Despite devoting a larger share of its GDP to health care than any other nation, the United States is one of the few developed countries that do not provide universal coverage to its citizens. The U.S. health care system is characterized by increasing costs in a competition-based market, questions about quality of care, and lack of access to health care by millions of U.S. citizens.
Competition in health care has become widespread since the mid-1980s. In the last few years, all of the stakeholders in health care have been scrambling to find the right approach, in terms of size and service, to remain competitive in the rapidly changing health care marketplace. The pervasive influence of managed care, the reductions in state and federal financial support and the ever-increasing sophistication of health care technology have combined to offer remarkable opportunities to break away from outdated traditions and take venturesome risks. The result has been better monitoring and control of costs, but legislators seem far more concerned with quality of care in managed care plans than they do in the cost of plans or access to care for the 40 million uninsured Americans.
The most significant issue facing the U.S. health care system is lack of health insurance and, as a result, access to health care. Estimated at some 40 million, the uninsured are among the country’s most economically and politically vulnerable citizens. Most are poor; two-thirds are in families with incomes less than twice the federal poverty level. Three-fourths of the uninsured are workers and their dependents. Many uninsured workers are employed only part-time, a growing segment of U.S. employment. These groups generally are in poorer health than those persons with health insurance. Health care resources are scarce relative to needs. The appetite for health care is virtually infinitely expandable. Furthermore, even if the United States increased the total resources devoted to health care (at the state or national level); there is a point at which other societal goals would force a limit to the allocation. In this context of scarcity, fair access must mean universal access to a basic level of health care or a basic benefits plan. There is a growing consensus that this question of access to health care services by all must be resolved.
In sum, the public and the other stakeholders in the health care system have a general dissatisfaction with the manner in which health care has been delivered the inexplicable variation in how patients are treated, the resultant costs, and the increasing number of people without access to at least a minimum level of basic care. Similar dissatisfaction exists among health care providers but for quite different reasons. Although the causes of the problems are easily identifiable, they do not lend themselves to simple, uncomplicated solutions. The vested interests in the traditional modes of health care delivery have repeatedly demonstrated their ability to generate political opposition to serious legislative challenges to the health care status quot. However, these same interests, including health care political lobbies, seem ineffectual in the face of overwhelming market forces. Rather than change occurring as a result of carefully crafted public policy, economic forces are driving a health care system reformation that is altering the roles of many traditional health care institutions. That some aspects of market-driven reform are painful and unpopular is simply a consequence of shifting the power from providers to purchasers and limiting consumer options. The end result, however, is expected to be a more comprehensive, coordinated, and cost-efficient system.