United States Health System

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Residents with private health insurance (either through their employer or self-insured), residents with public health insurance ( Medicaid , Medicare , Military Health, Tricare, Veterans Health Administration ) and residents without health insurance - each in millions in 2017

The health care system of the United States consists of all persons and all public and private organizations and institutions whose mission the promotion and maintenance of health and the prevention and treatment of diseases and injuries. It also includes all regulations that affect relationships in the healthcare system between insurance companies, insured persons, service providers and other groups involved. The relevant regulations treated the health insurance protection of residents up to 2014 as a private matter; there was no general health insurance requirement. State health care is only available in exceptional cases for residents under the age of 65. In 2008 45.7 million or 15.3% of the approximately 300 million inhabitants were neither privately insured nor could they claim state aid. In medical emergencies, hospitals are legally obliged under the Emergency Medical Treatment and Labor Act ( EMTALA ) to treat uninsured or insufficiently insured patients in the emergency room even if it is foreseeable that they will not be able to pay the bill. In the case of health problems that do not (yet) reach the level of a medical emergency, such patients may be turned away.

In 2008, 84.7% of US residents were eligible for private health insurance or were eligible for government health care. For 59.3% of the population, health insurance cover is arranged by the employer, 8.9% of the population have self-insurance (direct insurance) and 27.8% are entitled to state health care (with the percentages it should be noted that some people are Have changed their insurance status over the course of the year and are therefore recorded multiple times).

The inhabitants of the United States spent $ 7,536 per capita on the health system in 2008, which is around twice as much as in Germany (3,692 int. $ ) Or Austria (3,836 int. $) And still significantly more than in Switzerland (4,620 int. $) Int. $). The US healthcare system is by far the most expensive in the world.

In 2010, after intensive reform discussions, the Patient Protection and Affordable Care Act (“Obamacare”) was passed. This introduced compulsory insurance for most residents from 2014. Low-income residents receive a state subsidy for health insurance contributions, and health insurance companies are prohibited from discriminating against customers with previous illnesses. The number of citizens without private or public health insurance coverage fell to 29 million or 9.1% of the population by 2015.

history

Rise in health care costs. All expenditures for health care were determined as a percentage of the national gross domestic product . The following are compared: USA (olive green), Germany (red), Austria (blue), Switzerland (light blue), Great Britain (purple) and Canada (green)

Health insurance policies were initially not very popular with American doctors, partly because they feared that they could negotiate down prices. In 1919 the American Medical Association formulated the requirement that nothing should come between doctor and patient. During the Great Depression in the 1930s, however, many workers, doctors and hospitals recognized the benefits of health insurance, as only a few residents had enough money to pay a doctor in an emergency. Health insurances, on the other hand, helped the residents to gradually save up the money for larger health services. During this time, the first major health insurance companies came into being. These were independent insurances under the common name Blue Cross or Blue Shield ( franchisee ), which exempted their policyholders from the costs of health services in return for monthly premium payments in a contractually agreed extent. Until the end of the 1960s there was a direct doctor-patient relationship, with the doctor being able to make decisions without being influenced by health insurance companies. Patients submitted the bills to the health insurance company; co-payments by the patient were unusual. For more serious illnesses, smaller independent hospitals were available, most of which were operated in a non-profit manner.

During the Second World War, wages and prices were under state control for a time. The trade unions therefore demanded health services from the employer instead of wage increases; this counts as zero hour of the employer-mediated health insurance coverage. In 1960 the costs of the health system were only 5.2% of the gross domestic product (GDP); However, health expenditure per inhabitant was already 20% higher than in the second most expensive country in a global comparison. Only 21% of all health care costs were paid for by private health insurers; there were hardly any state health care programs; most of the residents therefore had no health insurance, but paid the bills themselves or did not seek medical help. With medical advances in the 1950s, surgeries became less risky than before and were more likely to bring about a cure. This increased the demand for hospital services and also for health insurance.

President Lyndon B. Johnson signing Medicare

On 30 July 1965 President led Lyndon B. Johnson to the 1965 Social Security Act of additions to the 1935 introduced social one. The tax and contribution-financed health protection includes

  • the Medicare , a public and federal health insurance mainly for pensioners over the age of 65, and
  • the Medicaid , a health care for the most deprived persons. This is funded only through federal, state, and local taxes.

At the end of the 1960s, more and more insurance companies such as Kaiser Permanente began to restrict the choice of doctor. Specified primary care contract doctors not only took over the basic care, but also, as gatekeepers , decided whether a policyholder should be referred to (more expensive) specialized doctors or to a hospital. Many insurance companies have also started giving their contracted doctors treatment instructions. Such health insurances developed into health maintenance organizations . These were sponsored financially and legally by the federal government under the Health Maintenance Organization Act of 1973. As medical advances required greater investment by care providers, large hospital chains such as the Hospital Corporation of America (HCA) emerged in the 1970s and 1980s ; they also developed treatment instructions for doctors and nurses to help hospitals work more efficiently.

The Prospective Payment System was introduced in the state health insurance Medicare in 1983 in order to make the costs of treatments transparent and understandable and to prevent unnecessary treatments (demand inducement) from being billed. Then the patients are classified into case groups (diagnosis-related groups ) based on the diagnoses and the treatments carried out . The Diagnosis Related Groups are divided according to the economic outlay required for the treatment.

In 1986 between 25 and 37 million citizens under 65 years of age had no health insurance coverage.

Private health insurance

Different types of private health insurance

Most private health insurances in the United States only allow a limited choice of doctors. The background is that there is in principle no perfect market in the healthcare sector . Policyholders have no incentive to thrift, as they are exempted from the costs of health care by health insurance ( moral hazard ). Likewise, the providers of health services (doctors, hospitals, pharmaceutical industry, etc.) have no incentive to be frugal. In addition, patients generally do not have enough medical knowledge to be able to judge for themselves which services are necessary or what quality the services offered are.

Kaiser Permanente Sunset Hospital in Los Angeles, California

Managed care models therefore try to link supply, demand and financing in such a way that there is no automatic cost explosion. This is to be achieved mainly through three strategies: The first strategy includes that contracts are concluded as far as possible with the providers of health care services that are cheapest if the quality is adequate (selective contracting). Incentives to thrift (innovative incentives) make up the second strategy: Patients often have to pay co-payments for treatments so that they do not take them lightly. Doctors and nurse practitioners often receive bonus payments if they refer as few patients as possible to specialists or to hospitals. The third strategy is the evaluation of patient histories so that the cheapest therapy can be found (“utilization review”). In addition to health maintenance organizations , the managed care models also include preferred provider organizations .

So-called Health Maintenance Organizations (HMOs) are contractually obliged to provide their voluntary members with outpatient, inpatient and in some cases also dental services. The costs for treatments by service providers are also taken over, provided that they belong to the network of contractual partners. The monthly contribution is fixed and independent of the use of the services. There is only an excess of the costs in exceptional cases. One of the major providers is Kaiser Permanente, which also has its own clinics. The HMOs have an annual budget, according to which the contributions for the policyholders are based. The advantage of this business model is that the costs are lower due to the synergy effects . HMOs issue treatment principles for their contractual partners, compliance with which is also monitored. The disadvantage is that an insured person is only treated by doctors and clinics that belong to the respective network.

Since the 1990s, the market share of PPOs (Preferred Provider Organizations) has increased significantly. In 2002, PPOs had already achieved a market share of 52 percent. With this business model, costs are also reimbursed that were not incurred by contract doctors and contract clinics. In the case of treatment by contract doctors or contract clinics, however, the insured person bears a lower contribution.

Conventional health insurance companies, on the other hand, have no restrictions on the choice of doctor. With these health insurances, the assumption of costs is less regulated, but the insurance premiums are higher than with HMOs and PPOs. Classic health insurance companies were able to hold a market share of 3%.

