. From
CDC: "Maternal deaths include deaths of women while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes." Variations in the
efficiency of healthcare delivery can cause variations in outcomes. The
Dartmouth Atlas Project, for instance, reported that, for over 20 years, marked variations in how medical resources are distributed and used in the US were accompanied by marked variations in outcomes. The willingness of physicians to work in an area varies with the income of the area and the amenities it offers, a situation aggravated by a general shortage of doctors in the US, particularly those who offer primary care. The ACA is anticipated to produce an additional demand for services which the existing stable of primary care doctors will be unable to fill, particularly in economically depressed areas. Training additional physicians would require some years. Lean manufacturing techniques such as
value stream mapping can help identify and subsequently mitigate waste associated with costs of healthcare. Other product engineering tools such as
FMEA and
Fish Bone Diagrams have been used to improve efficiencies in healthcare delivery. Since 2004 the
Commonwealth Fund has produced reports comparing healthcare systems in high income countries using survey and administrative data from the
OECD and
WHO which is analyzed under five themes: access to care, the care process, administrative efficiency, equity and healthcare outcomes. The US has been assessed as worst healthcare system overall among 11 high-income countries in every report, even though it spends the highest proportion of its gross domestic product on healthcare. In 2021 Norway, the Netherlands and Australia were the top-performing countries. The US spent 16.8% of GDP on healthcare in 2019; the next highest country on the list was Switzerland, at 11.3% of GDP. The lowest was New Zealand, which spent roughly 9% of its GDP on healthcare in 2019. It "consistently demonstrated the largest disparities between income groups" across indicators, apart from those related to preventive services and the safety of care.
Efficiency Preventable deaths In 2010,
coronary artery disease,
lung cancer,
stroke,
chronic obstructive pulmonary diseases, and traffic accidents caused the most years of life lost in the US. Low back pain,
depression,
musculoskeletal disorders, neck pain, and
anxiety caused the most years lost to disability. The most deleterious
risk factors were poor diet, tobacco smoking, obesity,
high blood pressure,
high blood sugar, physical inactivity, and alcohol use.
Alzheimer's disease, drug abuse, kidney disease and cancer, and falls caused the most additional years of life lost over their age-adjusted 1990 per-capita rates. According to a 2009 study conducted at
Harvard Medical School by cofounders of
Physicians for a National Health Program, a pro-single payer lobbying group, and published by the
American Journal of Public Health,
lack of health coverage is associated with nearly 45,000 excess preventable deaths annually. Since then, as the number of uninsured has risen from about 46 million in 2009 to 49 million in 2012, the number of preventable deaths due to lack of insurance has grown to about 48,000 per year. The group's methodology has been criticized by economist
John C. Goodman for not looking at cause of death or tracking insurance status changes over time, including the time of death. A 2009 study by former
Clinton policy adviser Richard Kronick published in the journal
Health Services Research found no increased mortality from being uninsured after certain risk factors were controlled for.
Value for money A study of international healthcare spending levels published in the health policy journal
Health Affairs in the year 2000 found that the US spends substantially more on healthcare than any other country in the
OECD (OECD), and that the use of healthcare services in the US is below the OECD median by most measures. The authors of the study conclude that the prices paid for healthcare services are much higher in the US than elsewhere. While the 19 next most wealthy countries by GDP all pay less than half what the US does for healthcare, they have all gained about six years of life expectancy more than the US since 1970. In 2024, a 22-year-old from Wisconsin died after being unable to afford an
asthma inhaler. Cole Schmidtknecht, who had battled chronic asthma since childhood, was denied his inhaler when he went to collect his prescription, as the price had jumped from $66 to over $500, a price he could not afford. He would die two weeks later.
Delays in seeking care and increased use of emergency care Uninsured Americans are less likely to have regular healthcare and use preventive services. They are more likely to delay seeking care, resulting in more medical crises, which are more expensive than ongoing treatment for such conditions as diabetes and high blood pressure. A 2007 study published in
JAMA concluded that uninsured people were less likely than the insured to receive any medical care after an accidental injury or the onset of a new chronic condition. The uninsured with an injury were also twice as likely as those with insurance to have received none of the recommended follow-up care, and a similar pattern held for those with a new chronic condition. Uninsured patients are twice as likely to visit hospital emergency rooms as those with insurance, burdening a system meant for true emergencies with less-urgent care needs. In 2008 researchers with the
American Cancer Society found that individuals who lacked private insurance (including those covered by Medicaid) were more likely to be diagnosed with late-stage cancer than those who had such insurance.
