BIOETYKA / WPROWADZENIE

BIOETYKA / WPROWADZENIE - Przeglądy aktów prawnych

Healthcare Systems: The USA – Civitas 2002 (2013)

Introduction s. 2

The health sector in the United States is characterised by a mix of public and private funding and provision; as such, it is not governed by a single philosophy.

Public sector health programmes s. 2

In 2009 the US spent a total of $2.5 trillion on healthcare or approximately 18% of GDP; 44.7% of that total expenditure was spent by the US government. Two public healthcare programmes are dominant in the United States - Medicare and Medicaid - and both were created in 1965 under Lyndon Johnson’s presidency and run by the US federal Department of Health and Human Services (HHS). Medicare is the federal government’s health programme that primarily serves Americans over the age of 65, whilst Medicaid is a joint federal-state programme principally designed to finance healthcare for the poor. Both provide care for the disabled. Together, Medicare and Medicaid cover approximately 87 million Americans.

Private sector health programmes

In 2010 195.9 million people in America (64% of the population) were covered by private health insurance.In 2000 these figures were 200 million and 72% respectively, meaning that proportionately fewer people have private insurance now compared with ten years ago.24 This may suggest that access to private insurance may not be keeping pace with population growth in the US (…).

Managed Care

Employer-Provided Health Insurance

Innovation: Health Savings Account

An appealing aspect of HSAs is that they encourage individuals to stay healthy and be cost-conscious. Any money from your HSA account that is not used to pay medical expenses is yours to keep (although you will pay taxes on amount withdrawn if it is spent on non-medical expenses). The theory is therefore that consumers will be more cautious when spending their own money compared to spending money that they see only indirectly through their employer or health insurance provider.

The Uninsured and the Unofficial Safety Net

Being uninsured does not mean that all medical care is out of reach. Any hospital in the United States that accepts Medicare or Medicaid patients is legally bound to provide medical treatment and stabilize any patient who presents a medical problem, whether or not that patient can pay the bill. Hospitals that treat a substantial number of poor patients, including those on Medicaid, Medicare, or without health insurance, receive a Disproportionate Share payment from the federal government to help compensate them. The uninsured also receive medical care through additional, joint private-public sector health programmes, including free clinics and Community Health Centres, described earlier. However there are many that slip through the net altogether and many will frequently wait until late stages of illness before seeking care because, in general, they will only have reliable access to emergency, not preventative care. Thus the uninsured or under-insured are more likely to face bankruptcy through illness or accident. It also makes hospital costs particularly high due to the aforementioned tendency for patients to be sicker and require more radical and expensive treatment when they finally seek help, than those who can come forward earlier.

Reform of US Healthcare: the Obama Administration

Key points included in the final Act

• Cost: the Act is expected to cost $1.1 trillion over the next 10 years but more immediately reduce the deficit by $143 billion. The costs will be offset by cutting waste and introducing higher payroll taxes, higher fees to prescription drug companies and lower payments to hospitals.
• Coverage: the Act brought coverage to 32 million currently uninsured Americans by expanding Medicaid and offering subsidies to low-income earners purchasing insurance through the new exchanges. This will increase total coverage to 94% of the population by 2019 (an increase from around 85% pre-implementation), bringing the US substantially closer to universality.
• Medicare: before the Act people had to pay if their prescriptions cost more than $2700 and they only qualified for coverage again if the cost passed $6154. The Act closed this gap (known as the ‘Medicare doughnut hole’) and also gives people rebates and discounts on brand name drugs. The Act also eliminates inefficiencies in Medicare Advantage and slows payment rates (see above), saving the US federal government $716 billion.
• Medicaid: an extra 16 million people will become eligible for Medicaid as it is expanded to include families under 65 with a gross income of up to 133% of federal poverty level.
• Insurance reforms: insurers can no longer deny coverage to those with pre-existing conditions and their use of annual limits will be restricted. Young adults will be able to stay on their parents’ health plans until they are 26. Currently many insurance companies drop dependents when they turn 19 or finish college. Insurance companies are also legally barred from spending more than 15-20% on administration, marketing and profits, and must spend the remainder on claims and quality improvements.
• Insurance exchanges: the uninsured, self-employed and those expected to pay more than 9.5% of their household income on premiums by their employer are now able to purchase insurance through state based exchanges. It is not compulsory to buy within the exchange but companies in the exchange are regulated (and therefore perhaps safer) and generally cheaper due to shared risk.
• Subsidies: as well as subsidies offered to low-income individuals and families wanting to purchase their own health insurance, subsidies will be available for small businesses to ensure that they can afford to offer health insurance to their employees. Meanwhile, employers who have 50 or more workers could face fines if they do not provide a health insurance plan.
• Individual mandate: from 2014 those not covered by Medicaid or Medicare must be insured or face a fine of at least $695 a year or 2.5% of their income.
• Tax: taxes on high end health plans were relaxed by the Act but the Medicare payroll tax on upper income earners was increased. From 2013 families with an income of over 250 000 will have to pay an additional 3.8% on their investment income and contribute more to Medicare from income tax.
• Other: the act also aims to streamline the American healthcare system and reduce costs by encouraging the use of preventative care and electronic records. Access to services on the Indian Health Service (IHS) will be strengthened somewhat