Insurance coverage through the employer

overview

Share of privately insured persons in percent

Most Americans get coverage through their employer (59.3%). However, this is a voluntary social benefit of the respective employer, to which there is no entitlement, unless it is part of a collective agreement. The number of employers offering health insurance to their employees has been falling for some time. In 2000, 68% of small businesses with 3 to 199 employees offered health insurance programs, compared to 59% of small businesses in 2007. In the large companies with more than 199 employees, however, 99% of the companies offered health insurance programs; this number remained the same in 2007. The main reason is believed to be that the cost of health insurance has risen sharply. For example, the average insurance premiums for a family insurance increased by 78% between 2001 and 2007, while average wages increased by 19% and inflation was 17%.

The state supports companies that offer their employees insurance protection with a tax exemption for insurance contributions in income tax .

Group insurance

Protecting employees by taking out group insurance with one or more insurance companies is one way of promising employees health care. As in Germany, employers and employees usually share the costs. The employees pay an average of 17% of the premium for a single insurance and 27% of the premium for a family insurance, the rest is paid by the employer. However, it is common for employees to have to pay co-payments for services they use. Unlike in Germany, the employer is the contract partner for the insurance, i.e. if an employee changes employer, the old insurance relationship ends. This type of insurance is particularly popular with smaller companies; 85% of companies with up to 199 employees have health insurance coverage through group insurance. 43% of all employees insured through the employer are insured in this way.

Self-insurance

According to the Employee Retirement Income Security Act , companies also have the option of providing insurance benefits themselves, known as self insurance . Very large companies often provide the insurance benefits themselves. For employers with thousands of employees, the risk pool is large enough to use actuarial calculations to calculate the cost risk. In this case, the employer often does not conclude a contract with insurance companies, but manages the health fund himself and saves himself the corresponding insurance contributions. If it manages insurance benefits as well as insurance companies, there is potential for savings; In particular, there is an opportunity to save the insurance company's profit surcharge. Furthermore, in this case there is no insurance tax, which in the USA (depending on the state) makes up between 2 and 3% of the insurance premiums. Another advantage is the greater flexibility, as in this case the statutory minimum scope of insurance cover does not apply and the employer (with effect for the future) can freely decide which treatment costs will be covered. The scope of the insurance coverage promised by the employer can be reduced at any time, especially if the profit situation deteriorates.

Medium-sized companies prefer self-funded health care . This is a variant of self insurance . Here, too, the company provides the insurance services itself. However, the company takes the help of insurance companies to the extent that certain administrative services such as access to a preferred provider network with the advantage of cost control in the sense of managed care or the collection of contributions Insurance companies are taken over. Furthermore, a stop-loss contract is often concluded with insurance companies in order to limit the financial risks that are more difficult to calculate in a smaller risk pool.

Employees are covered by self-insurance or self-funded health care in 48% of all companies with 200 to 999 employees; in companies with more than 999 employees, the proportion is already over 80%. 57% of all employees insured through the employer are insured in this way.

Transferability of employer-mediated health insurance

If an employee changes from one employer to the next, he must also switch to the group insurance taken out by the new employer. He also has to complete a health test, but the legal consequences of previous illnesses (see problem of previous illnesses) are mitigated by the Health Insurance Portability and Accountability Act (HIPAA).

An employee who becomes self-employed has to look for direct insurance because the insurance brokered by the employer expires on the last working day.

If, on the other hand, an employee loses his or her job, he or she can continue to be insured with employer-mediated health insurance for up to 18 months under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). In most states, however, this requires that the former employer has at least 20 full-time employees and that the employer has not fallen into bankruptcy. If COBRA is used, an additional 2% of the insurance premium must be paid as an administration fee. There is a significant increase in costs for the former employee, as the average employee has family insurance for an annual premium of $ 12,680. As long as he is employed by the employer, he usually only pays 27% or $ 3,423.60 himself, the rest is paid by the employer. In the event of unemployment, however, he must bear the entire insurance amount plus 2% COBRA fee himself. For example, if a single woman with an annual income of $ 30,000 becomes unemployed in the state of Colorado, she receives $ 1,385 a month from unemployment insurance. Average family insurance continued through COBRA costs $ 1,078 a month. Instead of COBRA, Medicaid or SCHIP can also be invoked under certain circumstances. The requirements for the purchase are very different in the individual states. Basically, it can be said that Medicaid is mostly out of the question for the unemployed (who receive unemployment insurance payments and have no children). Unemployed people with children, on the other hand, may be eligible for Medicaid if their income is low. As a result, 30% of the unemployed have private health insurance through COBRA or direct insurance, 20% are insured through Medicaid or another state social program and 50% are not insured .

Problems with previous illnesses

relevance

Employers who promise their employees health insurance cover (see insurance cover by the employer ) conclude a health plan with the respective insurance company. In this case, the possibility of a rejection of applicants because of pre-existing conditions (Pre-Existing Conditions) after the Health Insurance Portability and Accountability Act severely restricted. In contrast, 26.6 million US citizens have taken out their own health insurance (HMO, PPO or classic health insurance) (direct insurance). In this case, the insurance companies protect themselves against expensive risk patients by subjecting the applicant to a health examination and rejecting the application in the event of previous illnesses. Both in the case of direct insurance and in the case of health insurance brokered by the employer (group insurance), pre-existing conditions regularly lead to a refusal to cover the treatment costs (see other effects).

The background of the health check is that the insurance companies can refuse to conclude an insurance contract in the presence of certain physical conditions. The reasons for rejection include many serious pre-existing conditions such as arthritis, cancer, heart disease and so on, including widespread ailments such as acne, 10 kg overweight and 10 kg underweight. The applicant must ensure that they do not have any of the previous illnesses or health circumstances that entitle the insurer to refuse an insurance relationship. If necessary, the insurance company will also order a medical examination. There are various legal procedures within the states in applying this regulation, which is uniformly applicable in the United States. In some states the objective standard applies , according to which the applicant must state all previous illnesses for which he has received medical advice or help. In most countries, however, the prudent person standard applies , according to which the applicant must state all previous illnesses for which he has actually received medical advice or help, and also all previous illnesses that could have been suspected that a level-headed person would have sought medical advice .

A self-assessment and a possible medical examination are usually only necessary to conclude a health insurance contract. In most states, insurance companies do not have the right to request a new health exam later as long as the fixed premiums are always paid on time.

However, it is not uncommon for an insured person to change insurance after a few years and thus to pass a health examination again. Because the premiums can increase significantly if the average health of the policyholders of the same insurance product deteriorates. Young, healthy people then opt for another insurance policy with lower premiums, while the existing policyholders get older and therefore more expensive ( adverse selection ). Often the same insurance company puts out new products over and over again in order to attract customers with low premiums, while older insurance products are no longer actively sold. On average, insurance costs increase significantly (by around 35%) in the first five years.

Refusal to conclude a contract

A possible effect of a previous illness is the refusal to conclude a contract. In 2004, for example, 13% of applicants were denied insurance coverage. The rejection rate for under 18-year-olds is only 5%, while it rises to almost 33% for 60 to 64-year-olds.

Some states see the situation where a number of people cannot get insurance coverage as unsatisfactory:

  1. 34 states have created risk pools that serve to offer a state health plan to some people who cannot be insured because of previous illnesses. The specifics of these health plans vary considerably from state to state. Often the insurance premiums people have to pay are considerably higher than normal premiums despite government subsidies, and in some states they are twice as expensive as normal premiums. A total of 182,000 people (as of 2004) were provided with health insurance cover through such risk pools. So 25 uninsurable people received a health insurance cover. An expansion of the risk pool is currently not planned because of the already high costs.
  2. Insurance companies in the states of New York , New Jersey , Maine , Massachusetts, and Vermont are prohibited from rejecting applicants based on previous medical conditions. There, however, the insurance premiums are higher than in other countries.