Variations in provider practices The treatment given to a patient can vary significantly depending on which healthcare providers they use. Research suggests that some cost-effective treatments are not used as often as they should be, while
overutilization occurs with other healthcare services. Unnecessary treatments increase costs and can cause patients unnecessary anxiety. The use of prescription drugs varies significantly by geographic region. The overuse of medical benefits is known as
moral hazard—individuals who are insured are then more inclined to consume healthcare. The way the healthcare system tries to eliminate this problem is through cost sharing tactics like copays and deductibles. If patients face more of the economic burden they will then only consume healthcare when they perceive it to be necessary. According to the RAND health insurance experiment, individuals with higher coinsurance rates consumed less healthcare than those with lower rates. The experiment concluded that with less consumption of care there was generally no loss in societal welfare but, for the poorer and sicker groups of people there were definitely negative effects. These patients were forced to forgo necessary preventative care measures in order to save money leading to late diagnosis of easily treated diseases and more expensive procedures later. With less preventative care, the patient is hurt financially with an increase in expensive visits to the ER. The healthcare costs in the US will also rise with these procedures as well. More expensive procedures lead to greater costs. One study has found significant geographic variations in Medicare spending for patients in the last two years of life. These spending levels are associated with the amount of hospital capacity available in each area. Higher spending did not result in patients living longer.
Care coordination Primary care doctors are often the point of entry for most patients needing care, but in the fragmented healthcare system of the US, many patients and their providers experience problems with care coordination. For example, a Harris Interactive survey of
California physicians found that: • Four of every ten physicians report that their patients have had problems with coordination of their care in the last 12 months. • More than 60% of doctors report that their patients "sometimes" or "often" experience long wait times for diagnostic tests. • Some 20% of doctors report having their patients repeat tests because of an inability to locate the results during a scheduled visit. According to an article in
The New York Times, the relationship between doctors and patients is deteriorating. A study from
Johns Hopkins University found that roughly one in four patients believe their doctors have exposed them to unnecessary risks, and anecdotal evidence such as self-help books and web postings suggest increasing patient frustration. Possible factors behind the deteriorating doctor/patient relationship include the current system for training physicians and differences in how doctors and patients view the practice of medicine. Doctors may focus on diagnosis and treatment, while patients may be more interested in wellness and being listened to by their doctors. The use of hospitalists is sometimes mandated by health insurance companies as a cost-saving measure which is resented by some primary care physicians.
Administrative costs , there were 907 health insurance companies in the US, although the top 10 account for about 53% of revenue and the top 100 account for 95% of revenue. The number of insurers contributes to administrative overhead in excess of that in nationalized, single-payer systems, such as that in Canada, where administrative overhead was estimated to be about half of the US. Insurance industry group
America's Health Insurance Plans estimates that administrative costs have averaged approximately 12% of premiums over the last 40 years, with costs shifting away from adjudicating claims and towards medical management, nurse help lines, and negotiating discounted fees with healthcare providers. A 2003 study published by the
Blue Cross and Blue Shield Association (BCBSA) also found that health insurer administrative costs were approximately 11% to 12% of premiums, with Blue Cross and Blue Shield plans reporting slightly lower administrative costs, on average, than commercial insurers. For the period 1998 through 2003, average insurer administrative costs declined from 13% to 12% of premiums. The largest increases in administrative costs were in customer service and information technology, and the largest decreases were in provider services and contracting and in general administration. The McKinsey Global Institute estimated that excess spending on "health administration and insurance" accounted for as much as 21% of the estimated total excess spending ($477 billion in 2003). According to a report published by the
CBO in 2008, administrative costs for private insurance represent approximately 12% of premiums. Variations in administrative costs between private plans are largely attributable to economies of scale. Coverage for large employers has the lowest administrative costs. The percentage of premium attributable to administration increases for smaller firms, and is highest for individually purchased coverage. A 2009 study published by BCBSA found that the average administrative expense cost for all commercial health insurance products was represented 9.2% of premiums in 2008. One study of the billing and insurance-related (BIR) costs borne not only by insurers but also by physicians and hospitals found that BIR among insurers, physicians, and hospitals in California represented 20–22% of privately insured spending in California acute care settings.
Long-term living facilities As of 2014, according to a report published the higher the skill of the RN the lower the cost of a financial burden on the facilities. With a growing elderly population, the number of patients in these long term facilities needing more care creates a jump in financial costs. Based on research done in 2010, annual out of pocket costs jumped 7.5% while the cost for Medicare grew 6.7% annually due to the increases. While Medicare pays for some of the care that the elderly populations receive, 40% of the patients staying in these facilities pay out of pocket.
