Introduction to US Health Care Policy Flashcards
1
Q
US Health care system
A
- Health care has been a commodity distributed according to ability to pay (mostly…)
- Power has rested with the medical profession
- Government has had a minimal role
- No uniform standards of care (often reflects ability to pay)
- Historically (and to understand why we are where we are now, in the present, we need to look at our history), the US health care system has been based on these principles of social policy.
- Think of examples of each of these principles.
2
Q
Early medical care in the US
A
- 3 largest “sects” of doctors were:
- Homeopaths
- Osteopaths
- Allopaths
- Many others, including Naturopaths
- No common scientific basis
- No licensure or certification
- Large numbers of doctors
- Variety of providers, philosophies, training, no regulation or oversight
3
Q
American medical Association
A
- 1846 – formed primarily to improve physicians’ status
- Most members were allopathic physicians
- Instrumental in implementing recommendations of the Flexner Report
- Set standards for medical schools
- Requirements for licensure
- Defined code of ethics for physicians
- Developed rules for organizing and paying for medical practice – near total authority over physicians
- Powerful voice with lawmakers,
- Control of organization, financing and delivery of health care in the US
- Discouraged use of drugs not approved by them
- Segregation of blacks and women
4
Q
Flexner Report - 1910
A
- Standardized medical education
- Scientific basis
- State regulation and licensure
- KNOW THIS
- study of medical education in the United States and Canada,
- called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. Many American medical schools fell short of the standard advocated in the Flexner Report, and subsequent to its publication, nearly half of such schools merged or were closed outright.
- In 1904 the AMA created the Council on Medical Education (CME) whose objective was to restructure American medical education. At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation.
- Reduce the number of medical schools (from 155 to 31) and poorly trained physicians;
- Increase the prerequisites to enter medical training;
- Train physicians to practice in a scientific manner and engage medical faculty in research;
- Give medical schools control of clinical instruction in hospitals
- Strengthen state regulation of medical licensure
- Flexner believed that admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science.
- The AMA has consistently advocated strongly for autonomy of physicians and the provision of health care as a commodity
- Today, the U.S. is the only developed country that has a market approach to medical care, where it is a commodity to be bought and sold, rather than a social good that is available to all people
5
Q
early 20th century
A
- Authority vested in medical profession – early 20th Century
- AMA relied on by state and local governments in creation of regulations
- Medical profession was granted sovereignty over organization and financing of medical care
6
Q
Medical profession in the US
A
- Specialized knowledge, skills, ethics
- Altruism, paternalistic, unbiased agents for patients
- Control of knowledge, entry into profession, health care systems and finances
- Entrepreneurs
- Strong but developing conflicting roles, with development of technology and higher costs.
- Free services to the poor – in communities
- Maintenance of care as a commodity – fee-for-service (poor provided free care)
- With fee-for-service - Incentives to provide more care, perhaps more than medically necessary (US in comparison with other countries)
7
Q
Health care as a commodity in the US
A
- Generally commodities are exchanged in “Open Markets:”
- Free and open
- Equal information available for all parties
- Ability to compare/shop across sellers
- Product is voluntarily exchanged at a price arranged by mutual consent of the buyer(s) and seller(s)
- Governed by the laws of supply and demand
- Free of government interventions and regulations
8
Q
Health care markets: neither “free” nor “open”
A
- Buyers and sellers do not act independently to establish price, quality and quantity
- Third parties are involved: employers, insurers, administrators
- Competition is restrained by barriers
- Limits on expansion
- Licensure
- Accreditation
- Patients do not have information on price of services or providers
- Patients do not pay directly for services
- How do you decide whether you need to buy a medicine, hospitalization, or surgery?
- Elective vs non-elective – plastic surgery vs appendectomy
- Information is NOT equal
- Buyers don’t know:
- what the cost is
- what they are buying
- what the same service would cost elsewhere
- if they need the service
- Buyers are ill, scared, confused, overwhelmed, worried, unconscious,
- Regulation often dictates parameters and choices
- Lack of comparative information/data
- Buyers don’t know:
- Health care often obtained and purchased during times of extremis, based solely on the advice of a health care provider (who likely is not familiar with the financial options and consequences)
9
Q
United Nations Universal Declaration of Human Rights (1948)
A
- “…the equal and unalienable rights of all members of the human family..”
- “…Everyone has the right to a standard of living adequate for the health and well-being of him-self and of his family, including food, clothing, housing and medical care.”
- The US, despite its role in founding the UN, remains the only developed country choosing to have health care as a market commodity rather than a right.
10
Q
Market justice vs social justice
A
- Market Justice
- view health care as an economic good
- assumes free market conditions for health services delivery
- assumes that markets are more efficient in allocating health resources equitably
- production and distribution of health care determined by market based demand
- access to medical care veiwed as an economic reward for personal effort and achievement
- medical care distribution based on peoples ability to pay
- individual responsible for own health
- benefits based on individual purchasing power
- limited obligation to the collective good
- emphasis on individual well-being
- private solutions to social problems
- rationing based on ability to pay
- Social Justice
- views health care as a social resource
- requires active government involvement in health services delivery
- assumes that the government is more efficient in allocating health resources equitably
- medical resource allocation governed by need
- equal access to medical services viewed as a basic right
- ability to pay inconsequential for receiving medical care
- collective responsibility for health
- certain benefits ensured
- strong obligation to the collective good
- community well-being superseded that of the individual
- public solutions to social problems
- planned rationing of health care
11
Q
origins of US and Canadian culture
A
- 14 original British colonies in America:
- 13 Revolutionary vs 1 Loyalist
- Libertarian Accepted a strong state
- Egalitarian Respected authority
- Distrust of the state Deference
- Populism
- What are the origins of our culture?
- Historical origins – at least those with greatest influence on the development of policies laws regulations and commonly accepted practices.
- Does not necessarily take into account the influence and beliefs of minorities or those not in positions of power.
- Just one example is comparison with one of our neighbors - Canada
12
Q
Canada cultural beliefs
A
- Strong social democratic tradition, tradition of redistribution to maximize common good
- Accept the need for strong central government; health care as right of all residents, paid for by government
13
Q
Canada’s health care systems
A
- Health care is a basic right of all Canadians
- The power of the medical profession is limited to its social obligation
- Government retains monopsony power (single payer)
- There is one standard of care for all Canadians
- Monopsony – one buyer for many sellers of a commodity or service
- It is the flip side of a monopoly: It occurs when a buyer, rather than a seller, has sufficient market power to set its own price.
14
Q
united states - cultural beliefs
A
- Primacy on rights of individuals and distrust of central government.
- “Life, liberty, and the pursuit of happiness…”
- Health care is commodity in free market for individual to pursue
15
Q
US places high value on what?
A
- LIBERTY
- AKA, and expressed through:
- freedom
- autonomy (bioethics)
- privacy, choice, property, civil rights, entrepreneurialism, markets, dignity, respect, individuality
