Analyzing Form, Function, and Financing of the U.S. Health Care System PDF

Introduction

This book tells the story of the U.S. health care system by using a narrative approach identifying function rather than the more common data-driven focus on structure. This does not mean there are no numbers here and no attention to structure: there is both. Shifting the major focus to function changes the primary question from how the health care system operates to why. This shift in emphasis came after years of trying to explain the U.S. health care system to students and many different health care professionals. After a detailed explanation of how, the major question remaining is always, “But why do we do things this way?” Answering this question requires thinking about the U.S. health care system in a different way.

This includes integrating ideas from fields that are generally separated, such as the fields of public health, medical care organization, and health policy. This gives a more comprehensive view of the U.S. health care system, as well as an explicit discussion of philosophical and political values. The people who are usually interested in books such as this are students who want some kind of career in the health field. The multidisciplinary approach utilized in this book is also the most appropriate way to prepare for a health-related career. By focusing on telling the story of the American health care system, this book is accessible to those who do not want to work in this sector of the economy, but who need to understand it to utilize it better. This approach helps those already employed in the health care field. Since the training is so specialized, many do not understand anything other than their own small piece of the puzzle.

The U.S. health care system is an amazingly complicated puzzle: deconstructing it in order to describe and then analyze it is like the proverbial onion. Each topic reveals additional layers, but each layer is related to several others, so it is difficult to know where to begin. Almost no topic can be described without requiring knowledge of another. In the case of this book, there are three programs frequently referred to before they are fully explained. Two are long-standing programs that are part of our casual conversation about the health care field, but which few people actually understand. The Medicare program is a completely federally funded social insurance program that provides health care access to people over the age of 65, as well as disabled people of all ages. The Medicaid program is a joint federal–state entitlement program that provides access to people who are defined as poor, with an additional emphasis on women and children, as well as frail elders. These two programs are described in Chapters 18 and 19, but their impact is felt throughout the health care system, so there are many earlier references.

A similar situation occurs with the 2010 Patient Protection and Affordable Care Act, known colloquially as Obamacare, although this book will use the term Affordable Care Act (ACA). This Act has significantly influenced the entire health care system, and there are many references to it before it is fully explained in Chapter 17.

There are several topics included in this book that are not usually found in books about the U.S. health care system, even though their influence is very important. These are described in the summary of each section below. Three different fields are used in this book: medical care organization, public health, and health policy. Also included in this analysis are two philosophical frameworks. The first is based on the traditional economic values of free enterprise, where those with more money get more and better goods and service. Applying this allocation model to the health field produces some difficult situations, especially when we are faced with people in need of health care that they cannot afford. A different allocation model is based on medical need, without reference to ability to pay. This creates a different financing system: one that is funded by all through general taxes, and accessed when needed. The term social justice is used for this to emphasize the additional public health principle of believing that access to health care is a human right.

The tension between these two perspectives is an overarching theme of this book, as is the cost of our health care system. Cost and the desire to control expenditures are a primary driver for much of health policy, so it must be included as a major theme. However, this book is unusual in including two additional levels of analysis. The first is organizational structure, so there is much attention to whether medical care is being provided in a nonprofit or for-profit organization. This is important because of the second level of analysis, which covers the philosophical and political values that guide our health care system. Any discussion of the American health care system without understanding these values is incomplete and misleading. This perspective is woven through every chapter in this book.

There is no perfect health care delivery system. The overall goal of this book is to present policy decisions we have made about our health care system, and analyze some of their consequences in order to better understand the choices we have. To facilitate this analysis, this book is arranged in four major parts, each of which is described here.