Other effects

Instead of a complete refusal to conclude a contract, the insurance companies can also demand that certain risks are excluded from insurance cover:

  • The insurance company can request an examination of the applicant. All illnesses that become apparent at the time of the application can be excluded from the insurance cover when the contract is concluded.
  • Illnesses that have not been excluded from insurance cover can still be unilaterally excluded long after the insurance has been taken out. The prerequisite is that the insurance company can prove that it was a pre-existing illness which, even if it was not diagnosed at the time, already existed when the contract was signed. This look-back period is limited in most states. For example, if an insured with insurance taken out in the state of Iowa requires payment of medical bills, then the insurer may review the entire medical history of the policyholder for the past 5 years within the first 2 years of signing the contract. In Iowa, the prudent person standard applies. If the insurer finds out that the illness was so clearly recognizable before the conclusion of the contract that a level-headed person would have had a medical examination carried out at that time, insurance cover can be subsequently denied.

The amount of the contributions to health insurance is also based on the state of health of the respective applicant:

  • Those who were able to take out insurance paid standard rates 76% of the time. In 22% of the cases, however, the insurance companies demanded higher rates that included a risk surcharge.

State health care

A Veterans Health Administration hospital in Durham, North Carolina

Medicare is a welfare state public health insurance scheme for the elderly (65+) and disabled Americans that serves 41.4 million citizens. It was introduced on July 30, 1965.

Medicaid is a welfare state public health insurance scheme for low-income Americans serving 39.6 million citizens. Although the states and the federal government share the cost, each state determines the requirements for obtaining Medicaid. In addition to Medicaid, there may be other (smaller) state or municipal aid programs for the poor. Because of the bureaucratic effort and low remuneration, not all doctors accept Medicaid patients. As a result, Medicaid patients occasionally seek treatment in a hospital emergency room (under EMTALA) like uninsured people.

The State Children's Health Insurance Program (SCHIP) is a welfare state aid program that was founded in 1997. Eligible are children whose parents have an income that is too high for Medicaid but too low to be able to pay for private health insurance. Pregnant women whose income falls into this category are also eligible. 6.6 million children and 0.6 million women now take advantage of this program.

TRICARE is a government health program for military personnel and retired soldiers and their dependents. The Veterans Health Administration provides medical assistance to retired soldiers, war wounded or socially disadvantaged veterans.

The Indian Health Service (IHS) provides health care services to 1.8 of the 3.3 million members of the nationally recognized Indian tribes. For this purpose, there are hospitals and health stations operated by the IHS in the reservations.

Percentage of residents with state health insurance or state health care

In 1986 the Emergency Medical Treatment and Labor Act (EMTALA) was passed. According to this law, hospitals must accept any patient who is admitted as an emergency, even if they are not insured and cannot pay for the treatment. The treatment must be carried out with the necessary intensity until the immediately critical condition stabilizes. The state does not cover the costs of this treatment; the hospitals can only deduct these treatment costs from income tax as donations. An emergency within the meaning of the Emergency Medical Treatment and Labor Act exists if the patient has a condition that manifests itself through acute, very serious symptoms (including severe pain) and severe impairment of physical functions or organs can be expected without medical treatment is. This includes, for example, a woman giving birth who has a complication during childbirth that threatens the life of the woman or child. The hospitals may also be required to be transported by ambulance. EMTALA applies to “participating hospitals,” which are those that wish to treat Medicare or Medicaid patients. Since Medicare and Medicaid pay almost half of all medical services in the American health system, practically no clinic can afford not to participate in EMTALA. About 55% of the treatments in intensive care units fall under EMTALA and are in fact provided free of charge. Since the hospitals are not reimbursed for the costs of inevitable EMTALA treatments, these losses are passed on to the other patients as hidden costs, which is considered to be one reason for the disproportionately high rise in health insurance costs in the USA. The treatment of illegal immigrants, who are also covered by the EMTALA law, is a very controversial issue in the US. Since the Medicare Prescription Drug, Improvement, and Modernization Act was passed in 2003, a lump sum of $ 250 million has been paid annually for the treatment of illegal immigrants.

The Medical Expenditure Panel Survey estimates that 56.1% of the cost of all health care provided in the United States is paid for by the government assistance programs described here.

Situation of the uninsured

There are three main reasons 45.7 million Americans don't have health insurance:

  1. You are too poor to be able to afford private health insurance, but too high a income to be covered by Medicaid .
  2. Due to previous illnesses, they are rejected by the insurance companies, so they cannot get health insurance cover.
  3. You want to save yourself the insurance costs. Either they consider themselves financially strong enough to pay larger medical expenses themselves, or they consciously accept emergency care through EMTALA.
Proportion of residents who have neither health insurance nor entitlement to public health care, in%

Around 19% of those who are not insured have sufficient income to be able to afford insurance cover. 25% of the uninsured meet all the requirements to be able to take advantage of a state aid program (if necessary). 56% of the uninsured cannot afford health insurance, but neither do they meet the requirements for a state aid program.

The proportion of the population who do not have health insurance varies greatly depending on the ethnic group. While only 10.4% of the white population have no health insurance coverage, it affects 19.5% of African Americans , 16.8% of Asians, and 32.1% of Hispanics .

The uninsured include 8.1 million children and 8.0 million young adults between the ages of 18 and 24 years. In the young adult segment, 28.1% are not insured. This high percentage is due to the fact that they are no longer included in the private or state health insurance of their parents when they turn 19. Parents' private health insurance sometimes covers them until they graduate from college. Since this age group first has to establish itself on the job market, many do not manage to get hired by an employer who offers a health program for its employees. Since they usually have to take on less well-paid work at first, they cannot afford their own health insurance.

Because the uninsured does not have the same market power as health insurers, they are unable to negotiate prices with doctors or hospitals in the way that health insurers can. They often have to pay two and a half times as much for services used as insured patients. According to EMTALA, insolvent uninsured persons are also entitled to emergency care. However, it is seen as a major problem that EMTALA only covers emergency medical services, but not aftercare; so the diseases are mostly not cured. According to a study by Harvard Medical School and the University of Washington School of Medicine, the uninsured have a 25% higher risk of dying from an illness than the insured. According to this study, 45,000 uninsured people die every year due to poor medical care; these deaths can be avoided with normal medical treatment. The libertarian think tank National Center for Policy Analysis criticizes the study because it already takes into account all people who were uninsured in the last few years of life, and not just those who were uninsured for a long time.

Uninsured people paid approximately $ 30 billion themselves for health care services in 2008 and received unpaid benefits worth approximately $ 56 billion. 75% of the unpaid benefits were financed by lump-sum, not specifically performance-related, payments from government aid programs. The costs for unpaid services to the uninsured are also passed on to insured patients as hidden costs. It is estimated that this effect increased the annual cost of average family insurance in 2005 by $ 922.

In addition to private and state provision, there is a special form of insurance through religious mission organizations . There, members of a religious community come together and make a monthly contribution to pay the members' health costs in solidarity if necessary. The works are often cheaper than regular insurance, but are not legally obliged to pay for certain medical services, or cap reimbursements with upper limits. You are therefore under criticism.

Service provider for infrastructure and research

The following table shows the supply of the population with providers of medical services and infrastructure in an international comparison:

resources Number per 10,000 inhabitants
United StatesUnited States United States GermanyGermany Germany AustriaAustria Austria SwitzerlandSwitzerland Switzerland FranceFrance France
doctors 26th 34 37 40 34
Nurse 94 80 66 110 80
Dental staff 16 8th 5 5 7th
Pharmaceutical staff 9 6th 6th 6th 11
Hospital beds 32 83 76 57 73

The relatively low number of doctors in the United States is also due to the fact that nurse practitioners and dental hygienists are taking on more medical treatment. Nurse practitioners are better trained than nurses but worse than doctors. These professionals are mainly used to save costs, as their salaries are lower than the doctors' fees.

