Healthcare in the USA

The healthcare system in the United States is predominantly a private practice system. Most health care is provided by private providers and paid for through a combination of government programs, health insurance systems , and direct patient payments. In terms of medical expenses, the United States ranks first in the world both in absolute numbers and as a percentage of GDP—health care costs account for about 18% of the entire national economy. In 2022, this industry employed 14.7 million people, or 9.3% of all employed in the economy. The United States occupies a leading position in the world in the field of medical research and development, including thanks to a developed system of research universities , pharmaceutical and bioengineering industries.

At the same time, the United States is the only developed country in the OECD that does not guarantee its citizens a universal and comprehensive health insurance system . The world's largest health care expenditure does not necessarily mean better health of citizens or greater access to health care services compared to other developed countries. Health care coverage is uneven and varies by income, race, and location; The federal government provides coverage through programs like Medicare and Medicaid to only certain groups of the population, such as senior citizens and the poor.

The state of the US health care system, with its complex structure and high costs, remains the subject of political debate and attempts at reform, such as the 2010 Health and Patient Protection Reform. Despite statements about the highest preparedness for any epidemic and first place in the Global Health Security Index in 2019, the COVID-19 epidemic in 2020-2021 led to an unusually large number of cases and deaths, both in absolute numbers and in comparison with other developed countries, causing new discussions about the accumulated problems of the healthcare system.

Responsibility for the health of the nation lies with the US Department of Health and Human Services, headed by a secretary (minister), who reports directly to the president. The ministry includes 10 official representatives in the regions (“directors”). In the United States, the Department of Health plays a very modest role due to the small amount of government participation in the industry. Among the main tasks are control over the medical system and the implementation of social programs, control over medical science, monitoring and reporting to the authorities the situation in the field of health, welfare and social security of the population. The following departments within the Ministry are directly involved in solving medical problems: the Public Health Service and the Medical Care Financing Administration. In addition to the Ministry of Health, some of the functions in the field of health are carried out by special units of the Ministry of Labor, the Environmental Protection Agency and other government departments.

US medicine operates at the following levels:

• family medicine  - doctors conduct a general examination of patients, referring them to a more specialized specialist if necessary.
• Hospital care  occupies a central place in the medical system, although recently its importance has been declining and is being replaced by the activities of clinics, ambulances and nursing homes. Hospitals are divided into commercial and non-profit and are similar in structure to Russian hospitals.
• public health .

The health care system consists of numerous services that differ in the type of funding and functions they perform, including:

• Public health and preventive medicine services - deal with disease prevention, environmental  surveillance , quality control of food, water, air, etc.
• Non- emergency outpatient services
• Simple inpatient care - specializes in short-term hospitalization.
• Complex inpatient care - the provision of long-term, highly qualified and technically complex inpatient treatment.

The US healthcare system is pluralistic, which is reflected in the absence of a single centralized management and numerous types of medical institutions. But absolutely all institutions provide medical services exclusively for a fee. For a number of categories of citizens who are treated free of charge, expenses are compensated by the state or special funds.

The private sector of outpatient medical care is represented by both general practitioners and specialist doctors. In addition to individual practice, a system of group practice is widespread in the United States. Treatment at home is usually provided by nursing organizations, but is usually prescribed by doctors. At the same time, nurses in the United States constitute the main link in the provision of medical care, and it is often difficult to understand where their responsibilities end and the responsibility of the doctor begins. As a rule, American nurses have good professional training, are united in associations, and have a fairly high status in society.

The emergency medical service system in the United States consists of volunteer (22%), staff (38%) and combined (40%) organizations, where some employees are paid and some work on a volunteer basis. Most often, the ambulance service is a department of the local fire department (38% of cases), sometimes it exists as a separate municipal (23%) or private (13%) structure, a department of a hospital (7%) or a police department (1.5%). ).

