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US health-care system faces cost and insurance crises
SPECIAL REPORT
Loss of job leaves family without insurance Insurance loss leaves doctors scrambling for coverage Employer struggles with rising health costs US doctors press for malpractice reform Limits imposed on residents’ work hours McClellan’s FDA: boon to industry, consumers, or both? NIH director reviews first year on the job
US health-care system faces cost and insurance crises Rising costs, growing numbers of uninsured, and quality gaps trouble world’s most expensive health-care system Rights were not granted to include this image in electronic media. Please refer to the printed journal.
AP
he US health-care system again appears to be lurching towards crisis. The cost of health care continues to rise, eating up more and more of the country’s gross domestic product (GDP); the number of people who lack health-care coverage, after falling slightly during the 1990s, is again on the rise; and, despite the money spent, questions are being raised about the quality of care provided. US health-care spending reached US$1·4 trillion in 2001, up from $1·3 trillion the year before—a jump of 8·6%, according to a report by economists at the National Health Statistics Group at the US Center for Medicare and Medicaid Services. The increase outstripped the rate of overall inflation, raising the percentage of the country’s GDP being consumed by health-care spending from 13·3% to 14·1% (Health Aff 2003; 22: 154–64). Yet despite this spending, more than 41 million Americans—or roughly one in seven—went without health coverage for the entire year in 2001, and it is estimated that over a 2-year period about 80 million people will go without insurance for at least some period. Most of the uninsured adults are working poor employed in low-wage jobs or employees of small firms that cannot afford coverage. With employers facing a stubborn recession and sharp rises in insurance
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premiums, more workers are expected to lose insurance either because their employers stop offering coverage or because of layoffs. While most US hospitals must provide indigent care, the uninsured are less likely to receive care and the same quality of care than insured patients, according to a 2002 report by the US National Academy of Sciences Institute of Medicine (IOM, Care without coverage: too little, too late). Uninsured adults with diabetes, for example, were less likely to receive standard screening preventive care than insured adults, and one in four go without a checkup for 2 years if they have been uninsured for a year or more, the report said. 19% of uninsured people with heart disease and 13% with hypertension did not have a regular health-care provider, the IOM found, and when uninsured patients developed
acute cardiovascular disease, they were less likely to receive angiography and revascularisation procedures and more likely to die. But while the USA offers some of the finest, most advanced care in the world, many patients may not be getting the care they should, according a study by the RAND corporation that appeared in the New England Journal of Medicine in June (2003; 348: 2635–45). In the study, researchers interviewed and reviewed the medical charts of more than 6700 adults in 12 metropolitan areas. They found the participants received only 54·9% of recommended care. For example, only 24% of the participants with diabetes had received three or more glycosylated haemoglobin tests over the 2-year study period. And although 68% received the recommended care for coronary artery disease, only
THE LANCET • Vol 362 • August 2, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
45% of people presenting with myocardial infarction received -blockers and only 61% of those who were candidates for aspirin therapy were put on the drug. Despite these and other problems with the US system, there seems to be little popular support for a major overhaul of the system. The last major attempt at reform was by President Bill Clinton in the early 1990s, shortly after he was elected. At the time the country faced similar challenges: an economy in recession, soaring health-care costs, and a growing number of uninsured. Clinton’s ambitious reform legislation, however, was defeated, attacked by powerful interests in the health-care industry —including doctors groups, insurers, and pharmaceutical companies—and abandoned by an electorate that tends to be wary of government intervention. Since that defeat, major health reforms have been scarce. But unless the US economy turns around and people grow more confident that they will be able to get jobs with health insurance, health care is likely to become a major political issue in next year’s presidential election, especially as the Democrats are beginning to perceive health care as an issue on which President Bush is vulnerable. Michael McCarthy
375
Loss of job leaves family without insurance Insurance loss leaves doctors scrambling for coverage Employer struggles with rising health costs US doctors press for malpractice reform Limits imposed on residents’ work hours McClellan’s FDA: boon to industry, consumers, or both? NIH director reviews first year on the job
US health-care system faces cost and insurance crises Rising costs, growing numbers of uninsured, and quality gaps trouble world’s most expensive health-care system Rights were not granted to include this image in electronic media. Please refer to the printed journal.
AP
he US health-care system again appears to be lurching towards crisis. The cost of health care continues to rise, eating up more and more of the country’s gross domestic product (GDP); the number of people who lack health-care coverage, after falling slightly during the 1990s, is again on the rise; and, despite the money spent, questions are being raised about the quality of care provided. US health-care spending reached US$1·4 trillion in 2001, up from $1·3 trillion the year before—a jump of 8·6%, according to a report by economists at the National Health Statistics Group at the US Center for Medicare and Medicaid Services. The increase outstripped the rate of overall inflation, raising the percentage of the country’s GDP being consumed by health-care spending from 13·3% to 14·1% (Health Aff 2003; 22: 154–64). Yet despite this spending, more than 41 million Americans—or roughly one in seven—went without health coverage for the entire year in 2001, and it is estimated that over a 2-year period about 80 million people will go without insurance for at least some period. Most of the uninsured adults are working poor employed in low-wage jobs or employees of small firms that cannot afford coverage. With employers facing a stubborn recession and sharp rises in insurance
T
premiums, more workers are expected to lose insurance either because their employers stop offering coverage or because of layoffs. While most US hospitals must provide indigent care, the uninsured are less likely to receive care and the same quality of care than insured patients, according to a 2002 report by the US National Academy of Sciences Institute of Medicine (IOM, Care without coverage: too little, too late). Uninsured adults with diabetes, for example, were less likely to receive standard screening preventive care than insured adults, and one in four go without a checkup for 2 years if they have been uninsured for a year or more, the report said. 19% of uninsured people with heart disease and 13% with hypertension did not have a regular health-care provider, the IOM found, and when uninsured patients developed
acute cardiovascular disease, they were less likely to receive angiography and revascularisation procedures and more likely to die. But while the USA offers some of the finest, most advanced care in the world, many patients may not be getting the care they should, according a study by the RAND corporation that appeared in the New England Journal of Medicine in June (2003; 348: 2635–45). In the study, researchers interviewed and reviewed the medical charts of more than 6700 adults in 12 metropolitan areas. They found the participants received only 54·9% of recommended care. For example, only 24% of the participants with diabetes had received three or more glycosylated haemoglobin tests over the 2-year study period. And although 68% received the recommended care for coronary artery disease, only
THE LANCET • Vol 362 • August 2, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
45% of people presenting with myocardial infarction received -blockers and only 61% of those who were candidates for aspirin therapy were put on the drug. Despite these and other problems with the US system, there seems to be little popular support for a major overhaul of the system. The last major attempt at reform was by President Bill Clinton in the early 1990s, shortly after he was elected. At the time the country faced similar challenges: an economy in recession, soaring health-care costs, and a growing number of uninsured. Clinton’s ambitious reform legislation, however, was defeated, attacked by powerful interests in the health-care industry —including doctors groups, insurers, and pharmaceutical companies—and abandoned by an electorate that tends to be wary of government intervention. Since that defeat, major health reforms have been scarce. But unless the US economy turns around and people grow more confident that they will be able to get jobs with health insurance, health care is likely to become a major political issue in next year’s presidential election, especially as the Democrats are beginning to perceive health care as an issue on which President Bush is vulnerable. Michael McCarthy
375