See also: Health care reform in the United States and Health care reform debate in the United States
Health care in the United States is provided by many separate legal entities. Health care facilities are largely owned and operated by the private sector. Health insurance is primarily provided by the private sector, with the exception of programs such as Medicare, Medicaid, the Children's Health Insurance Program and the Veterans Health Administration. According to data compiled and published by multiple international pharmaceutical trade groups, the US is the world leader in biomedical research and development as well as the introduction of new biomedical products; pharmaceutical trade organizations also maintain that the high cost of health care in the U.S. has encouraged substantial reinvestment in such research and development.
At least 15% of the population is completely uninsured, and a substantial additional portion of the population is "underinsured", or less than fully insured for medical costs they might incur. More money per person is spent on health care in the United States than in any other nation in the world, and a greater percentage of total income in the nation is spent on health care in the U.S. than in any United Nations member state except for East Timor. Medical debt is the principal cause of personal bankruptcy in the United States.
Active debate about health care reform in the United States concerns questions of a right to health care, access, fairness, efficiency, cost, and quality. Many have argued that the system does not deliver equivalent value for the money spent. The US pays twice as much yet lags behind other wealthy nations in such measures as infant mortality and life expectancy. Currently the U.S. has a higher infant mortality rate than most of the world's industrialized nations. The USA's life expectancy lags 42nd in the world, after most rich nations, lagging last of the G5 (Japan, France, Germany, UK, USA) and just after Chile (35th) and Cuba (37th). The USA's life expectancy is ranked 50th in the world after the European Union (40th). The World Health Organization (WHO), in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study). A 2008 report by the Commonwealth Fund ranked the United States last in the quality of health care among the 19 compared countries.
According to the Institute of Medicine of the National Academy of Sciences, the United States is the "only wealthy, industrialized nation that does not ensure that all citizens have coverage" (i.e. some kind of insurance). The same Institute of Medicine report notes that "Lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States." while a 2009 Harvard study published in the American Journal of Public Health found a much higher figure of more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance. More broadly, the total number of people in the United States, whether insured or uninsured, who die because of lack of medical care was estimated in a 1997 analysis to be nearly 100,000 per year.
Health care providers
Facilities
Main article: Medical centers in the United StatesIn the United States, ownership of the health care system is mainly in private hands, though federal, state, county, and city governments also own certain facilities.
The non-profit hospitals share of total hospital capacity has remained relatively stable (about 70%) for decades. There are also privately owned for-profit hospitals as well as government hospitals in some locations, mainly owned by county and city governments.
There is no nationwide system of government-owned medical facilities open to the general public but there are local government-owned medical facilities open to the general public. The federal Department of Defense operates field hospitals as well as permanent hospitals (the Military Health System), to provide military-funded care to active military personnel. The federal Veterans Health Administration operates VA hospitals open only to veterans, though veterans who seek medical care for conditions they did not receive while serving in the military are charged for services. The Indian Health Service operates facilities open only to Native Americans from recognized tribes. These facilities, plus tribal facilities and privately contracted services funded by IHS to increase system capacity and capabilities, provide medical care to tribespeople beyond what can be paid for by any private insurance or other government programs.
Hospitals provide some outpatient care in their emergency rooms and specialty clinics, but primarily exist to provide inpatient care. Hospital emergency departments and urgent care centers are sources of sporadic problem-focused care. "Surgicenters" are examples of specialty clinics. Hospice services for the terminally ill who are expected to live six months or less are most commonly subsidized by charities and government. Prenatal, family planning, and "dysplasia" clinics are government-funded obstetric and gynecologic specialty clinics respectively, and are usually staffed by nurse practitioners.
Medical products, research and development
As in most other countries, the manufacture and production of pharmaceuticals and medical devices is carried out by private companies. The research and development of medical devices and pharmaceuticals is supported by both public and private sources of funding. In 2003, research and development expenditures were approximately $95 billion with $40 billion coming from public sources and $55 billion coming from private sources. These investments into medical research have made the United States the leader in medical innovation, measured either in terms of revenue or the number of new drugs and devices introduced. In 2006, the United States accounted for three quarters of the world’s biotechnology revenues and 82% of world R&D spending in biotechnology.. According to multiple international pharmaceutical trade groups, the high cost of patented drugs in the U.S. has encouraged substantial reinvestment in such research and development.
Health care spending
Current estimates put U.S. health care spending at approximately 16% of GDP, second only to East Timor (Timor-Leste) among all United Nations member nations. The health share of GDP is expected to continue its historical upward trend, reaching 19.5 percent of GDP by 2017. Of each dollar spent on health care in the United States 31% goes to hospital care, 21% goes to physician services, 10% to pharmaceuticals, 8% to nursing homes, 7% to administrative costs, and 23% to all other categories (diagnostic laboratory services, pharmacies, medical device manufacturers, etc.
The Office of the Actuary (OACT) of the Centers for Medicare and Medicaid Services publishes data on total health care spending in the United States, including both historical levels and future projections. In 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person, up from $2.1 trillion, or $7,026 per capita, the previous year. Spending in 2006 represented 16% of GDP, an increase of 6.7% over 2004 spending. Growth in spending is projected to average 6.7% annually over the period 2007 through 2017. Health insurance costs are rising faster than wages or inflation, and medical causes were cited by about half of bankruptcy filers in the United States in 2001.
The Congressional Budget Office has found that "about half of all growth in health care spending in the past several decades was associated with changes in medical care made possible by advances in technology." Other factors included higher income levels, changes in insurance coverage, and rising prices. Hospitals and physician spending take the largest share of the health care dollar, while prescription drugs take about 10 percent. The use of prescription drugs is increasing among adults who have drug coverage.
One analysis of international spending levels in the year 2000 found that while the U.S. spends more on health care than other countries in the Organisation for Economic Co-operation and Development (OECD), the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study concluded that the prices paid for health care services are much higher in the U.S.
Health care spending in the United States is concentrated. An analysis of the 1996 Medical Expenditure Panel Survey found that the 1% of the population with the highest spending accounted for 27% of aggregate health care spending. The highest-spending 5% of the population accounted for more than half of all spending. These patterns were stable through the 1970s and 1980s, and some data suggest that they may have been typical of the mid-to-early 20th century as well. One study by the Agency for Healthcare Research and Quality (AHRQ) found significant persistence in the level of health care spending from year to year. Of the 1% of the population with the highest health care spending in 2002, 24.3% maintained their ranking in the top 1% in 2003. Of the 5% with the highest spending in 2002, 34% maintained that ranking in 2003. Individuals over age 45 were disproportionately represented among those who were in the top decile of spending for both years.
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