AHAAP

***Summaries of the five following sections are in bold

​

Overview

​

           Essentially, every aspect of the American healthcare system is varied - coverage, physician hours and paychecks, healthcare services, institutions, and others - and we pay more for this varied system than other first-world countries do for a universal system. The healthcare model in the United States relies on a direct-fee system, where people in the US have private health insurance plans. In most cases, people can get health insurance through their employers, though Americans are required to pay out of the pocket for any medical costs that their insurance doesn’t cover. Many uninsured citizens are still able to access some form of healthcare, either through public clinics, government programs, charity, or other means, but it is infinitely more difficult and tenuous to get it, and many are unable to, as they can legally be turned away at the emergency room or other typical hospitals without insurance. 

​

           "The United States spends more on health care services than any other nation—on average, more than twice as much per person as other first world countries. There is no single nationwide system of health insurance or singular way of funding healthcare services.

           The United States primarily relies on employers to voluntarily provide health insurance coverage to their employees and dependents; all of the government programs are confined to the elderly, the disabled, and some of the poor. These private and public health insurance programs all differ with respect to benefits covered, sources of financing, and payments to medical care providers. There is little coordination between private and public programs: Some people have both public and private insurance while others have neither.

           Nevertheless, people without health insurance are not entirely without health care. Although they receive fewer and less coordinated services than those with insurance, many of these “uninsured” individuals receive at least some health care services through public clinics and hospitals, state and local health programs, or private providers who finance the care through charity and by shifting costs to other payers.

           Health services are provided by a loosely structured delivery system organized at the local level, meaning it is different from place to place. Hospitals can open or close according to community resources, preferences, and the dictates of an open market for hospital services. Also, physicians are free to establish their practice where they choose. There is no health planning at the Federal level, and State planning efforts vary from none to extensive review of all healthcare organizations.

           In areas without sufficient private providers (e.g., inner cities and remote rural areas), Federal-and State-funded programs provide some primary care to populations not otherwise served by the fee-for-service (FFS) system, which is where people pay or get paid for each individual service. Municipal and county public health departments provide limited primary care services through public health clinics and regulate sanitation, water supply, and environmental hazards. Most hospitals are owned by private non-profit institutions; the remainder are owned by governments or private for-profit corporations.

           Physicians, the vast majority of whom are in private practice and paid on an FFS basis, see their patients in their offices and admit them to hospitals where they can continue to serve them. About two-fifths of physicians are in solo practice. A relatively small number of physicians are not in the FFS sector but are employed by the government, corporations, managed care networks, or hospitals." 

 

A Layman’s Guide to the US Healthcare System

​

Private PLANs

​

           The majority of the population, those who are under 65, get their health insurance through a private plan, which is accessed through a work program or purchased individually in programs offered to the public. Through this, they also achieve healthcare for those under their care, such as children or other people in their families. Because it is not required for employers to offer a healthcare plan, coverage of these plans varies, with some people having both kinds and some having none. Each of the plans covers different operations and services, and the government has the legal ability to mandate that certain fields be offered in plans (like chiropractic services), but the majority of the time they don’t. All of these plans are offered by for-profit insurance companies, which make money off of people not needing extensive health insurance.

​

           "The vast majority of the population, about 74 percent, is covered by private health insurance. Those under 65 years of age and their dependents (ie. children or people under their guardian) obtain private health insurance either through their employers (61 percent of the population) or by direct purchase of non-group health insurance (13 percent of the population), which is individual. A small proportion of the population, 13 percent, has multiple health insurance coverages (e.g., both private and public health insurance), and 14 percent have no insurance. Not all firms offer health insurance. In fact, the majority of the uninsured (75 percent) are employees or their children or people under their guardians.

           There are more than 1,000 private health insurance companies providing health insurance policies with different benefit structures, premiums, and rules for paying the insured or medical care providers. These companies are regulated by state insurance commissioners; the Federal Government does not generally regulate insurance companies. States sometimes specify that certain, often narrowly defined, benefits or providers (e.g., chiropractic services) be covered by all health insurance policies sold in the State. States may also regulate insurance premium increases and other aspects of the insurance industry.

