Looking at the U.S. Health Care System

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The health care system and public health

Careers in Public Health has recieved many questions about the health care system in the United States. The authors of "The Health Care Handbook," Elisabeth Askin, Nathan Moore and Vikram Shankar, give us some insight. 


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Q: What factor(s) do you think are different between the U.S. health care system and those of most Northern European countries, which have outstanding health care systems?
Elisabeth: The biggest single difference is that Northern European countries – or, more notably, all other Organisation for Economic Co-operation and Development countries – offer universal insurance coverage and access to health care for all citizens. 
Vikram: These countries embrace more government regulation of the health care industry, but they also produce lower levels of innovation. Another important difference from the U.S. is very different models of payment for health care services.
Q: What do you think is the biggest area for improvement in light of cuts to health care spending?
Elisabeth: Efficiency, efficiency, efficiency! 
Nathan: Payments to health care providers and institutions based on health outcomes and quality, rather than the fee-for-service model that encourages over-utilization of services. 
Vikram: Better alignment of parties – i.e. coordination of services and reimbursements among patients, providers, and third-party "payors" (that is, insurance companies).
Q: If you are going to categorize health care users, which categories would you use?
Nathan: By insurance status. The type of insurance someone has (i.e., private insurance, Medicare, Medicaid, no insurance, etc.) plays a role in determining where and how they get care – as well as how good that care is. 
Elisabeth: By health status. In the U.S., the sickest five percent of the population accounts for half of total health care spending, while the healthiest fifty percent of the population only accounts for three percent of health care spending.
Q: How would you evaluate the Affordable Care Act?
Elisabeth: Pretty good on access, questionable on cost, mostly quiet on quality. Obviously, though, we should remain agnostic until it has actually been implemented and studied. 
Nathan: I don’t think we’ll know for several years, especially after the Supreme Court’s decision regarding Medicaid expansion. An ambitious expansion of the health care system intended to improve affordability and access to care for middle and lower class citizens. 
Vikram: An ambitious expansion of the health care system intended to improve affordability and access to care for middle and lower class citizens. Evaluating the ACA won’t really be possible for several years, as many important aspects of the law haven’t even been implemented yet.
Q: What do you think results in the phenomenon that many medical school graduates cannot find a job while many sick people have to wait long to get treated?
Elisabeth: The current unemployment rate for physicians is eight percent, so I don’t believe this is the crux of the problem. Actually, the limit on residency slots functions similarly to a labor cartel for physicians. 
Nathan: I think the issue is that the number of residency slots is determined by the U.S. Congress, and it has not been increased in 15 years. Meanwhile, many new medical schools have opened up to meet the growing demand for physicians. 
Vikram: This restriction of slots leads to intense competition among students for well-paying specialties (plastic surgery, dermatology, radiation oncology, etc.) while primary care specialties have a hard time filling their open slots. With fewer primary care physicians being trained, people may have a more difficult time accessing care.