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... through their jobs. Employers used to buy the insurance from a third party, typically the local Blue Cross/Blue Shield not-for-profit plan. Recently the Blues have lost ground to more aggressive for-profit insurers. But their strongest competitor is now employers themselves, stung by rising health-care costs and the state authorities' burdensome regulation of the insurance industry. Federal law allows employers who "self-insure" (usually through an arm's-length intermediary) to escape state regulation.
Over half of America's biggest employers have now made the switch, in effect paying their workers' medical bills themselves. The other main insurer in America is the government. The old and the disabled are covered by a federal programme, Medicare. Medicare, which will spend about $ 110 billion this year - roughly twice the cost of Britain's NHS -, is divided into two parts: the first pays for most hospital care out of payroll taxes; the second pays for doctors' fees out of general taxation and a premium paid by the patient.
Medicaid, a state-federal programme that will cost nearly $ 90 billion this year, pays all the medical bills of the poor, including those for long-term care. Retired and serving soldiers are covered by the Veterans' Administration, which has a network of inefficient hospitals, and by a special programme with the colourful acronym campus. This patchwork quilt (see chart 4 on next page) has two gaping holes. One is that it leaves a large and growing number of people - currently around 35 m - without any insurance at all. The plight of the uninsured is bad, but not as bad as it sounds: most get care from hospitals that are, in theory, not allowed to turn anyone away. Figures from the census bureau and the American Hospital Association suggest that overall spending on the uninsured is comparable to spending on the insured, though it is unevenly distributed.
Uninsured people can be bankrupted by big medical bills. And the bills they cannot or will not pay are a time-bomb passed among others involved in the system. The hospitals try to pass it to the insured in higher premiums; insurers try to pass it back in lower hospital profits, or to offload it on to state and local governments. The other flaw in the American way is caused by costs that are spinning out of control.
At over $ 600 billion, the cost of health care in America now absorbs 12 % of GDP. And whereas in other countries it has roughly stabilised, in America the share has been rising throughout the 1980 s. Employers have reacted by trimming the health benefits they offer, especially undertakings to cover staff who have retired. Those undertakings will knock a $ 200 billion hole in profits when they have to be shown in company accounts from next year. One result is that in four-fifths of labour disputes in the past two years, the main fight has been over health benefits. Foreigners like to blame the tribulations of American health care on excessive reliance on the free market.
In fact, government policy has played a big part. Instead of improving equity, well-intentioned state regulation of the insurance market has made insurance all but impossible for small employers to buy. Two-thirds of the uninsured work, many for employers who would like to offer insurance if they could find it. The other third ought to have Medicaid cover, but budget cuts and a diversion of cash into long-term care for poor, old people mean that the programme now covers only 40 % of those below the federal poverty line. As for costs of treatment, the biggest source of inflation has been reliance on expensive fee for-service medicine that gives doctors and hospitals an incentive to treat people in the most expensive possible ways. This might look like a market fault.
But another prime contributor is the government's decision to exempt employer-paid insurance premiums from federal and state income taxes - amounting to an annual subsidy of nearly $ 60 billion. It is bad enough that this subsidy is biased to the better-off; worse, it destroys any incentive for employees to choose cheaper insurance. The government is also partly to blame for a legal system that has produced astronomical awards to patients in malpractice suits. These feed straight into the costs of health care through malpractice insurance taken out by doctors. High premiums and the fear of being sued have also made some types of care hard to get (try finding an obstetrician in Florida to deliver a baby). Even more expensively, they encourage doctors to practise defensive medicine - such as ordering unnecessary tests.
Not everything about American health care is bad. Its quality is widely thought to be high which is why one opinion poll had 90 % of respondents favouring "major changes" in the system, but over half satisfied with their own care. There is plenty of choice of doctors and hospitals: European indifference to patients is rare in America. America has made the biggest progress in developing quality assessment and output measures for health. It remains the world leader in innovation, experiment and new technology, both in medical care and in different ways of delivering and paying for it.
In 1915 a labour pressure group looked forward to national health insurance as the "next great step in social legislation." Truman tried and failed to introduce it in 1948. In the mid- 1960 s Johnson managed to push through Medicare and Medicaid. Richard Nixon encouraged the spread of HMOS (in which patients pay a fixed fee to cover all their health care) and managed care. But when he suggested a national health programme based on a mandate for employers to provide health insurance for their workers, it died - partly because Democrats like Edward Kennedy wanted government insurance instead. Ironically Senator Kennedy now supports something like the Nixon plan, but it is opposed by George Bush.