Third-party payment problem and consumer-driven insurance Most Americans pay for medical services largely through insurance, and this can distort the incentives of consumers since the consumer pays only a portion of the ultimate cost directly. In 2003, the
Medicare Prescription Drug, Improvement, and Modernization Act was passed, which encourages consumers to have a
high-deductible health plan and a
health savings account. In October 2019, the state of Colorado proposed running public healthcare option through private insurers, which are to bear the brunt of the costs. Premiums under the public option are touted to be 9% to 18% cheaper by 2022.
Equity Mental health In 2020, 52.9 million adults were affected by mental illness, nearly one in five adults in the country. 44.7 million adults were affected in 2016. In 2006, mental disorders were ranked one of the top five most costly medical conditions, with expenditures of $57.5 billion (equivalent to $ in ). A lack of mental health coverage for Americans bears significant ramifications to the
US economy and social system. A report by the
US Surgeon General found that mental illnesses are the second leading cause of
disability in the nation and affect 20% of all Americans. It is estimated that less than half of all people with mental illnesses receive treatment (or specifically, an ongoing, much needed, and managed care; where medication alone, cannot easily remove mental conditions) due to factors such as stigma and lack of access to care, including a shortage of mental health professionals. Treatment rates are understood to vary between different conditions; as an example, only 16% of adults with schizophrenia and 25% with bipolar disorder were estimated to be untreated with appropriate medication in 2007. Some entities try to expand access to mental health services by providing access on a
sliding-scale or reduced fee structure. Networks such as
Open Path Collective are composed of professionals who offer their services to people who cannot otherwise find affordable treatment through insurance. The Paul Wellstone Mental Health and Addiction Equity Act of 2008 mandates that group health plans provide mental health and
substance-related disorder benefits that are at least equivalent to benefits offered for medical and surgical procedures. The legislation renews and expands provisions of the
Mental Health Parity Act of 1996. The law requires financial equity for annual and lifetime mental health benefits, and compels parity in treatment limits and expands all equity provisions to addiction services. Insurance companies and third-party disability administrators (most notably, Sedgwick CMS) used loopholes and, though providing financial equity, they often worked around the law by applying unequal copayments or setting limits on the number of days spent in inpatient or outpatient treatment facilities.
Oral health In the US, dental care is largely not recognized as healthcare, even though individuals visit a dentist more often than a general practitioner, and thus the field and its practices developed independently. In modern policy and practice, oral health is thus considered distinct from primary health, and dental insurance is separate from health insurance. Disparities in oral healthcare accessibility mean that many populations, including those without insurance, the low-income, uninsured, racial minorities, immigrants, and rural populations, have a higher probability of poor oral health at every age. While changes have been made to address these disparities for children, the oral
health disparity in adults of all previously listed populations has remained consistent or worsened. In New York state, where the Medicaid program includes dental coverage, seven out of ten older adults (aged ≥ 65) have periodontal disease, and one in four adults (aged > 65) has no teeth. Older adults are also more likely than those in younger age groups to have medical conditions, such as diabetes and cardiovascular disease, that worsen their oral health.
Medical underwriting and the uninsurable Prior to the ACA,
medical underwriting was common, but, after the law came into effect in 2014, it became effectively prohibited.
