Chapter 4:
Overview of the Health Care System
Chapter Overview
- Chapter 4 is intended to provide a general understanding of how the health care system works in the United States as
- Chapter 4 focuses on:
- Health care finance
- Access to health care services
- Quality of care
- Comparative Health Systems
Health Care Finance
- 2009, US spent $2.5 trillion on health care services, representing 17.6% of GDP
- Health care spending estimated to reach 19.6% GDP by 2019
- Spending projected to grow by 9.2% in 2014 when many provisions of the Affordable Care Act (ACA) will be effective
Health Care Finance — Insurance
- An estimated 93% will be insured once the ACA is implemented
- 22 million insured in state health exchanges
- 16 million newly insured in Medicaid or CHIP
- Most people in US obtain insurance through their employer
- Health insurance acts as an intermediary between patients and providers
Health Care Finance — Direct Service
- Federal, state, and local governments fund programs that directly provide care to individuals
- FQHCs
- HIV/AIDS programs
- Family Planning programs
Health Care Access
- Access refers to ability to obtain needed services
- Key barriers to access
- Lack of health insurance
- Inadequate health insurance
- Insurance coverage limitations
- Workforce issues
Health Care Access – Uninsured and Underinsured
- Key characteristics
- Poor, low education, non-native, racial/ethnic minority, location, age
- Problems with being uninsured
- Less access to care, less timely care, less likely to follow treatment recommendations due to cost
- Underinsured do not have financial resources to cover the gap between what their insurance covers and their medical bills
- Safety net providers serve many uninsured and underinsured
Health Care Access – Insurance coverage limitations
- High cost-sharing
- Co-payments, deductibles, premiums
- Reimbursement and visit caps
- Service exclusions
Health Care Access – Workforce Issues
- Provider shortages
- Especially primary care and public health
- Problem will be exacerbated by influx of newly insured individuals under the ACA
- Uneven distribution of providers
- Significant problem in rural areas
- Several ACA provisions address these workforce issues
Health Care Quality
- US spends more per person on health care but often ranks poorly on preventive and primary care health care measures
- IOM focuses on six areas to improve quality
- Safety, efficacy, patient-centeredness, timeliness, efficiency, and equity
Comparative Health Systems
- Three common types of health care systems
- Publically financed, privately delivered national health care system (Canada)
- Publically financed and delivered national health systems (Britain)
- Socialized insurance system with mandatory contributions and private delivery (Germany)
Comparative Health Systems
- Type of health insurance design relates to key issues for patients
- Affordability
- Differences in access by income level
- Waiting lists/wait times
- Choice
- Complexity of interacting with insurance system/paperwork
- Patient satisfaction
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