A trend towards the formation of larger group practices can be seen among general practitioners. This results on the one hand from efficiency gains through specialization based on the division of labor, on the other hand from the increased administrative effort caused by managed care (Health Maintenance Organizations, Preferred Provider Organizations) and the prospective payment system (at Medicare). The average size of a group practice is 14.5 doctors.

The hospitals in the United States provide outpatient care, particularly in the emergency rooms or in the case of specialist clinics; in the majority of cases, however, the patients are treated as inpatients. Private hospitals are operated either as profit-oriented or non-profit organizations. Nonprofit hospitals are exempt from property tax, sales tax, and income tax, so only about 13% of hospitals in the United States are for profit. Acute care facilities are hospitals in which patients are treated for less than 30 days, on the other hand there are long-term care facilities such as nursing homes, rehabilitation centers and psychiatric hospitals. University clinics combine nursing, medical training, and research; large university hospitals are for example the Johns Hopkins Hospital or the Massachusetts General Hospital .

Many cities, counties, or states have their own hospitals. Most of them specialize in financially unprofitable health services. Some of them are located in sparsely populated areas, some of them specialize in costly treatments such as trauma treatment, emergency psychiatric treatment, treatment of alcohol and drug abuse cases, and treatment of burns. State hospitals are only open to special audiences. The Veterans Health Administration operates more than 150 veteran-only hospitals. This makes it the largest state health care provider. The Military Health System , which is subordinate to the Ministry of Defense , operates not only field hospitals, but also fixed hospitals in which active soldiers are cared for, including the Landstuhl Regional Medical Center located in Germany . The Indian Health Service operates hospitals and other health facilities that are open to members of the nationally recognized Indian tribes.

Urgent care providers are a relatively young institution, i.e. private companies that offer low-threshold emergency medicine for minor cases. The target group includes u. a. insured patients who, if they went to the emergency room , would have to bear a much higher share of their own costs than with the inexpensive private service provider.

The National Library of Medicine on the campus of the National Institutes of Health in Bethesda, Maryland is considered the world's largest medical library

There are tons of nonprofits in the United States that offer medical services for free or at greatly discounted prices. Often these are organizations that collect donations and that doctors register with on a daily basis for voluntary unpaid service. Although these societies play an important role in filling the loopholes in the safety net of the American healthcare system, their importance has long been underestimated. The organization "Remote Area Medical" was featured on the TV show 60 Minutes in 2008 . This organization was founded to provide medical assistance in the developing world. However, several years ago, founding member Stan Brock stated that health care was as inaccessible (for financial reasons) to some residents of the United States as it was in parts of the developing world. Since then, 60 percent of the missions have taken place in the USA. The American Red Cross is also a non-profit organization that, like the German Red Cross, is financed through donations and the sale of blood products. In addition to providing health services to those in need, the focus of activity is on the training of first aiders and health education of the population. In addition, the American Red Cross is officially responsible for disaster control .

The United States is a leader in medical research. For example, 70% of drug research is done by organizations headquartered in the United States. American researchers have received a Nobel Prize in Medicine 53 times. In 2000, nonprofit research institutes such as the Howard Hughes Medical Institute contributed 7% of the research costs, for-profit organizations contributed 57% of the costs, and the state-run National Institutes of Health contributed 36% of the research costs . Basic research is mainly carried out by universities and state research institutions.

Control, oversight and transparency

The Centers for Disease Control and Prevention's Emergency Operations Center
for investigating swine flu cases

A large number of public service organizations review risks to public health and the quality of health care services. The Centers for Disease Control and Prevention is an agency that researches risks to public health. The Food and Drug Administration (FDA) is a government agency that must seek approval for new drugs. The Centers for Medicare and Medicaid Services (CMS) have, among other competencies, the task of monitoring the quality of nursing homes and publishes a quality ranking for nursing homes to inform the population. There is state oversight of the content of health insurance policies that is jointly exercised by federal and state agencies. Resident doctors are monitored by state health departments.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a private, non-profit organization that reviews the safety and quality of medical services. Many health care organizations volunteer to be monitored by JCAHO inspections. This also publishes its results. The National Committee for Quality Assurance is a private, non-profit organization that has been reviewing health insurance benefits since it was founded in 1990. The so-called Healthcare Effectiveness Data and Information Set (HEDIS) contains a detailed assessment of a good 90% of American health insurance companies. The background to this is that many Americans, especially those who are insured with an HMO, are suspicious that their health insurance will be ready to cover the health care they need in an emergency. The Healthcare Effectiveness Data and Information Set is published regularly on the Internet and can be accessed free of charge by any user. However, this has so far only been used by a small number of policyholders for comparison purposes, as the evaluations are difficult to interpret. The National Committee for Quality Assurance is therefore trying to simplify the comparison even further.

financing

Also in the United States, the largest financier of health services is the state. 46.2% of the total expenditure is paid by the state; this includes both health services that are provided directly by state institutions and those that are provided by private institutions at state expense. The federal government contributes 33.7% of the total expenditure and the states, counties and municipalities 12.6%. Private health insurances finance 36% of the total expenditure. 14% of the total expenditure is paid directly by the residents. A smaller part of 3.8% is financed by others, especially private non-profit institutions.

Of the total health expenditure, 33% was used for hospital services, 23% for medical services, 13% for prescription drugs, 7% for care in old people's homes, 5% for dental services, 3% for services of the health authorities, 7% were for state Administrative costs and administrative costs of private health insurance companies and 9% were used for other services.

International quality comparison

The evaluation of health systems has long been a subject of research in health science. In 2000 the World Health Organization ( WHO) set targets against which it measures national health systems and carried out an international quality comparison. The following were defined as goals against which the health systems are to be measured:

  • the health level of the population,
  • the fair distribution of the financial burden (financial fairness) and
  • responding to the needs of the population in more general issues such as dignity, self-determination, data protection and customer orientation (dealing with patients).

The United States' health system was measured against these goals. The main results of this study are presented in the following sections. Since the database of the World Health Report 2000 study comes from 1997, these results are supplemented (as far as possible) by more recent studies. Further related studies are also presented.

Health system costs

According to the World Health Report 2000 (based on 1997 data), the US health system is by far the most expensive health system of the 191 member states. At the time, health care spending was 13.7% of GDP, or $ 4,187 per inhabitant.

According to the latest study by the OECD (based on data from 2009), the percentage of gross domestic product used for the costs of the health system has increased further. Likewise, per capita expenditure on health care has increased significantly:

OECD rank country Costs in% of GDP
1 United StatesUnited States United States 17.4
2 NetherlandsNetherlands Netherlands 12.0
3 FranceFrance France 11.8
4th GermanyGermany Germany 11.6
6-7 SwitzerlandSwitzerland Switzerland 11.4
8th AustriaAustria Austria 11.0
average OECD countries 9.5
OECD rank country Cost in
US dollars adjusted for purchasing power per capita
1 United StatesUnited States United States 7,960
2 NorwayNorway Norway 5,352
3 SwitzerlandSwitzerland Switzerland 5,144
8th AustriaAustria Austria 4,289
9 GermanyGermany Germany 4,218
average OECD countries 3.223
Number of obese people (BMI 30 or higher) in percent by country

Factors that drive costs up include smoking and obesity : obesity costs 36%, medical and hospital expenses and 77% medicines; for smokers, medical and hospital costs rise by 21% and drug costs by 28%. The number of adult smokers in the United States is now very low by international standards, at 16.7% of the population; only in Sweden there are fewer adult smokers. However, at 34.3%, the adult obesity rate is by far the highest rate among OECD countries. Another factor is stress . The economic damage caused by stress - stress-related loss of work and production as well as expenditure in the health system - is estimated at US $ 300 billion annually.

