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