THE ECONOMICS OF HEALTH CARE
The United States has no national health program that provides physician services, medications, and a hospital bed when required. A multiplicity of insurance plans exists instead, including voluntary nonprofit plans such as Blue Cross, commercial plans of the major insurance corporations, the national Medicare plan (primarily for those over 65), and Medicaid, a federal-state scheme for those needing financial aid. In all of these insurance schemes a limit exists to coverage, and in most there is a copayment requirement for coverage of physician services. Thus in all of these plans 30% to 40% of health costs, on the average, turn out to be the responsibility of the patient.
One growing trend in this area is the development of health maintenance organizations, or HMOs. Enrollees in an HMO select a primary-care physician from the plan's panel. For a set fee, the enrollee is provided with primary physician services, specialist services as needed, drugs, and hospital coverage. There is less choice of physician and hospital in an HMO than in an insurance plan, but the financial advantage both to the employer and to the employee are powerful motivating forces. That is, health-care costs in the United States are continuing to increase, and these costs are paid for either from the tax dollar (Medicare and Medicaid) or by health insurance, which as part of the wage package directly reduces the take-home pay of an employee. Consequently, there is great appeal in the notion of reducing costs without diminishing the amount of health care. Because the largest single item in the total health-care bill is hospital care, increasing emphasis has been placed on decreasing lengths of hospital stay and restricting the ease of admission into a hospital. In fact, medical economists have been aware for some time that the major cost reduction in HMOs has resulted from reducing the number of hospital days per thousand enrollees.
The pressure exerted on all hospitals by the various insurance plans has resulted in a shorter length of stay for the average admission and in a heightened competition for admissions among hospitals. The result is that a patient currently admitted into a hospital is more acutely ill, on the average, than a patient in years past, thereby requiring more complex and advanced and, inevitably, more expensive therapy. Those hospitals that cannot compete have a decreased percentage of bed occupancy, which can swiftly lead to financial pressure to close the hospital. Some 10% of the hospitals currently functioning in the United States are expected to close within the 1990s; many of them will be small, inefficient, ill-equipped rural hospitals. At the same time, since patients can no longer be admitted to hospitals solely for testing (insurers no longer pay the costs for such admissions), the trend has been established to do testing on an ambulatory basis. Ambulatory surgical centers have been developed in which procedures that once required days of hospitalization are done within an hour of the patient's entrance in the early morning.
Worldwide, as many systems of health-care financing exist as there are countries. They range from the comprehensive schemes of Great Britain and the Scandinavian countries to nations that can or do provide little or no care.
TRENDS IN MEDICINE
The rapid changes just described as taking place in the U.S. medical-care system are likely to continue. Establishment of a national health plan, as in Great Britain, is considered less probable than the expansion of insurance coverage to selected groups. In 1994, President Bill Clinton proposed a health-care-reform plan that included private comprehensive insurance coverage for all Americans, but the bill was dismantled in Congress. Numerous other proposals to reform health care (to a greater or lesser extent) and to control costs are under discussion.
Medicine and the law are currently maintaining an uneasy relationshipas seen in the rising number of malpractice suits. Of equal moment are new medical dilemmas with strong ethical and legal overtones that have been brought about by the introduction of new therapies and techniques. These include the definition of death for purposes of organ transplantation or for cessation of care to the terminally ill, surrogate motherhood, and decisions as to who shall benefit from treatment modalities. In the United States these legal problems are exacerbated by the fact that most of them fall under state law, so that similar cases must be tried in several jurisdictions before legal precedents are firmly established.
On the whole, medical care in the United States, at its best, is unequaled anywhere else in the world. Such care, however, is not uniformly available. For example, infant mortality in the nation exceeds that of other technologically advanced countries. Much of the population enjoys an infant mortality rate comparable to the rates observed in Scandinavian countries, but at the lowest socioeconomic stratum the infant mortality rate is comparable to those in Third World countries. Thus the United States simultaneously enjoys the best andÑin terms of developed countriesÑthe worst of medical care.