Another reason given is that uninsured persons and those policyholders who have to pay high co-payments for medical examinations often postpone urgently needed treatments or do not make use of preventive medical examinations due to the costs involved. As a result, they would suffer more severe forms of illness and more complications, which increases the cost of medical treatment. Cases of admission to hospital, which could be avoided with timely treatment, occur four times more frequently among uninsured persons than among those with health insurance. According to estimates by the National Center for Health Statistics, half of the treatments in American emergency rooms are non-emergency medical cases. This is mainly due to the fact that, according to EMTALA, insolvent patients are only eligible for treatment in the emergency room of a hospital, but this is more expensive than treatment by a resident doctor or dentist.

According to a study by the McKinsey Global Institute, the high costs are not due to an above-average use of health services in an international comparison. After that, US citizens, for example, take less medication and have shorter hospital stays than Europeans or Canadians. The high costs are due, on the one hand, to higher prices for health services and, on the other hand, to the high administrative costs of private health insurances: health insurers calculate a profit margin, have high advertising and brokerage costs and a high administrative burden for checking contracts and policyholder claims. American doctors and nurses or nurses achieve an above-average income in an international comparison. According to a study, health insurance costs, based on a comparable level of medical benefits, increased significantly more between 1970 and 2000 in private health insurances than in state Medicare. This is partly due to the fact that cost control through the selection of particularly efficient service providers (selective contracting) is not applied to the highest possible extent, because the health maintenance organizations precisely because of the strict limitation of the choice of doctor and hospital compared to less strict forms of insurance such as preferred provider organizations Have lost market share.

The American legal system is discussed as another reason for the high costs. Due to the American jury system, there are occasionally very high judgments for damages, most of which relate to non-physical damage such as mental cruelty and punitive damages . It is assumed that many doctors treat very carefully for fear of claims for damages (defensive medicine), in particular commission more radiological and laboratory examinations than necessary, or opt for a caesarean section more often . To what extent this has a financial impact is controversial. The highest estimate is $ 60-108 billion. Another study concludes that there is little financial impact of $ 54 million. According to various studies, restrictions on civil action in various states had little effect (approximately 0.3%) on the level of health insurance contributions compared to states with no restrictions.

Health level of the population

The average health of the population, which the WHO measures on the basis of the disease-reduced average life expectancy (= until 2001: disability-adjusted life expectancy , DALE; since 2002: healthy life expectancy , HALE), is relatively good, compared to other developed industrial nations, however, below average. According to the World Health Report 2000 study (based on data from 1997), the average life expectancy with reduced disease was 70.0 years, placing the United States in 24th place in an international comparison.

According to the WHO study (based on data from 2002) the average life expectancy of the population with reduced disease is 69.3 years. The United States ranked 27th:

It should be noted that there is a regionally and socially determined inequality of health opportunities: The average life expectancy within the USA is up to 18 years apart: In the ten richest areas, white men have a life expectancy of over 76.4 years, in poorly supplied areas the life expectancy of black men is 57.9 years. In addition, in many rural areas there is an undersupply of doctors and hospitals, which is why these areas have significantly higher rates of illness and mortality among babies and the elderly than the national average. According to a survey by the WHO, a disproportionately large number of Americans die from controllable infectious diseases such as pneumonia.

One reason for the shortened life expectancy of the poorer part of the population is inadequate health insurance coverage. Uninsured persons and those policyholders who have to pay high co-payments for medical examinations often delay urgently necessary treatments due to the associated costs or do not make use of preventive medical examinations. Since some diseases, such as cancer, are often incurable at an advanced stage, this also results in a relatively lower life expectancy for this population group. In addition, it is believed that the American healthcare system as a whole is too fixated on healing and too little money is spent on disease prevention.

Not only for the uninsured, but also for many low-income residents who have health insurance, there is a supply gap in dental services. With private health insurances, dental services are often not included in the scope of benefits. In those cases in which they are included in the scope of insurance, high co-payments often have to be made by the policyholder. In many states, Medicaid also bears no dental care for adult patients. For children, state health insurances such as Medicaid or SCHIP also cover dental treatment, but in many states the reimbursement is so low that the majority of dentists will not accept Medicaid or SCHIP patients. As a result, 25% of American children live with untreated tooth decay in their permanent teeth.

The WHO's Healthy Life Expectancy (HALE) was last updated on June 29, 2016:

WHO rank country Years of life in good health (as of 2015)
1 JapanJapan Japan 74.9
2 SingaporeSingapore Singapore 73.9
3 Korea SouthSouth Korea South Korea 73.2
4th SwitzerlandSwitzerland Switzerland 73.1
5 ItalyItaly Italy 72.8
8th FranceFrance France 72.6
14th AustriaAustria Austria 72.0
21st United KingdomUnited Kingdom United Kingdom 71.4
23 GermanyGermany Germany 71.3
36 United StatesUnited States United States 69.1
41 China People's RepublicPeople's Republic of China People's Republic of China 68.5
104 RussiaRussia Russia 63.4

Cost efficiency related to the state of health

When assessing the cost efficiency of the health system based on the state of health of the population, the United States only came 72nd in the World Health Report 2000 study (based on 1997 data):

WHO rank country
1 OmanOman Oman
2 MaltaMalta Malta
3 ItalyItaly Italy
4th FranceFrance France
15th AustriaAustria Austria
26th SwitzerlandSwitzerland Switzerland
41 GermanyGermany Germany
72 United StatesUnited States United States

Financial fairness

According to the World Health Report 2000 study (based on data from 1997), the US health system only ranks 54-55 (these two) when it comes to the fairness of participation in the costs of the health system and protection from financial risks Places are shared by the USA with the Republic of the Fiji Islands ). To measure this fairness, the level of the average income of a household - minus the expenses to cover the subsistence level - was compared with the level of its health expenditure. The health expenditure of a household includes all contributions, regardless of whether they are taxes, social security contributions, contributions to private health insurance or co-payments and co-payments from patients:

WHO rank country
1 ColombiaColombia Colombia
2 LuxembourgLuxembourg Luxembourg
3 BelgiumBelgium Belgium
6-7 GermanyGermany Germany
12-15 AustriaAustria Austria
38-40 SwitzerlandSwitzerland Switzerland
54-55 United StatesUnited States United States

The very high premiums of private health insurance in the USA are considered to be the basic problem . They often make it impossible for low wage earners to insure themselves and their families. They also prevent small businesses from offering health insurance to their employees. As a result, 40 million US citizens currently have no health insurance; According to estimates, insurance cover is inadequate for as many people as they only have one insurance policy with an inadequate range of benefits.

But US citizens with comprehensive health insurance also live with the risk of becoming insolvent if they become seriously ill. On the one hand, unlike in Germany, for example, there is no sickness benefit in the event of illness-related occupational disability . On the other hand, very high additional payments or deductibles are often agreed in the insurance policies. As a result, medical bills were the trigger for personal bankruptcies in 46.2% of all bankruptcy cases in the US in 2001. In 2007 the number increased to 62.1%. However, if the policyholder can no longer pay the insurance premiums, the private health insurers have the right to terminate the insurance contract. Medicare also provides for high co-payments, so that medical and medical bills can be a major financial problem even after retirement.