           In recent years, most large employers have opted to “self-insure,” or cover health expenses as they occur, rather than purchase insurance from a company, because this exempts them from State insurance regulation as detailed later. Although employer-provided health insurance is voluntary, it is encouraged by tax policy. The majority of those with private health insurance are covered for inpatient hospital services and physician services; the breadth and depth of coverage of other services vary. Industries with strong unions (e.g., steel, automobile) have the broadest benefit packages. On the other hand, service industries (e.g., restaurants) may provide little or no coverage.

           Home care is covered in most insurance plans after a hospitalization for an acute episode of illness in order to allow recovery in a less costly setting. Home care and long-term care for chronic conditions and frailty related to aging are not generally covered by public or private insurance. Most long-term care and home care are purchased out-of-pocket or provided informally by family and friends." 

 

A Layman’s Guide to the US Healthcare System

​

Medicare

​

           Medicare is the primary healthcare program for the elderly, or those 65 and above in years, and the disabled. It is the biggest individual program for healthcare in the country and is composed of Part A, which covers inpatient hospital care, very limited nursing home services, and some home health services and is paid for by a tax that is paid while a person is employed, and Part B, which covers physician and other ambulatory services, durable medical equipment (e.g., wheelchairs), and certain other services and is paid for by another price imposed while under coverage from Medicare. However, Medicare can’t cover all services, only about half for the average patient, and focuses on acute care rather than long-term care, which is paid for by other means, like supplemental insurance. 

​

           "Medicare is a uniform national health insurance program for the aged and disabled. Administered by the Federal Government, it is the single largest health insurer in the country, covering about 13 percent of the population, including virtually all the elderly 65 years of age or over (31 million people), and certain persons with disabilities or kidney failure (3 million people). The program is financed by a combination of payroll taxes, general Federal revenues, and premiums.

           It is comprised of two parts: Coverage under Part A is earned through payment of a payroll tax during one's working years; coverage under Part B is voluntarily obtained through payment of a premium once eligibility for Medicare is established (through receipt of retirement or disability benefits under the Social Security income assistance program). Coverage under Part A includes inpatient hospital care, very limited nursing home services, and some home health services. The Part A payroll tax is paid by virtually all employed individuals. Coverage under Part B includes physician and other ambulatory services, durable medical equipment (e.g., wheelchairs), and certain other services. It is funded through premiums (about 25 percent of the program cost), by enrollees, and by general Federal revenues (about 75 percent of the program cost).

           Medicare is oriented towards acute care, and such services as long-term nursing home care, routine eye care, and outpatient prescription drugs are not covered. Moreover, Medicare patients must also pay coinsurance and deductibles. Medicare covers less than one-half of the total medical care expenses of the elderly. To pay for Medicare coinsurance and deductibles and, in some cases, uncovered benefits, about 68 percent of Medicare beneficiaries have private supplemental health plans, provided by former employers or self-purchased, and an additional 9 percent have Medicaid."

 

A Layman’s Guide to the US Healthcare System 

​

Medicaid

​

           Medicaid is a government-funded program that covers certain groups of people who are poor, including mothers and dependent children (68 percent of Medicaid recipients), the elderly (13 percent), the blind and disabled (15 percent), and others (4 percent). States further define eligibility levels (e.g., maximum income and asset levels) within certain broad parameters. However, the remaining 60% of people who fall below the poverty line are exempt from Medicaid. Those who are a part of the program receive acute medical care as well as long-term and nursing home care, being the only public program that covers both.

​

           "Medicaid is a health insurance program for certain groups of the poor. It covers preventive, acute, and long-term care services for 25 million people or 10 percent of the population. Medicaid is jointly financed by Federal and State governments. Medicaid is administered by the States under broad Federal guidelines governing the scope of services, the level of payments to providers, and population groups eligible for coverage.

           In order to be eligible for Medicaid, a person must be poor as well as aged, blind, disabled, pregnant, or the parent of a dependent child. Mothers and dependent children comprise about 68 percent of Medicaid recipients, the elderly 13 percent, the blind and disabled 15 percent, and others 4 percent. States further define eligibility levels (e.g., maximum income and asset levels) within certain broad parameters.

           Consequently, about 60 percent of the poor below the Federal poverty line are excluded from Medicaid. Childless, non-disabled adults under 65 years of age, no matter how poor or how high their medical expenses, are not eligible, nor are individuals with assets above State-defined levels. On the other hand, because Medicaid is the only public program that finances long-term nursing home care, a significant number of middle-class elderly have become eligible for Medicaid-covered nursing home care by intentionally transferring assets to their children and exhausting their income on nursing home expenses."

