FPL and capping expenses from 2% to 9.8% of annual income.^[218][219] For the first time, all health policies sold in the United States must cap an individual's (or family's) medical expenses out of pocket annually.^[220] Other provisions include 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;^[221] 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).^[222] 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.^[223] However, two months later, the office subsequently acknowledged that there was an additional $115 billion in funds needed that were not originally included in the estimate. Additionally, the CBO estimated that although projected premiums in 2016 would be lower by $100 per person for small and large business health insurance plans with the Affordable Care Act than without, individual plans would be higher by $1,900 with the bill.^[224]

The first open enrollment period of the Affordable Care Act began in October 2013. Prior to this period, access to healthcare and insurance coverage trends were worsening on a national level. A large, national survey of American adults found that after the act's first two enrollment periods, self-reported coverage, health, and access to care improved significantly. Furthermore, insurance coverage for low-income adults were significantly greater in states that expanded Medicaid in comparison with states that did not expand Medicaid.^[225] However, discrepancies do exist between those covered by Medicaid versus those covered by private insurance. Those insured by Medicaid tend to report fair or poor health, as opposed to excellent or very good health.^[226]

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. After reviewing the costs and procedures for implementing such a program, the state decided against such a measure in late 2014.^[227]

On December 22, 2017 the Tax Cuts and Jobs Act of 2017 was signed into law by President Donald Trump. Inside the final version of the bill was a repeal of the individual mandate in the Affordable Care Act, which required individuals and companies to get healthcare for themselves and their employees. It was this mandate which kept healthcare costs down under the PPACA by promoting cost sharing over a larger pool. Economists believe the repeal of the individual mandate will lead to higher premiums and lower enrollment in the current market though they do not agree with how much.^[228] In 2017 the new Republican healthcare bill known as the American Health Care Act was passed by the House of Representatives under President Donald Trump. Although the Affordable Care Act and the American Health Care Act both propose tax cuts in order to make insurance more affordable for Americans; however, each of these bills affected Americans in different ways. The people most affected by President Trump's plan are young people, individuals of a higher socioeconomic status, and people who live in urban areas. Young people because individuals between the age of 20 and 30 will see drops in the premiums they pay within their plans. Individuals with higher socioeconomic status because whereas under Obamacare individuals could only make up to $50,000 dollars annually and still receive tax breaks, now under Trump's plan that number has been increase so that individuals who make up to $115,000 annually can receive tax breaks. In addition, those in urban areas can also benefit from the plan because under Obamacare tax credits were designated also by the cost of local healthcare, but the American Health Care Act does not take this into consideration although rural healthcare is generally more expensive due to the lack of hospitals and available services.^[229]

Health insurance coverage for immigrants[edit]

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 noncitizens, who are 43.6% uninsured. In each age and income group, immigrants are less likely to have health insurance.^[230] With the recent healthcare changes, many legal immigrants with various immigration statuses now are able qualify for affordable health insurance.^[231]

Undocumented immigrants within the United States do not have access to government funded health insurance. Although The Affordable Care Act allows immigrants to receive insurance at a discounted rate, the same does not go for those without US citizenship.^[232] Undocumented immigrants in the US can seek medical help from community centers, or what is termed Safety Net Providers, and participate in fee for service medical assistance, but can only buy health insurance from privatized health insurers.^[233]

See also[edit]

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Further reading[edit]

• Burnham, John C. Health Care in America: A history (2015), A standard comprehensive scholarly history excerpt


• Byrd, W. Michael, and Linda A. Clayton. An American health dilemma: A medical history of African Americans and the problem of race: Beginnings to 1900 (Routledge, 2012).


• Christensen, Clayton Hwang MD, Jason, Grossman MD, Jerome, The Innovator's PrescriptionMcGraw Hill, 2009. ISBN 978-0-07-159208-6


• Deutsch, Albert. The mentally ill in America: A History of their care and treatment from colonial times (1937).


• Johnston, Robert D., ed. The politics of healing: histories of alternative medicine in twentieth-century North America (Routledge, 2004).


• Judd, Deborah, and Kathleen Sitzman. A history of American nursing (2nd ed. Jones & Bartlett Publishers, 2013).


• Leavitt, Judith Walzer, and Ronald L. Numbers, eds. Sickness and health in America: Readings in the history of medicine and public health 3rd ed. 1997). Essays by experts.


• Mahar, Maggie, Money-Driven Medicine: The Real Reason Health Care Costs So MuchHarper/Collins, 2006. ISBN 978-0-06-076533-0


• Risse, Guenter B., Ronald L. Numbers, and Judith Walzer Leavitt, eds. Medicine without doctors: Home health care in American history (Science History Publications/USA, 1977).


• Starr, Paul, The Social Transformation of American MedicineBasic Books, 1982. ISBN 0-465-07934-2


• Warner, John Harley Warner and Janet A. Tighe, eds. Major Problems in the History of American Medicine and Public Health (2001) 560pp; Primary and secondary sources

Historiography

• Burnham, John C. What Is Medical History? (2005) 163 pp. excerpt


• Numbers, Ronald L. "The History of American Medicine: A Field in Ferment" Reviews in American History 10#4 (1982) 245–63 in JSTOR

External links[edit]