Question

Describe at least two ways in which you think history is repeating itself in today's health care delivery system.

At least 350 - 500 words in length

Answer 1

For Americans to enjoy optimal health—as individuals and as a population—they must have the benefit of high-quality health care services that are effectively coordinated within a strong public health system. In considering the role of the health care sector in assuring the nation's health, the committee took as its starting point one of the recommendations of the Institute of Medicine (IOM) report Crossing the Quality Chasm (2001b: 6): “All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.”

This chapter addresses the issues of access, managing chronic disease, neglected health care services (i.e., clinical preventive services, oral, and mental health care and substance abuse services), and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, the workforce, financing, information technology, and emergency preparedness. In addition, the chapter discusses the responsibility of the health care system to recognize and play its appropriate role within the intersectoral public health system, particularly as it collaborates with the governmental public health agencies.

The health care sector in the United States consists of an array of clinicians, hospitals and other health care facilities, insurance plans, and purchasers of health care services, all operating in various configurations of groups, networks, and independent practices. Some are based in the public sector; others operate in the private sector as either for-profit or not-for-profit entities. The health care sector also includes regulators, some voluntary and others governmental. Although these various individuals and organizations are generally referred to collectively as “the health care delivery system,” the phrase suggests an order, integration, and accountability that do not exist. Communication, collaboration, or systems planning among these various entities is limited and is almost incidental to their operations. For convenience, however, the committee uses the common terminology of health care delivery system.

As described in Crossing the Quality Chasm (IOM, 2001b) and other literature, this health care system is faced with serious quality and cost challenges. To support the system, the United States spends more per capita on health care than any other country ($4,637 in 2000) (Reinhardt et al., 2002). In the aggregate, these per capita expenditures account for 13.2 percent of the U.S. gross domestic product, about $1.3 trillion (Levit et al., 2002). As the committee observed in Chapter 1, American medicine and the basic and clinical research that inform its practice are generally acknowledged as the best in the world. Yet the nation's substantial health-related spending has not produced superlative health outcomes for its people. Fundamental flaws in the systems that finance, organize, and deliver health care work to undermine the organizational structure necessary to ensure the effective translation of scientific discoveries into routine patient care, and many parts of the health care delivery system are economically vulnerable. Insurance plans and providers scramble to adapt and survive in a rapidly evolving and highly competitive market; and the variations among health insurance plans—whether public or private—in eligibility, benefits, cost sharing, plan restrictions, reimbursement policies, and other attributes create confusion, inequity, and excessive administrative burdens for both providers of care and consumers.

Because of its history, structure, and particularly the highly competitive market in health services that has evolved since the collapse of health care reform efforts in the early 1990s, the health care delivery system often does not interact effectively with other components of the public health system described in this report, in particular, the governmental public health agencies. Health care's structure and incentives are technology and procedure driven and do not support time for the inquiry and reflection, communication, and external relationship building typically needed for effective disease prevention and health promotion. State health departments often have legal authority to regulate the entry of providers and purchasers of health care into the market and to set insurance reimbursement rates for public and, less often, private providers and purchasers. They may control the ability of providers to acquire desired technology and perform complex, costly procedures that are important to the hospital but increase demands on state revenues. Finally, virtually all states have the legal responsibility to monitor the quality of health services provided in the public and private sectors. Many health care providers argue that such regulation adds to their costs, and high-profile problems can create additional tensions that impede collaboration between the state public health agency and the health care delivery system.

Furthermore, when the delivery of health care through the private sector falters, the responsibility for providing some level of basic health care services to the poor and other special populations falls to governmental public health agencies as one of their essential public health services, as discussed in Chapter 1. In many jurisdictions, this default is already occurring, consuming resources and impairing the ability of governmental public health agencies to perform other essential tasks.

Although this committee was not constituted to investigate or make recommendations regarding the serious economic and structural problems confronting the health care system in the United States, it concluded that it must examine certain issues having serious implications for the public health system's effectiveness in promoting the nation's health. Drawing heavily on the work of other IOM committees, this chapter examines the influence that health insurance exerts on access to health care and on the range of care available, as well as the shortcomings in the quality of services provided, some of the constraints on the capacity of the health care system to provide high-quality care, and the need for better collaboration within the public health system, especially among governmental public health agencies and the organizations in the personal health care delivery system.

ACCESS TO HEALTH CARE

Health care is not the only, or even the strongest, determinant of health, but it is very important. For most Americans, having health insurance— under a private plan or through a publicly financed program—is a threshold requirement for routine access to health care. “Health insurance coverage is associated with better health outcomes for adults. It is also associated with having a regular source of care and with greater and more appropriate use of health services. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and the effective treatment of acute conditions,” IOM notes in a recent report (IOM, 2002a: 6).

Private insurance is predominantly purchased through employment-based groups and to a lesser extent through individual policies (Mills, 2002). Publicly funded insurance is provided primarily through seven government programs Medicare provides coverage to 13.5 percent of the population, whereas Medicaid covers 11.2 percent of the population (Mills, 2002). Additionally, public funding supports directly delivered health care (through community health centers and other health centers qualified for Medicaid reimbursement) accessed by 11 percent of the nation's uninsured, who constitute 41 percent of patients at such health centers (Markus et al., 2002). Because the largest public programs are directed to the aged, disabled, and low-income populations, they cover a disproportionate share of the chronically ill and disabled. However, they are also enormously important for children. In early 2001, Medicaid and the State Children's Health Insurance Program (SCHIP) provided health care coverage to 23.1 percent of the children in the United States, and this figure had risen to 27.7 percent according to data from the first-quarter estimates in the National Health Interview Survey (NCHS, 2002).

Government ernment Health Programs.

Being uninsured, although not the only barrier to obtaining health care, is by all indications the most significant one. The fact that more than 41 million people—more than 80 percent of whom are members of working families—are uninsured is the strongest possible indictment of the nation's health care delivery system. Those without health insurance or without insurance for particular types of services face serious, sometimes insurmountable barriers to necessary and appropriate care.

Adults without health insurance are far more likely to go without health care that they believe they need than are adults with health insurance of any kind (Lurie et al., 1984, 1986; Berk and Schur, 1998; Burstin et al., 1998; Baker et al., 2000; Kasper et al., 2000; Schoen and DesRoches, 2000). Children without health insurance may be compromised in ways that will diminish their health and productivity throughout their lives.

When individuals cannot access mainstream health care services, they often seek care from the so-called safety-net providers. These providers include institutions and professionals that by mandate or mission deliver a large amount of care to uninsured and other vulnerable populations. People turn to safety-net providers for a variety of reasons: some because they lack health insurance and others because there are no other providers in the area where they live or because language and cultural differences make them uncomfortable with mainstream care. Safety-net providers are also more likely to offer outreach and enabling services (e.g., transportation and child care) to help overcome barriers that may not be directly related to the health care system itself.

In this section, the committee reviews concerns about the barriers to health care that are raised by the lack of health insurance and by threats to the nation's safety-net providers.

The Uninsured and the Underinsured

The persistently large proportion of the American population that is uninsured—about one in five working-age adults and one in seven children— is the most visible and troubling sign of the nation's failure to assure access to health care. Yet the public and many elected officials seem almost willfully ignorant of the magnitude, persistence, and implications of this problem. Surveys conducted over the past two decades show a consistent underestimation of the number of uninsured and of trends in insurance coverage over time (Blendon et al., 2001). The facts about uninsurance in America are sobering . By almost any metric, uninsured adults suffer worse health status and live shorter lives than insured adults

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