Essentials_of_the_U._S._Health_Care_System_----__Chapter_1_Major_Characteristics_of_U.S._Health_Care_Delivery_-2

Introduction to the U.S. Health Care Delivery System

• The U.S. health care delivery system is unique, contrasting with other developed countries that provide universal health insurance programs.

• The Affordable Care Act (ACA) expanded health insurance but did not achieve universal coverage.

• Major challenges include inadequacies in access to affordable health care and complex coordination of various health care components.

Overview of Health Care Delivery

• The U.S. system features nearly 12.3 million employees in diverse health roles including:

  • Doctors (MDs, DOs)

  • Nurses

  • Pharmacists

  • Therapists

• Facilities involved:

  • 5,627 hospitals

  • 15,656 nursing homes

  • 2,806 inpatient mental health facilities

  • 12,400 home health agencies and hospices

Insurance Coverage

• Approximately 176.6 million Americans under 65 have private health insurance; most via employers.

• Medicare and Medicaid cover about 110.7 million people:

  • Medicare: Federal program

  • Medicaid: Joint federal-state program.

• There are around 1,000 private insurance companies and approximately 470 HMOs and 934 PPOs in the private market.

Subsystems of Health Care Delivery

• Multiple subsystems exist to meet diverse population health needs through:

  • Market forces

  • Government interventions.

Managed Care

• Dominant health care delivery model in the U.S. that covers most Americans.

• Features contractual agreements between Managed Care Organizations (MCOs) and health care providers.

• The MCOs pay providers through:

  • Capitation (fixed per enrollee payment)

  • Discounted fee arrangements.

• Emphasizes efficiency and controls costs associated with medical services.

Military Medical Care

• Available largely at no cost to active-duty military and certain non-military personnel.

• Comprehensive services provided through military hospitals and TriCare for families and dependents.

• The Veterans Administration (VA) offers extensive health services to veterans, focusing on hospital, mental health, and long-term care.

Special Populations and Safety Nets

• Vulnerable populations typically rely on public insurance programs (Medicare, Medicaid) and safety net systems (community health centers, emergency services).

• Federally qualified health centers provide primary and preventive care to underserved populations.

• In 2016, 1,367 community health organizations served 26 million people.

Medicare and Medicaid

• Medicare: Major program for the elderly and disabled offering hospital, nursing, and outpatient care.

• Medicaid: Covers low-income individuals, children, and disabled, expanded under the ACA.

• Children’s Health Insurance Program (CHIP): Established to provide insurance for uninsured children.

Integrated Delivery Systems (IDS)

• Networks established in the early 2000s to provide coordinated health care services and focus on quality outcomes.

• An Accountable Care Organization (ACO) model that emphasizes integrated care under new Medicare incentives.

Long-Term Care Delivery

• Provides medical and non-medical services to individuals with chronic health issues:

  • Delivered in various settings: homes, assisted living, nursing homes.

  • Notably costly and often leads to family financial strain.

Public Health System

the needs of the population and emphasizes community health protection.

• Essential public health services include:

  1. Monitoring health status

  2. Investigating health hazards

  3. Educating the public on health issues.

• The ACA's Prevention and Public Health Fund aims to enhance community health support and improve health outcomes.

Health Care Reform

• Goals of health care reform include expanded coverage and access.

• The ACA extended Medicaid to low-income adults and subsidized insurance coverage.

• As of 2017, 33 states expanded Medicaid under ACA guidelines.

• The uninsured rate decreased from 41 million in 2013 to 27 million by 2016.

Characteristics of the U.S. Health Care System

• Distinctions between the U.S. system and other nations include:

  • No central governing agency

  • Technology-driven and acute care focused

  • High costs and unequal access.

• The delivery system operates under imperfect market conditions influenced by various economics, sector interests, and population needs.

Access to Health Care Services

• Access to care is influenced by insurance coverage, with many barriers still prevailing for the uninsured.

• Legal risks lead to defensive medicine practices that raise costs.

Comparison with Other Developed Countries

• Models in Canada, Germany, and the UK illustrate varied approaches:

  • Canada: Government-financed but privately offered services.

  • Germany: Employer-mandated contributions among a mixed private provider model.

  • UK: Government-managed infrastructure with tax-supported health services.

Systems Framework

• The healthcare delivery system consists of interrelated components intended to achieve common health care goals and improve health outcomes.

• Major components include:

  • System inputs (resources)

  • Structures

  • Processes

  • System outcomes (access, cost, quality).

Conclusion

• The U.S. health care system features various subsystems responding to specific population needs, ultimately lacking universal access and efficiency but offering extensive private sector engagement.