Dealing with patients

According to the World Health Report 2000 study (based on data from 1997), the US health system is the world leader in responsible treatment of patients. This was measured by respect for the patient (dignity, autonomy, confidentiality), the speed at which help is obtained, freedom in choosing a doctor and hospital and other criteria:

WHO rank country
1 United StatesUnited States United States
2 SwitzerlandSwitzerland Switzerland
3 LuxembourgLuxembourg Luxembourg
5 GermanyGermany Germany
12-13 AustriaAustria Austria

Overall rating in the WHO ranking

The overall assessment in the World Health Report 2000 study (based on data from 1997) was split into two parts. In the first evaluation, only the achievement of the defined goals was assessed:

WHO rank country
1 JapanJapan Japan
2 SwitzerlandSwitzerland Switzerland
3 NorwayNorway Norway
10 AustriaAustria Austria
14th GermanyGermany Germany
15th United StatesUnited States United States

In the second evaluation, the achievement of the defined goals was assessed taking into account the financial expenditure:

WHO rank country
1 FranceFrance France
2 ItalyItaly Italy
3 San MarinoSan Marino San Marino
9 AustriaAustria Austria
20th SwitzerlandSwitzerland Switzerland
25th GermanyGermany Germany
36 Costa RicaCosta Rica Costa Rica
37 United StatesUnited States United States

The study was criticized in the USA for the fact that the evaluation of the state of health and performance does not take into account the fact that in some countries such as the USA there is a politically deliberate inequality of health opportunities. Nor had it been taken into account that the more expensive health systems had a greater chance of medical advances. Other voices pointed out that research spending is only a small fraction of the cost of the United States' health system anyway, and that future medical advances cannot be reliably foreseen. The greatest possible equality of health opportunities has also been a generally recognized goal in international scientific discourse since the Alma-Ata declaration (1978) at the latest . The evaluation of the treatment of patients was also criticized, the high ranking of the USA in this area contradicts the quite low satisfaction of the American population in international comparison. According to a survey by the American Hospital Association, the majority of Americans see their health care system as a consumer-unfriendly one, in which health insurance companies are characterized primarily by maximizing profit by refusing to cover costs and by reducing quality.

Emergency care

The congestion of emergency rooms in American hospitals is increasingly coming into the focus of the American public. According to a study by the Joint Commission on Accreditation of Healthcare Organizations , the condition poses a high risk for patients not to receive timely or inadequate treatment. The National Center for Health Statistics, part of the Centers for Disease Control and Prevention , published a study in 2002 that showed that the number of hospitals providing emergency rooms declined by 2% from 1997 to 2000, while the number of emergency room cases fell by 2% increased by 16% in the same period. The waiting time of patients who are in a condition that is not immediately life threatening has increased by 33%. For patients with an acute heart attack, the (average) waiting time has been increased from 8 minutes to 20 minutes. The main cause of this situation is the Emergency Medical Treatment and Labor Act (EMTALA) , which obliges hospitals to treat uninsured emergency patients free of charge. Since there is no reimbursement of costs for this from the state, the number of emergency admissions is steadily decreasing.

Number of beds in intensive care units per 1000 inhabitants (as of 2005):

country number
United StatesUnited States United States 2.7
GermanyGermany Germany 6.4
AustriaAustria Austria 6.1
SwitzerlandSwitzerland Switzerland 3.6

Health system reform

General lines of discussion

Proponents of general government health insurance
“Health care is not a 'right'. Nobody has a 'right' to someone else's work. The ghosts of Gettysburg . "
Proponent of the public-private model

General state health insurance

Some Americans, such as the Physicians for a National Health Program , point out that the premiums for private health insurance are now so high that more and more companies are canceling the agreed health insurance programs for their employees. They advocate the introduction of state health insurance for the entire population based on the European or Canadian model, which is known as "Universal Single-Payer Healthcare". As a single-payer system, this would be cheaper than the current system and there would no longer be the problem of those who are not or only insufficiently insured. Michael Moore's film Sicko took up this discussion . The film shows, among other things, cases of refusals of benefits by private health insurers that were malicious and only served to maximize profits. For example, a woman says that she ran to the nearest hospital with her feverish baby. There she was turned away because her health insurance (a health maintenance organization) only pays for treatment in contract hospitals. The baby suffered cardiac arrest on the way to the nearest contract hospital and could not be saved. Another scene shows how an insolvent patient after an emergency operation is dropped off on the street in front of the next best homeless shelter, where she walks up and down for hours, confused and disoriented. Critics close to the Republicans oppose the idea of ​​general state health insurance that this is a communist idea, namely socialized medicine, and therefore would not work. TV presenter John Stossel claimed in his television production “Whose Body is it Anyway? Sick in America. ”That“ socialized medicine ”is causing people in Canada to die waiting for medical treatment and people in the UK pulling their own teeth because of the long waiting times for dentists there.

Free market model

Libertarians like John Stossel and former presidential candidate Ron Paul declare that health care is not a human right. The solution to the problems of the American health system is a complete withdrawal of the state ( Free-Market Health Care). Medicare, Medicaid, the State Children's Health Insurance Program, and all other government co-payments for health care should end. The Emergency Medical Treatment and Labor Act (EMTALA) is to be repealed. Any state regulation of the health system, including with regard to the quality of the training of doctors and the monitoring of research and production of medicines, is to be repealed.

Public and private health insurances are generally useless. Health insurances create bureaucracy, encourage fraud and cause a moral hazard ” in that the insured use all services without looking at the prices. Stossel refers to the “mushrooming” doctor stands in supermarkets, where people who do not have health insurance can get small medical services for cash. As the United States has a growing number of people without health insurance, these doctor stands are becoming increasingly popular. Since the services are not billed through an insurance company and therefore there are no administrative costs, they are a little cheaper than in regular medical practices. This is countered by the fact that citizens without insurance are usually financially overwhelmed in the event of an expensive operation or lengthy treatment (for example in the case of chronic illness). Ex-President Barack Obama rejected the exit from the social security programs favored by Ron Paul, among others, as social Darwinism : It is easy to believe that the free market solves all problems better, in particular, this idea does not require sacrifices from those who are big Have drawn.

Single payer model

Proponents of health insurance based on the single-payer model, such as Healthcare-NOW! or the Progressive Democrats of America may also support the idea of ​​universal public health insurance. However, some reject the idea of ​​compulsory membership or prefer state-regulated, but privately-run insurance. However, they all agree that the introduction of a single-payer system would eliminate a large part of the administrative costs. Currently, administration accounts for 24% of spending in the US healthcare system. In European single-payer systems, however, the administrative effort is considerably lower. They also point out that 45% of US health care spending is already being absorbed by Medicare and Medicaid and thus financed by taxes. If private health insurances were to be abolished in favor of single-payer insurance, citizens would have to bear higher taxes or social security contributions, but at the same time payments to private health insurers would no longer apply, and the bottom line would be that citizens would have more money in their pockets.

Public-private model

Still others prefer a less radical change in the insurance system called a public-private model . They point out that in Germany, for example, state and private health insurances can coexist. Nevertheless, the costs in the German health system are lower. On the one hand, this is based on the fact that private insurance companies in Germany have far less freedom to reject insurance applications or to reject claims to benefits and, as a result, have a smaller administrative apparatus than American insurance companies. On the other hand, private health insurance companies in Germany would benefit from the fact that the state health insurance companies are lowering the prices for health services. The most prominent proponent of this model is former President Barack Obama.

Health reform 2010 ("Obamacare")

President Obama's campaign program

Barack Obama at a campaign event (2008)
Opponents of health reform in West Hartford on September 2, 2009
Healthcare reform advocate in Seattle on September 3, 2009
President Barack Obama's address to Congress on health system reform on September 9, 2009

Barack Obama had rejected compulsory health insurance in his election manifesto. He only wanted an exception for the children: in the future, all of them should be insured without exception. It is reasonable for parents to have their children insured, since health insurance for children is very cheap. However, since some parents are still unable to pay for insurance for their children, the State Children's Health Insurance Program (SCHIP) should be expanded.

