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«United States of America Health system review Thomas Rice • Pauline Rosenau Lynn Y. Unruh • Andrew J. Barnes Richard B. Saltman • Ewout van ...»

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Health Systems in Transition

Vol. 15 No. 3 2013

United States of America

Health system review

Thomas Rice • Pauline Rosenau

Lynn Y. Unruh • Andrew J. Barnes

Richard B. Saltman • Ewout van Ginneken

(editors)

Richard B. Saltman and Ewout van Ginneken (Editors) and Reinhard Busse (Series editor)

were responsible for this HiT

Editorial Board

Series editors

Reinhard Busse, Berlin University of Technology, Germany

Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene & Tropical Medicine, United Kingdom Elias Mossialos, London School of Economics and Political Science, United Kingdom Sarah Thomson, European Observatory on Health Systems and Policies Ewout van Ginneken, Berlin University of Technology, Germany Series coordinator Gabriele Pastorino, European Observatory on Health Systems and Policies Editorial team Jonathan Cylus, European Observatory on Health Systems and Policies Cristina Hernández-Quevedo, European Observatory on Health Systems and Policies Marina Karanikolos, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Dimitra Panteli, Berlin University of Technology, Germany Wilm Quentin, Berlin University of Technology, Germany Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Anna Sagan, European Observatory on Health Systems and Policies International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Harvard University, United States Johan Calltorp, Nordic School of Public Health, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Allan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Soonman Kwon, Seoul National University, Republic of Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Ellen Nolte, Rand Corporation, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Federal Statutory Health Insurance Physicians Association, Germany Igor Sheiman, Higher School of Economics, Russian Federation Peter C. Smith, Imperial College, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland Health Systems in Transition Thomas Rice, Fielding School of Public Health, University of California, Los Angeles Pauline Rosenau, School of Public Health, Health Science Center, University of Texas, Houston Lynn Y. Unruh, Department of Health Management and Informatics at the University of Central Florida Andrew J. Barnes, Virginia Commonwealth University School of Medicine

Editors:

Richard B. Saltman, Emory University in Atlanta and European Observatory on Health Systems and Policies Ewout van Ginneken, Berlin University of Technology and European Observatory on Health Systems and Policies

–  –  –

The European Observatory on Health Systems and Policies is a partnership, hosted by the WHO Regional Office for Europe, which includes the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden, the United Kingdom and the Veneto Region of Italy; the European Commission; the European Investment Bank; the World Bank; UNCAM (French National Union of Health Insurance Funds); the London School of Economics and Political Science; and the London School of Hygiene & Tropical Medicine.

Keywords:

DELIVERY OF HEALTH CARE

EVALUATION STUDIES

FINANCING, HEALTH

HEALTH CARE REFORM

HEALTH SYSTEM PLANS – organization and administration

UNITED STATES OF AMERICA

–  –  –

Suggested citation:

Rice T, Rosenau P, Unruh LY, Barnes AJ, Saltman RB, van Ginneken E.

United States of America: Health system review. Health Systems in Transition, 2013; 15(3): 1– 431.

–  –  –

Preface

T he Health Systems in Transition (HiT) series consists of country-based reviews that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific country. Each review is produced by country experts in collaboration with the Observatory’s staff. In order to facilitate comparisons between countries, reviews are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a report.





HiTs seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building

blocks that can be used:

• to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems;

• to describe the institutional framework, the process, content and implementation of health-care reform programmes;

• to highlight challenges and areas that require more in-depth analysis;

• to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policymakers and analysts in different countries; and

• to assist other researchers in more in-depth comparative health policy analysis Compiling the reviews poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, vi Health systems in transition United States of America including the World Health Organization (WHO) Regional Office for Europe’s European Health for All database, data from national statistical offices, Eurostat, the Organisation for Economic Co-operation and Development (OECD) Health Data, data from the International Monetary Fund (IMF), the World Bank’s World Development Indicators and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate review.

A standardized review has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages, because it raises similar issues and questions. HiTs can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals.

Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to info@obs.euro.who.int.

HiTs and HiT summaries are available on the Observatory’s web site (http:// www.healthobservatory.eu).