​

A Layman’s Guide to the US Healthcare System

​

Uninsured

​

           The uninsured can receive healthcare from a variety of sources, often resulting in inadequate care. Many public health clinics and hospitals funded by federal, state, and local governments provide at least some level of care and preventative medical measures, such as vaccinations, cancer screening programs, and well-child care is additionally paid for by the government. These services are often available to all, although a fee that varies according to income may be charged.

​

           "The uninsured receive fewer health services than insured individuals with comparable health status. Services for the uninsured are provided through a variety of sources, the amount and scope of which vary by community. Federal, State, and local governments support public health clinics and hospitals with a primary mission of providing care to the indigent. In some cases, they pay private providers to care for the indigent as well. Public health expenditures support preventive health measures such as vaccinations, cancer screening programs, and well-child care. The services are often available to all, although a fee which varies according to income may be charged."

 

A Layman’s Guide to the US Healthcare System

​

Benefits

​

           If able to pay through having insurance, and there are a multiplicity of plan options, American citizens have access to some of the best medical equipment, procedures, physicians, medicines, supplies, and institutions with generally minimal wait times. Though this is all granted they can access the care, which is difficult in the current healthcare model with all the systemic complications.

​

           "If you have the money to pay for a premium health insurance package, you will have outstanding medical care whenever you have a health problem. Hospitals across the United States have modern equipment and highly qualified doctors. Physicians and surgeons have to go through rigorous specialty and sub-specialty training. This allows them to effectively treat even the rarest conditions. In the United States, you can also get the best mental health services in the world provided you can pay for them. Due to the high costs of medical care under the direct-fee system, hospitals can afford equipment that can help people battle various life-threatening illnesses.

           You won’t have to wait a long time to see a surgeon or specialist if you’re in the United States. In a study conducted by the Commonwealth Fund, it was concluded that 57% of Canadians wait more than 4 weeks to get an appointment with a specialist. In the US, only 23% wait longer than 4 weeks to see a specialist. Although the medical systems in these two countries often get compared, the truth is that it’s much easier to get an appointment or surgery in the United States. In the US, there is minimal wait time even for complex procedures.

           There are many different Medicare options available that you can choose based on your preferences or the lifestyle you lead. For instance, there are special Medicare Advantage plans for people who travel often or who want extra benefits like prescription drug coverage. If you enroll in a Medicare Advantage plan, your original coverage will continue being billed directly through Medicare. On the other hand, the advantage plan will be billed through your private insurance company.

           There are many countries across the globe where there are not enough medical supplies both for the workers and the patients. The United States has adequate resources to make sure that every patient with health insurance can get the treatment they need."

​

The Pros and Cons of the US Health Care Model

​

Faults

​

           "In summary, the healthcare system suffers from uneven care (Health consumers are receiving different levels of care determined not by a standardized level of quality but by their location, condition, or insurance plan. More rural areas may not have enough physicians, while urban areas may have more than needed), lack of insurance coverage (many health consumers can’t afford the high cost of primary care due to high insurance costs), physician off-time (Many disciplines only serve patients on weekdays during regular office hours, with no availability on nights and weekends), inflexibility (Physician assistants and nurse practitioners can deliver primary care with the same quality as physicians but at a lower cost, yet they are underutilized), limited access (Some health consumers may be turned away from practices that limit access if they have Medicare or Medicaid. These patients aren’t as profitable a venture for providers), and lack of efficiency (Compliance-related activities such as clinical documentation and electronic medical record administration limit a physician’s ability to offer more care)."

​

           "The biggest issue Americans have with the current healthcare model is that medical services are extremely expensive. In case you don’t have insurance or are underinsured, you’ll have to pay medical costs out of your pocket. People who don’t get insurance also have a very limited number of services they can get access to. It’s worrying that medical debt is the leading cause of bankruptcy in the United States. What a lot of Americans don’t realize is that the standard Medicare coverage isn’t enough to provide the treatment for certain treatments and procedures.