However, the number of uninsured people should be reduced by expanding government aid programs and financial incentives as well as new guidelines:

  1. The introduction of new tax credits should make it easier for small businesses to provide health insurance to their workers and employees.
  2. At the same time, larger companies that offer their workers little or no health insurance coverage should be (compulsorily) involved in the financing of the public health system through a kind of payroll tax .
  3. In the future, health insurers should be prohibited from referring to previous illnesses , so-called pre-existing conditions . Given this justification, they should no longer be able to refuse payments or increase contributions.

In addition, Obama wanted to introduce state health insurance as a complement to private health insurance in line with the public-private model. This was similar to Medicare, but should be aimed at people who are not yet 65 years old. The target group should be primarily those people who cannot obtain health insurance from their employer and who are not already insured through Medicaid or SCHIP.

Legislative proposal by the leadership of the Democratic Party

The America's Affordable Health Choices Act of 2009 was designed by John Dingell , Charles B. Rangel , Henry Waxman , George Miller , Pete Stark , Frank Pallone and Rob Andrews introduced. He represents the legislative proposal of the leadership of the Democratic Party . The bill takes up President Obama's reform plans.

Extremely violent protests on the part of the Conservatives followed the reform plans presented in America's Affordable Health Choices Act of 2009 . One accusation with great media impact was the repeated assertion that the reform would introduce “death panels”. The background was that in the extensive legislative proposal, a sub-item was intended to be an amendment to Section 1861 of the Social Security Act in such a way that Medicare patients could in future be informed at state expense, among other things, of their doctor about the (already existing) possibility of an advance directive . This idea was borrowed from a legislative initiative tabled by Republican Congressman Charles Boustany , the Life Sustaining Treatment Preferences Act of 2009 . The right-wing newspaper Investor's Business Daily said it saw a plan to fathom the will to live of elderly citizens who should be systematically urged to euthanize by their doctor . Ultimately, euthanasia is planned for the elderly and the sick. The paper drew a comparison with the UK's national health system, the National Health Service , claiming that people with severe disabilities such as famous scientist Stephen Hawking had no chance of survival there. The "death panel" argument has been taken up by many Republicans , particularly former Republican candidate for Vice President Sarah Palin . Moderate Republicans opposed this strategy. Palin and others were criticized by the Republican Senator Lisa Murkowski : since there is no reason to deliberately stir up fear in the population about "death panels", which the America's Affordable Health Choices Act of 2009 does not provide at all, one should better practice serious and objective criticism. Republican Charles Boustany noted that the discussion on the subject had unfortunately gotten out of hand. Stephen Hawking finally felt compelled to make it clear that he had lived in Great Britain since his birth and was only still alive at all because of the very good medical care provided by the National Health Service .

Furthermore, the option of a state health insurance was discussed controversially. There are fears that private health insurance companies could lose customers on a large scale and therefore have to lay off employees. The cost of the reform was also discussed, especially the situation of smaller companies that could not afford to insure their workers. There is also controversy over whether the proposed bill could result in illegal immigrants benefiting from health insurance as well. President Obama attempted to address existing concerns in a speech to Congress on September 9, 2009.

Adoption of the 2010 health reform

The House of Representatives passed the Affordable Health Care for America Act , the successor to America's Affordable Health Choices Act of 2009 , on November 8, 2009 .

Max Baucus , chairman of the Senate Finance Committee (center) and Chuck Grassley , member of the Finance Committee (left)

On September 13, 2009, the Senate Finance Committee approved America's Healthy Future Act, introduced by Senator Max Baucus . This largely corresponds to the reform plans of the leadership of the Democratic Party, but provides for state-regulated private-law health insurance instead of optional state health insurance. On November 21, the Senate voted with a Democratic majority to put the Patient Protection and Affordable Care Act , an advancement of America's Healthy Future Act , on the agenda for debate. On December 21, 2009 the Senate finally voted with the necessary 3/5 majority for a time limit for the debates, thereby preventing a filibuster . A vote on the draft law took place on December 24, 2009, and the proposed law was adopted with 60 to 39 votes.

As a further step, the Senate and the House of Representatives had to agree on a uniform bill. However, the Democrats lost their 3/5 majority in the Senate through a by-election. This gave the Republicans the opportunity to delay the legislative process considerably through filibusters .

Therefore, a path has been taken to avoid the possible blockade in the Senate. Accordingly, on March 21, 2010, the House of Representatives passed the Senate Patient Protection and Affordable Care Act by 219 votes to 212 , which became law. The Health Care and Education Affordability Reconciliation Act of 2010 contains the changes requested by the Democratic representatives in the House of Representatives to the Patient Protection and Affordable Care Act . In a second step, the Health Care and Education Affordability Reconciliation Act of 2010 was passed on the same day with 220 votes to 211. The Senate met and voted on this law on March 25, 2010 in the reconciliation process , in which a filibuster is not possible. The Health Care and Education Affordability Reconciliation Act of 2010 was passed in the Senate with 56 votes to 43.

Endorsed by the United States Supreme Court

Some organizations (such as the National Federation of Independent Business), parts of the Republican Party and some states had brought legal action against the health care reform. The main point of contention was the introduction of general compulsory insurance. On June 28, 2012, the Supreme Court of the United States ( National Federation of Independent Business v. Sebelius ) upheld the constitutionality of essential parts of the Patient Protection and Affordable Care Act . The court denied that Congress had a competence, which can be derived from the Commerce Clause of the constitution, to oblige citizens to take out health insurance. The majority of constitutional judges interpreted the fine for (non-exempt) uninsured persons, which will come into effect from 2014 when the health reform is passed, as a tax that is covered by the federal taxation authority. Only the power of the federal government provided for in the law to punish the states in the upcoming expansion of the Medicaid program with the withdrawal of all Medicaid funds in the event of a lack of cooperation, the court ruled that it was constitutional.

Effects of the reform

Changes made by the Patient Protection and Affordable Care Act :

Changes that come into force within six months of being passed:

  • Health insurance companies are prohibited from rejecting patients because of pre-existing conditions .
  • Health insurance companies are prohibited from charging higher insurance premiums for children with previous illnesses.
  • Children may remain insured in their parents' family insurance until they are 26 years old.
  • In all new insurance policies, health insurers must undertake to cover the costs of preventive examinations without being able to demand additional payments from the insured.
  • All insurance companies must publish their balance sheet on the Internet and, in particular, break down the administrative costs in detail.
  • Small businesses can claim increased tax deductions when they offer health insurance to their employees .
President Obama and other members of the government are watching the House of Representatives vote on health care reform in the White House's Roosevelt Room

Changes that should take effect by 2014:

  • Health insurance companies are also prohibited from charging higher insurance premiums for adults with previous illnesses.
  • The health insurance contributions of old people cannot be more than three times as high as the health insurance contributions of young people with the same insurance company.
  • Residents with an income of up to 133%, measured against the state-defined poverty line (2010: USD 11,344 annual income), are insured by the (welfare state) Medicaid .
  • For residents with an income of up to 400%, measured against the state-defined poverty line, the health insurance contributions are subsidized by the state.
  • Families can deduct health insurance costs more from tax than before.
  • Residents who do not have health insurance must pay fines (up to 2% of income) unless they are very poor or have religious reasons not to get health insurance.
  • Companies with more than 49 full-time employees have to pay a fine per employee if they fail to provide their employees with (adequate) health insurance coverage.
  • States are allowed to establish state-run health insurance exchanges so that small businesses ( too small for self-funded health care ) and residents without employer -sponsored health insurance can jointly take out group insurance with private health insurance providers .
  • Residents who must spend more than 9.5% of their income on health insurance contributions are allowed to take out the health insurance policy with a government agency. This authority is to set up at least two group insurances in cooperation with private health insurances, of which at least one works for the public benefit.