There is a host of other ideas on offer: Insurance reform. Some want to ban "experience rating" (skimming the cream of insurance risks) and insist on community rating. Others want to encourage the small-employer insurance market, perhaps by pooling risks. A third idea is an "all-payer" system such as Maryland's, under which all insurers agree to pay the same price to hospitals - an attempt to create the monophony power among purchasers that is common in most other countries. But the insurance market already suffers from too much regulation. And an all-payer system could stop the move towards cheaper selective contracts with providers.
Medicaid expansion to cover more of the uninsured. This might include letting people above the poverty line, but who cannot otherwise find insurance, buy into the public programme. An alternative is to expand Medicare to cover the whole population. But in deficit-ridden, taxophobic America, neither the federal nor any state government is in a position to take on a new spending commitment that could add up to $ 250 billion a year (even if it saves more in private spending).
State governors have repeatedly asked Congress to stop expanding the coverage of Medicaid. Price and volume controls. The most successful of these has been Medicare's prospective budgeting for hospitals, where payments are based not on the costs incurred but on fixed prices per case (known in the jargon as diagnosis-related groups, or DRGS). This has been copied by many private insurers.
The average patient now stays in hospital for a shorter period in America than in any other country, and a recent Rand Corporation study confirmed that the quality of patient care has not been affected. A new set of Medicare price and volume controls on doctors comes into force next year. But though such controls might hold down spending in one place, bills have a nasty habit of popping up somewhere else as providers fight to maintain incomes. Alain Enthoven of Stanford University has put forward the most sophisticated single reform plan. TO encourage managed care (of which more below) he would cap the tax exemption for health insurance at the cheapest insurance policy available. He would create state insurance pools under healthcare "sponsors" for those who cannot get coverage.
Employers who did not give their workers insurance would have to contribute to a state pool - an idea known as "play-or-pay." Congress's Pepper commission, which reported in 1990, also wanted a play-or-pay plan. But such employer mandates would increase business costs, and without firm cost controls they might lead to more overall spend on health care. Individual mandates. The Heritage Foundation, a right-wing think-tank based in Washington, DC, is touting a plan that would replace the employee-tax exemption by a tax credit to help people buy their own health insurance. The government would require everyone to take out "catastrophic" health insurance - a long-stop protection against the biggest medical bills. Potting the burden on individuals sounds attractive, but it would make it harder to avoid adverse selection by both insurer and insured.
As a variant, a government commission headed by Deborah Steelman has been considering replacing both Medicare and Medicaid with catastrophic coverage for all. More patient charges or what are known in the jargon as "co-payments." But these are already high, in both the private and the public sectors (on some estimates, old people now pay as much out of their own pockets for health care as they did before Medicare). And if they are pushed too far, people simply take out extra private insurance. Managed care in HMOS or PPOS (preferred-provider organisations that offer more choice of doctor and hospital than most HMOS).
This still looks the most promising option. About 70 m Americans now belong to a managed-care plan. Some plans do little more than insist on second opinions before surgery. But the best of them offer patients all the care they need for an annual prepayment, reversing fee-for-service medicine's incentive to excessive treatment. HMOS have been touted as the answer for American health care since Paul Ellwood, a health economist, coined the phrase in 1972. But after a one-off cut in costs, their spending growth has since matched the inflation of the fee for-service sector.
Many HMOS have lost money; some have gone bust. No wonder Bob Evans of the University of British Columbia says that "HMOS are the future; always have been and always will be. " Is America ready to make any changes to its chaotic system at all? One day, it must: the uninsured are a growing embarrassment; spending cannot rise for ever; growing paperwork will become intolerable; increasing interference in doctors' clinical judgments will provoke revolt. But the short-term prospects for reform are poor. The White House appears to think that any change would be politically riskier than letting the system bumble along as it is.
As for the Democrat-controlled Congress, it was badly burnt when it expanded Medicare to cover catastrophic health-care costs in 1988, only to be forced to retract it in 1989 when the better-off elderly objected to paying extra taxes. In recent months the Democrats, especially in the Senate, have gingerly begun to discuss changes in health care. Some hope to make a version of national health insurance a big issue in the 1992 election campaign. The biggest problem for Republicans and Democrats alike is the mulish conservatism of America's powerful interest groups. John Ring, president of the American Medical Association, says his organisation is firmly against national health insurance, or any plan that involves a single payer. (It might - horrors - reduce doctors' incomes from their present average of $ 150, 000 a year. ) Insurers and private hospitals similarly guard against invasion by "socialized medicine" - especially of the iniquitous British variety.
Free research essays on topics related to: long term care, fee for service, medicare and medicaid, health care costs, american health care
Research essay sample on American Health Care Long Term Care