Acknowledgements

Acknowledgements T he Health Systems in Transition (HiT) profile on the United States was written by Thomas Rice (University of California, Los Angeles), Pauline Rosenau (University of Texas), Lynn Unruh (University of Central Florida) and Andrew Barnes (Virginia Commonwealth University). It was edited by Ewout van Ginneken (Berlin University of Technology) and Richard Saltman (Emory University). The Research Director for this HiT was Reinhard Busse (Berlin University of Technology).

The European Observatory on Health Systems and Policies is grateful to Gerard Anderson (Johns Hopkins University), Lawrence D. Brown (Columbia University), Nick Fahy (Independent consultant and researcher), Jon Gabel (NORC at the University of Chicago), George Greenberg (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health – ASPE), Richard Kronick (ASPE), Jonathan Oberlander (University of North Carolina-Chapel Hill), Mark Peterson (University of California, Los Angeles), Marc Rodwin (Suffolk University Law School), Richard Scheffler (University of California, Berkeley), Katherine Swartz (Harvard University), and Leon Wyszewianski (University of Michigan) for reviewing all or part of the report. All opinions are those of the authors and do not reflect the views of the reviewers. The authors are also grateful to Beth Umland of Mercer for providing information on the scope of private insurance coverage for Chapter 3.

Thomas Rice thanks the Rockefeller Foundation for providing him with a residency at its Bellagio Center in Italy, during which he worked on Chapter 7 of the book. Pauline Rosenau thanks the University of Otago Medical School in New Zealand for setting time aside to work on the book during her William Evans Visiting Fellowship. Lynn Unruh thanks the University of Central Florida for providing a sabbatical to work on Chapters 4 and 5 of the book.

viii Health systems in transition United States of America Ewout van Ginneken thanks the Commonwealth Fund for allowing him to work on this HiT while on a Commonwealth Fund Harkness Fellowship in Health Care Policy and Practice at the Harvard School of Public Health.

The current series of HiT profiles has been prepared by the staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden, the United Kingdom and the Veneto Region of Italy, the European Commission, the European Investment Bank, the World Bank, UNCAM (French National Union of Health Insurance Funds), the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

The Observatory team working on the HiT profiles is led by Josep Figueras, Director, and Elias Mossialos, Co-Director, and heads of the Research Hubs Martin McKee, Reinhard Busse and Richard Saltman. The production and copy-editing process was coordinated by Jonathan North, with the support of Caroline White, Mary Allen (copy-editing), Steve Still (design and layout) and Sarah Cook (proofreading).

Special thanks are extended to the OECD Health Data from which international data on health and health services were extracted; and to the Commonwealth Fund for data from their International Health Policy Surveys.

The HiT reflects data available in November 2012.

List of abbreviations List of abbreviations

–  –  –

Abstract

T his analysis of the United States health system reviews the developments in organization and governance, health financing, health-care provision, health reforms and health system performance. The US health system has both considerable strengths and notable weaknesses. It has a large and well-trained health workforce, a wide range of high-quality medical specialists as well as secondary and tertiary institutions, a robust health sector research program and, for selected services, among the best medical outcomes in the world. But it also suffers from incomplete coverage of its citizenry, health expenditure levels per person far exceeding all other countries, poor measures on many objective and subjective measures of quality and outcomes, an unequal distribution of resources and outcomes across the country and among different population groups, and lagging efforts to introduce health information technology. It is difficult to determine the extent to which deficiencies are health-system related, though it seems that at least some of the problems are a result of poor access to care. Because of the adoption of the Affordable Care Act in 2010, the United States is facing a period of enormous potential change.

Improving coverage is a central aim, envisaged through subsidies for the uninsured to purchase private insurance, expanded eligibility for Medicaid (in some states) and greater protection for insured persons. Furthermore, primary care and public health receive increased funding, and quality and expenditures are addressed through a range of measures. Whether the ACA will indeed be effective in addressing the challenges identified above can only be determined over time.

Executive summary Executive summary

Introduction

T he United States economy is the largest in the world, and its gross national income per head is among the highest in the world. The United States has a federal system of government, with substantial authority delegated to its regional governments – the 50 states – and a historical reluctance regarding central planning or control either at federal or state level.



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