Changes that should take effect by 2018:

  • Health insurers are also obliged to cover the costs of preventive medical examinations for policyholders with long-term insurance policies without being able to demand additional payments from the insured.
Signing of the Patient Protection and Affordable Care Act on 23 March 2010

Changes made by the Health Care and Education Affordability Reconciliation Act of 2010 :

  • The state subsidy for health insurance costs for residents with an income of up to 400%, measured against the state-defined poverty line, is being expanded in relation to the Patient Protection and Affordable Care Act.
  • Medicare patients will be reimbursed up to $ 250 for prescription drugs. (This is to close the so-called "donut hole" in Medicare insurance benefits).
  • Penalty payments from residents who have not taken out health insurance are increased by an additional 0.5% of income over the Patient Protection and Affordable Care Act.
  • Medicaid patient treatment payments have been 20% lower than Medicare patient treatment payments. As a result, many doctors refused to treat Medicaid patients. The payments for Medicaid patients are therefore to be increased.
  • Companies from the 31st full-time uninsured employee must pay a fine of $ 2000 per employee if they fail to provide their employees with (adequate) health insurance. The regulation of the Patient Protection and Affordable Care Act has been tightened.

According to estimates by the Congressional Budget Office , this has the following effects:

The number of uninsured people should decrease by a total of 32 million. An expansion of Medicaid is expected to reduce the number of uninsured by 17 million. Another 17 million uninsured and around 9 million already insured are to get (better) private health insurance through state health insurance exchanges, with the state paying part of the insurance premiums in most cases.

The cost of the reform is expected to be $ 940 billion over the next 10 years. These expenses are to be counter-financed by tax increases of $ 400 billion (mainly through a higher payroll tax for high-income workers and a higher income tax for residents with high capital income and the so-called Cadillac tax on particularly expensive health insurance policies). Another major item is to reduce Medicare spending by $ 483 billion through efficiency gains. Overall, the reform is expected to reduce the budget deficit by $ 130 billion over the next 10 years.

The problem is that "Obamacare" only provides for mild fines for non-insured persons. Therefore, many young healthy people remain uninsured, while older sick people have taken out health insurance on the Obamacare exchanges. The result is that Obamacare policies only pay for emergency care. Even so, more than 75 percent of these insurances make losses. The insurance industry lost $ 2.7 billion in 2014 to Obamacare policies, and in 2015 the loss was almost double. In 2016, many insurers announced that they would withdraw from "Obamacare". Others are considering premium increases of up to 60 percent. The Republican Party announced a bill to abolish parts of Obamacare, namely the approaches to compulsory insurance.

President Trump's reform plans

Congressional Budget Office forecasts of the number of people under the age of 65 without health insurance (in%) under various legislative initiatives to amend Obamacare (green line = Better Care Reconciliation Act; blue, orange and red lines = alternative legislative initiatives). Forecast if Obamacare is retained = black line.

With the election of Donald Trump as president, the Republicans can theoretically abolish Obamacare or modify it heavily. However, there are different trends: Libertarians want Obamacare to be abolished without replacement. Others want to heavily modify Obamacare, but not abolish it. The Republican legislative proposal (as of mid-July 2017: Better Care Reconciliation Act ) provides for the following changes to Obamacare:

  • The obligation either to take out health insurance or to have to pay a moderate fine should be dispensed with.
  • Companies should no longer have to offer their employees a health insurance plan.
  • Taxes for people earning more than $ 200,000 a year, which were introduced to fund Obamacare, are to be abolished.
  • Health insurance should be able to offer people with previous illnesses cheaper health insurance with a reduced range of benefits.
  • Government spending on Medicaid is expected to decrease by 35% over the next 20 years.
  • Health insurances should be allowed to charge older people who take out health insurance for the first time or who change health insurance, five times as high contributions as young people (under Obamacare they cannot be more than three times as expensive).

This would make health insurance a little cheaper on average. However, 22 million people could lose their health insurance coverage. So far, the legislative initiatives have failed because of Republican deviants for whom the plans go too far or not far enough. In May 2017, Trump threatened to discontinue state subsidies to private health insurances, thereby “burning” Obamacare.

On July 25, 2017, the US Senate voted 50:50; Vice President Mike Pence (who has the right to vote as incumbent Senate President in a stalemate) voted to open a debate on an alternative law. A day later, 55 out of 100 senators voted against Majority Leader Mitch McConnell's plan to abolish Obamacare and only replace it later.

On September 25, 2017, the third attempt to amend Obamacare failed after Republican Senator Susan Collins announced that she would not support her party's latest bill. Senators Rand Paul and John McCain had previously announced that they would vote no. In addition, the deadline ended in September 2017 within which a bill to abolish or fundamentally amend Obamacare could have been passed with a majority of 50 votes in the Senate. 60 votes are required as of October 2017, making it unlikely that Obamacare will be abolished.

literature

  • Ronald M. Andersen, Thomas H. Rice, Gerald F. Kominski, Abdelmonem A. Afifi and Linda Rosenstock: Changing the US Health Care System: Key Issues in Health Services Policy and Management . Jossey-Bass, 2007, ISBN 978-0-7879-8524-0 . (English).
  • David Dranove: The Economic Evolution of American Health Care: From Marcus Welby to Managed Care . Princeton University Press, 2002, ISBN 978-0-691-10253-5 . (English).
  • Steven Jonas, Raymond Goldsteen, and Karen Goldsteen: An Introduction to the US Health Care System . Springer Publishing Company, 2007, ISBN 978-0-8261-0214-0 . (English).
  • Alan I. Marcus, Hamilton Cravens (Ed.): Health Care Policy in Contemporary America. Pennsylvania State University Press, University Park 1997, ISBN 978-0-271-01740-2 . (English).
  • Harry A. Sultz and Kristina M. Young: Health Care, USA: Understanding Its Organization and Delivery . Jones & Bartlett Publishers, 2008, ISBN 978-0-7637-4974-3 . (English).

Web links

Commons : United States Health System  - Collection of Pictures, Videos, and Audio Files

Individual evidence

  1. a b c United States Census Bureau : Study 2008 (English, accessed April 13, 2009; PDF; 3.0 MB)
  2. WHO : National health accounts: Country health information (accessed September 15, 2010)
  3. ^ Anthony Kovner, James Knickman, Viktoria Weisfeld, Health Care Delivery in the United States , 2011, ISBN 978-0-8261-0687-2 , pp. 25, 26
  4. United States Census Bureau, Health Insurance Coverage in the United States: 2015 , Report Number: P60-257, Jessica C. Barnett and Marina Vornovitsky, September 13, 2016
  5. ^ Harry A. Sultz, Christina M. Young: Health Care USA - Understanding Its Organization and Delivery , page 34, Jones and Bartlett Publishers LLC 2003, ISBN 978-0-7637-2571-6
  6. David Dranove: The Economic Evolution of American Health Care: From Marcus Welby to managed care , page 37, Princeton University Press 2002, ISBN 978-0-691-10253-5
  7. a b David Dranove: The Economic Evolution of American Health Care: From Marcus Welby to managed care , page 28, Princeton University Press 2002, ISBN 978-0-691-10253-5
  8. ^ Harry A. Sultz, Christina M. Young: Health Care USA - Understanding Its Organization and Delivery , p. 55, Jones and Bartlett Publishers LLC 2009, ISBN 978-0-7637-4974-3
  9. David Dranove: The Economic Evolution of American Health Care: From Marcus Welby to Managed Care , page 48, Princeton University Press 2002, ISBN 978-0-691-10253-5
  10. David Dranove: The Economic Evolution of American Health Care: From Marcus Welby to managed care , page 41, Princeton University Press 2002, ISBN 978-0-691-10253-5
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This article was added to the list of excellent articles on December 16, 2009 in this version .