Hospitals in America are divided into three types:

• public  - funding is provided by the federal and state governments. They provide services for veterans, the disabled, government employees, and patients with tuberculosis and mental illness.
• private profitable (commercial) (up to 30% of all hospitals) - represent a typical business enterprise that forms its capital on an individual, group and shareholder basis.
• private “non-profit”  - created on the initiative of religious or ethnic groups or local residents, they account for up to 70% of the total final fund. The main difference from the previous type is that the income received does not go to shareholders in the form of dividends, but is invested in the hospital, which improves the quality of service, technical equipment, etc. The state supports such activities in the form of preferential taxation. Despite the “non-profit” status of the institution, treatment, like in a commercial hospital, remains paid. The popularity of this hospital status can be explained by the desire to avoid paying taxes.

There are 1,100 teaching hospitals in the country. 375 large institutions belong to the Association of American Medical Colleges' Council of Teaching Hospitals and Health Systems (COTH )  . COTH hospitals account for approximately 40% of hospital philanthropy in the country.

Health insurance

Unlike most developed countries , the United States does not guarantee universal access to health care. Most citizens receive these services through various health insurance programs - private, provided by the federal government and the authorities of individual states. Only a fraction of American citizens receive health insurance through government programs such as Medicaid for the poor and Medicare for the elderly. More than half of US residents have health insurance through private insurance companies through group insurance contracts, most of which are issued by the employer at the place of work; another part is based on individual insurance contracts, both direct medical insurance and as part of a package along with other insurance services.

In 2020, 8.6 to 9.7% of US residents, or 28 to 31.6 million people, had no health insurance at all and had to pay entirely out of pocket for medications and medical services. The proportion of the uninsured population has varied over the years—prior to the US Health Care Reform and Patient Protection Reform in 2010, it was as high as 18%, decreased to 10.9% in 2016, and rose again to 13.7% by 2018. In 2020, out-of-pocket consumer health care spending accounted for 9.9% of total health care spending, or $389 billion. These costs included both payments from uninsured citizens and payments from insured people for medical services not covered by insurance or not paid in full by the insurance company.

Insurance does not cover everything, but only a clearly limited list of medical services. This does not include, for example, the services of a dentist, ophthalmologist, pediatrician and psychiatrist, etc. Only very rich people can afford all-inclusive insurance. As a result, a serious injury or illness can greatly undermine a family's budget—medical bills are the cause of half of personal bankruptcies in the United States.

Most health insurance companies refuse to cover seriously ill people.

According to Bloomberg View, the health insurance market in the United States is not competitive enough : in most cases, workers are forced to purchase health insurance offered to them by their employer. Technically, all Americans have equal access to emergency medical care, and doctors should not ask arriving patients for insurance. However, uninsured patients see a doctor much later; They have to wait a long time for the necessary help in the corridors of the hospital.

State insurance programs

For needy citizens of the country, the US government provides two special programs - Medicaid and Medicare . According to data at the end of the 1990s, spending on these two programs exceeded $300 billion.

The Medicaid program , designed to help people with low incomes, is funded by both the federal government and the states. Since each individual state has its own Medicaid program, this creates significant complexity in government administration. To use Medicaid, you must prove that the person's financial situation is below a certain level. This program provides 5 services: inpatient and outpatient treatment, consultations with various specialists, stay in nursing homes, laboratory diagnostics and x-ray methods. Medicaid plays a huge role in terms of building starting opportunities for different categories of the population and redistributing income in the country. As of 2006, the program helped 38.3 million Americans.

Medicare is aimed at helping people over 65 years of age, as well as citizens of pre-retirement age who have health problems. The sources of financing are: payroll tax, progressive income tax and corporate income tax . Medicare consistently provides between 35% and 50% of hospital revenue. Services covered by the program include inpatient care, some preventive services, home care, diagnostic procedures, and short stays in nursing homes. However, long-term hospitalization, free hearing aids and prescription drugs are not provided. The program covers 40.3 million patients. By the beginning of the 21st century. This social program faced significant difficulties associated with the aging of the population and the increase in the proportion of pensioners: in 1996, only three workers provided  one recipient of social insurance benefits . As a result, payments under the program significantly exceed previous investments. At the end of the 1990s, Medicare spending was 2.6% of GNP.