Demographic differences image depicting racial health disparities in the US for
tuberculosis Health disparities are well documented in the United States in ethnic minorities such as
African Americans,
Native Americans, and
Hispanics. When compared to
White people, these minority groups have a higher incidence of chronic diseases, higher mortality, poorer health outcomes
, and poorer rates of diagnosis and treatment. Among the disease-specific examples of racial and ethnic disparities in the US is the cancer incidence rate among African Americans, which is 25% higher than among White people. In addition, adult African Americans and Hispanics have approximately twice the risk as White people of developing diabetes and have higher overall obesity rates. Minorities also have higher rates of
cardiovascular disease and
HIV/AIDS than White people. A 2001 study found distinguished racial differences exist in healthy life expectancy at lower levels of education. Public spending is positively correlated with age; average per capita public spending for seniors was more than five times that for children ($6,921 versus $1,225, equivalent to $ versus $ in ). Average public spending for non-Hispanic blacks ($2,973, equivalent to $ in ) was slightly higher than that for White people ($2,675, equivalent to $ in ) while spending for Hispanics ($1,967, equivalent to $ in ) was significantly lower than the population average ($2,612, equivalent to $ in )). Total public spending is also strongly correlated with self-reported health status ($13,770 [equivalent to $ in ] for those reporting "poor" health versus $1,279 [equivalent to $ in ] for those reporting "excellent" health). A new study has also found that older men and women in the South are more likely to be prescribed antibiotics than older Americans elsewhere, even though there is no evidence that the South has higher rates of diseases requiring antibiotics. There is considerable research into inequalities in healthcare where in certain cases, these inequalities are caused by income disparities that result in lack of health insurance and other barriers, such as medical equipment, to receiving necessary services. In some cases, these inequalities are caused by income disparities that result in lack of health insurance and other barriers, such as medical equipment, to receiving services. According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive
preventive services in healthcare. For example, minorities are not regularly screened for
colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic people. In other cases, inequalities in healthcare reflect a
systemic bias in the way medical procedures and treatments are prescribed for different racial and ethnic groups. Raj Bhopal, professor emeritus at University of Edinburgh, writes that the history of
racism in science and medicine shows that people and institutions behave according to the ethos of their times. Nancy Krieger, professor of social epidemiology at Harvard, wrote that racism underlies unexplained inequities in healthcare, including treatment for heart disease, renal failure, bladder cancer, and pneumonia. Results from a 2023 scoping review of the literature found that in studies conducted in multiracial or multiethnic populations, race or ethnicity variables were rarely included in conceptually thoughtful and analytically informative ways concerning race or ethnicity as markers of exposure to racialized social disadvantage. Bhopal writes that these inequalities have been documented in numerous studies whose consistent and repeated findings were that Black Americans received less healthcare than White Americans—particularly when the care involved expensive new technology. The consistent and repeated findings were that Black Americans received less healthcare than White Americans—particularly when the care involved expensive new technology. One recent study has found that when minority and White patients use the same hospital, they are given the same standard of care. The lack of equitable access to different resources is intrinsically tied to the field of public health, which works to supplement the traditional medical system with other services and opportunities.
Medical devices are expensive because the process of designing and approving them is extensive and costly, requiring that they be sold at higher than market price. The costs include research, design and development, meeting the U.S. Food and Drug Administration's regulatory guidelines, manufacture, marketing, distribution, and business plan. Cost, alongside the impact of systematic oppression and inequality of communities of color within healthcare, together make medical equipment inaccessible. Most studies focused on access to medical devices and enhancement of affordable local production have concluded that increasing access to medical devices in an attempt to meet healthcare needs is highly critical. Audio-based telehealth has been identified as a tool for improving healthcare access among underserved populations, including older adults, rural communities, and Black, Indigenous, and People of Color (BIPOC). The increase of
artificial intelligence (AI) in health care raises issues of equity and bias related to how health applications are developed and used. AI expansion is now of serious global interest towards public and private investment. The
Harrow Council launched the IBM Watson Care Manager system to match individuals, considering budget, with a provider and develop individual care plans. Within the US, the
FDA in 2017 cleared an AI medical imaging platform for clinical use as well as future devices. A recent scoping review identified 18 equity issues with 15 strategies to address them to try to ensure that AI applications equitably meet the needs of the populations intended to benefit from them.
Coverage of social determinants of health The access to medical care and services in the US is tied to the field of
public health, which works to supplement the traditional medical system with other services and opportunities to improve the
social determinants of health (SDOH) of populations. SDOH are external factors, systems, and structures that shape the experiences of different individuals and their access to healthcare. Examples of SDOH are poverty, work conditions, exposure to violence, substance abuse history, housing insecurity, and more. Studies have shown that people have adverse SDOH are more likely to experience negative health effects. In order to address these other upstream factors, some states have implemented Section 1115 waivers under Medicaid and Children's Health Insurance Program (CHIP), which allow for coverage of nontraditional services such as home-delivered meals, medical transportation, and educational services.
Trauma-informed care Some providers in the US advocate for the use of
trauma-informed care frameworks within their practice. Trauma-informed care frameworks center a patient's experience with trauma in the treatment plan and view medical care as one aspect of treatment. Advocates argue that doing so fosters more equitable and culturally sensitive care that is especially important when serving patients from
marginalized communities. Clinically, trauma-informed care can strengthen the
social determinants of health of patients, as well as provide impactful interventions for patients at high risk. Others suggest that upstream education during medical training is more beneficial, so healthcare providers themselves can manage
clinical medicine and SDOH together. == Prescription drug issues ==