           The majority of Americans get health insurance through their employers. That means that in the event that they lose their job, they can lose their coverage. When someone doesn’t have a job, it can be impossible for them to continue paying for insurance. The fact that you could easily lose your healthcare insurance is why most Americans are now in favor of medical system reform.

           What nearly every medical service available in the US lacks is price transparency. People are not able to shop around and figure out what their most budget-friendly option is. Health care is what Americans spend most of their family budget on after housing. In order for the healthcare system in the United States to improve, there needs to be price transparency for medical costs. People simply don’t know what to expect when they go to a hospital because the same procedure (even if performed by the same physician) has a different price in each institution. Today, only 12% of the US population is opposed to price transparency in health care. Meanwhile, hospitals claim that the reason why prices are not transparent is that it allows them to offer discounts to insurance agencies. However, this doesn’t make a lot of sense since the goal of each hospital is to make as much money as possible.

           Physicians and surgeons are equipped to handle any type of injury or disease, but they hardly put any emphasis on preventive care. Although they can treat even rare medical conditions, they don’t offer quality follow-up services."

​

The Pros and Cons of the US Health Care Model

​

           "There are too many preventable medical errors. A recent study by Johns Hopkins analyzed medical death rate data for eight years and found that medical errors are to blame for more than 250,000 deaths per year in the U.S. This accounts for 10% of all U.S. deaths and makes it the third leading cause of death after heart disease and cancer.

           The U.S. ranked last on the Healthcare Access and Quality (HAQ) Index in amenable mortality among eight other comparable countries. Amenable mortality measures premature death that is preventable and treatable by effective and timely care. The HAQ index is a scale from 0 (worst) to 100 (best) and measures preventable mortality rates for 32 causes of death. A higher rating suggests fewer deaths due to a higher standard of care and access.

           Fraud and cover-ups are rampant in the U.S. healthcare system. A significant problem is upcoding which becomes a tug-of-war between providers and insurance providers, with policyholders stuck in the middle. Providers “upcode” a procedure to get more money from insurance companies, but insurance may charge higher premiums to employers, and tighten its belt when paying consumers. Health consumers get stuck in the middle without any control over health outcomes and pricing.

           With a lack of accessible information on doctor credentials and accomplishments, health consumers cannot easily find a good doctor. Consumers rely on uninformed online reviews that can help with assessing traits like staff friendliness and wait times. But, these platforms do not offer critical information such as information about health conditions consumers may be facing, the right doctors with skills treating those conditions, and how to assess a physician’s skill level in helping them with their health maladies.

           According to annual report data from the Health Cost Institute, average healthcare prices have increased year over year, with rates that were 15.0% higher in 2018 compared to 2014. In 2018, U.S. firms and consumers spent 10% of GDP on healthcare—and this number has risen over the years. The Centers for Medicare & Medicaid Services (CMS) Office of the Actuary predicts that national healthcare spending in the U.S. (avg. annual rate of 5.4%) is expected to outpace GDP growth (avg. yearly growth rate of 4.3%) until the year 2023. Spending reached $3.81 trillion in 2019 and is predicted to reach $6.19 trillion in 2028 and account for 19.7% of the GDP. The International Federation of Health Plans (IFHP) and member companies, in partnership with the Health Care Cost Institute (HCCI) in the United States, published the International Comparison of Health Prices Report. The report compares the median costs for health services in nine countries. Aside from two outliers (the cost of the drug Kalydeco in the UAE and cataract surgery in New Zealand), every drug and procedure surveyed costs substantially more in the U.S.

           Uninsured Americans face more health hardship than insured Americans. As reported by healthypeople.gov, a division of the Office of Disease Prevention and Health Promotion, the uninsured may not seek medical care due to high costs and may forgo preventive care and regular health screenings, negatively affecting health. Children are also less likely to access preventive services or receive care for treatable conditions like asthma.

           Preventable medical errors and hospital readmissions due to lack of quality care put consumers’ health at risk, but they also waste valuable time and resources, making healthcare inefficient. A 2017 international healthcare comparison report published by The Commonwealth Fund reported that the U.S. ranks 10th among 10 comparable countries in Administrative Efficiency. Doctors spend unnecessary time updating EHRs and coordinating with insurance companies due to coverage restrictions (each plan differs in coverage options), which wastes money and resources."

​

Major Problems with the US Healthcare System Today