For active military personnel and their families, insurance is provided by the US Department of Defense through the Tricare program, and veterans receive insurance from the US Department of Veterans Affairs .

Doctors

The medical profession in the USA is prestigious and highly paid. Doctors consistently occupy the top ten in the list of the highest paid professions in the country. The average salary for a doctor in the United States is $150,000 per year. This is a wealthy, influential social group with broad lobbying capabilities.

Medical school (after high school and college) takes 4-6 years, after which students receive a medical degree and a medical degree. In total, there are 125 medical institutes (schools) in the United States. Students are examined by the private sector using standards set by the Medical Education Coordinating Committee. This is followed by a period of 3-year residency (a close analogue of the Russian residency), when trainees choose one of 24 specialties. For some professions, the duration of residency is different - for a cardiac surgeon it is 8 years, for a cardiologist - 6 years.

In the American medical tradition, there is a practice when not the whole person is treated, but his individual organs. Treatment is left to “narrow” specialists who pay attention only to what is the object of their professional qualifications.

A distinctive feature of American medicine is the special personal relationship between doctor and patient. The patient is considered a partner of the doctor, his condition is explained to the patient in detail and his opinion is listened to when choosing treatment tactics. The patient's opinion in assessing the quality of medical care is given great, sometimes excessive, importance. This situation, according to a number of experts, leads to a distortion of the assessment, since the patient is always subjective and is not always able to objectively assess the quality of service. This state of affairs is most likely due to fear of lawsuits.

Lately, there has been a tendency towards the proliferation of doctors working in shifts - “hospitalists”. A physician's hospitalist may examine a patient who needs to be admitted to the hospital, while the physician himself will attend to patients as scheduled. Similar functions in obstetrics and gynecology are performed by “laborists”.

Compared to other countries, the United States has few doctors per 1 thousand people.

The cost of training is high. As a result, the educated specialist has a huge debt - for a graduate of a municipal medical university it is $100,000, for a graduate of private universities - $135,000 (as of 2003). In 1984 these figures were $22,000 and $27,000 respectively. Moreover, between 1995 and 2003, a doctor’s net income decreased by approximately 7%. All this encourages young American applicants to go to study at medical schools in the Caribbean, which allow them to save a lot on medical education.

There are also huge risks associated with lawsuits from the patient. And although 91% of all claims for malpractice by doctors are successfully contested, the long duration of consideration of cases (on average 4.5 years) and high costs for lawyers represent a huge inconvenience. As a result, American doctors, unlike their European counterparts, are forced to purchase extremely expensive professional liability insurance policies to protect them from lawsuits.

According to the American Medical Association (AMA), over the next 15 years the United States will experience a shortage of 90 to 200 thousand doctors. This is due to an aging population and a stagnant number of medical school graduates.

Medical expenses

According to current estimates, health care expenditures in the United States amount to 16% of GDP, according to this indicator the United States ranks second among UN member states , after East Timor. According to the Ministry of Health, by 2017, medical expenses will increase by 6.7% and amount to 19.5% of GDP.

In 2009 , federal, state and local governments, businesses and individuals spent $2.5 trillion, or $8,047 per person, on health care. This amount represents 17.3% of GDP, up from 16.2% in 2008. Health insurance costs are rising faster than wages or inflation, and medical debt was cited as the cause of about half of the bankruptcies filed in the United States in 2001. Of every dollar spent on health care in the United States, 31% goes to hospital care, 21% to physician/clinical services, 10% to drug treatment, 6% to nursing homes, and 6% to dental care. 4%, home care - 3%, other retail products 3%, government health activities - 3%, investments - 7%, administrative expenses - 7%, the rest comes from other professional services (physiotherapists, ophthalmologists and etc).

According to the Congressional Budget Office, half of the increase in medical costs was driven by changes in care due to technological advances. Other factors include high income levels, changes in insurance coverage, and rising prices.

According to a study by the Organization for Economic Co-operation and Development , although the United States spends more on healthcare than any other country on the planet, healthcare consumption is below average by most measures. The study authors concluded that procurement prices for medical services are much higher in the United States. According to economist Hans Sennholz ,  the main reason for the increase in health care costs in the United States may be the Medicare and Medicaid programs.

Moreover, medical expenses in the United States are distributed unevenly across the population. A 1996 analysis of health care spending found that the top 1% of the population accounted for 27% of total health care spending. 5% of the population accounted for more than half of all expenditures.

People in older age groups spend, on average, much more than working-age adults and children.

According to The Wall Street Journal as of September 2008, consumers are responding to the current economic slowdown by cutting back on medical spending. Moreover, this applied to both the purchase of medications and the frequency of doctor visits.

As of 2009, living in a private room in a nursing home cost $219 per day. House doctor services average $21 per hour.

US health care reform

Healthcare reform in the United States (Affordable Care Act, ACA) was initiated by US President Barack Obama, who took office in 2009. This is the first attempt to reform the US medical system since the 1960s, when President Johnson created the government programs Medicare and Medicaid to help retirees and the poor. The current reform was attempted back in 1993, albeit unsuccessfully, by a team of Democrats from the Bill Clinton administration .

Over the past 30 years, healthcare costs have increased disproportionately in America, although there were no objective prerequisites for improving the quality of services. In the first decade of the 21st century, the cost of insurance per employee more than doubled. A significant portion of the population remains uninsured, and the proportion is growing. The insurance market provided by employers is extremely monopolized, which impedes the mobility of labor resources and creates conditions for discrimination against patients both before and after the conclusion of an insurance contract, including in the form of denial of payments. The ever-increasing cost of Medicare and Medicaid is one of the reasons for the prohibitive budget deficit.

The current medical system is characterized by unresolved interaction between the public and private sectors of the economy. Despite the fact that the state allocates enormous sums to the industry, it does not have effective controls over the prices and costs of services and drugs. As a result, healthcare that is almost entirely privatized, although consistent with American ideals, is in fact prohibitively expensive.

 On March 21, 2010 , the US Congress approved health care reform; Some of its provisions were considered unconstitutional by the Supreme Court in 2012 (National Federation of Independent Business v. Sebelius). The program is designed for 10 years and will cost the American budget $940 billion. The “stretched” nature of the reform will allow patients, market participants and the economy as a whole to adapt to it.

The goal of the reform was to create a universal health care system that would cover the 50 million currently uninsured citizens. The reform is designed to improve the conditions of health insurance for citizens who already have a policy. Exchanges for insurers will be created, thanks to which it will be possible to obtain a policy for those who were unable to obtain insurance from their employer. In this case, a “ceiling” will be set for insurance premiums at 3-9.5% of the client’s income. Private insurance companies will be deprived of the right to refuse to purchase insurance for people who are already sick. Citizens will be able to purchase insurance without the assistance of employers in centers specially created for this purpose. Administrative liability will appear in relation to persons refusing to purchase and companies refusing to sell a policy; starting in 2014, such fines for citizens will be $95 or 1% of income and will gradually increase to $695 or 2% of income. As a result, insurance coverage will cover 95% of the country's population (versus 84% ​​today). The reform is expected to create 400 thousand new jobs. It will be possible to reduce costs per individual patient and invest more money in medicine.

Opponents of the reform argue that the reform violates the freedom of choice of each person and increases costs and taxes. In addition, the very possibility of universal access to timely treatment raises doubts - in the UK and Canada, citizens have to spend a lot of time in queues to get advice from a specialist doctor. Due to decreased profitability, investments in medical science, new technologies and drugs will decrease.

The financial conditions for receiving medical care in the United States are a controversial topic in the media. “The American health care system is rigged against you,” writes former physician and journalist Elizabeth Rosenthal in her new book, American Sickness; According to Rosenthal, “normal prices and information transparency” should take first place in reforming medicine in the United States.