Organization of Health Care Systems and Levels of Care

Question 1

Essential components of health care systems

Answer 1

• “…A good health system delivers quality services to all people, when and where they need them.”
• a robust financing mechanism;
• a well-trained and adequately paid workforce;
• reliable information on which to base decisions and policies;
• well maintained facilities and logistics to deliver quality medicines and technologies

Question 2

characteristics of the organization of health care service delivery

Answer 2

• The mix of organizations that provide health-care services;
• The division of activities among these organizations;
• The interactions among these organizations and their relationship with the rest of the political and economic environment—especially how they get the resources they need to continue to exist;
• The internal administrative and management structures and processes of these organizations.

Question 3

in the ideal health care delivery system:

Answer 3

• Patients’ clinical information is available
• Patient care is coordinated
• There is clear accountability for the total care
• Patients have access
• Providers are culturally competent and responsive
• The system is continuously innovating
• If we do not want the status quo, how do we want health care to be delivered? The Commission has identified six attributes of an ideal health care delivery system, each of which has been demonstrated to be an important driver of high performance:
  
  • 1.Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.
  • 2.Patient care is coordinated among multiple providers, and transitions across care settings are actively managed.
  • 3.Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work, and collaborate to reliably deliver high-quality, high-value care.
  • 4.Patients have easy access to appropriate care and information including after hours; there are multiple points of entry to the system; and providers are culturally competent and responsive to patients’ needs.
  • 5.There is clear accountability for the total care of patients.
  • 6.The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery.

Question 4

Regionalization and coordination of services vs dispersed services

Answer 4

• Regionalization and coordination of services in a defined area (primary care base)
• Dispersed services – with more value on tertiary services, and more direct access to specialists.
• British NHS – an example of regionalized care
  
  • 1. 2/3 of UK physicians are GPs.
  • 2. Secondary care – specialists, usually in hospital based clinics, consultants
  • 3. Tertiary care sub-specialists – immunologists, pediatric hematologists, transplant specialists
• Hospitals and provider placement follows population calculations – i.e. what number of people, with particular demographics, require what number of providers, at what level.
• Dispersed model in the US – less structured approach, less oversight, regulation and guidance form government.
• Patients can access specialists directly.
• 2nd tier specialists like internists and pediatricians function as primary care providers, and have provided hospital as well as out patient care. Which is changing now, with use of hospitalists. Even with pediatricians and internists as PC providers, this only accounts for 1/3 of US providers.
• Hospitals in US do not operate within a secondary and tertiary classifications, with many private hospital offering highly specialized services to attract patients and providers. Not efficient, or high quality.
• While it may offer greater flexibility of services and convenience - top-heavy with specialists, expensive, fragmented often uncoordinated care.

Question 5

American health care is delivered by a “cottage industries”

Answer 5

• fragmentation at national, state, community, and practice levels
• no single national entity or set of policies guiding the health care system
• states divide their responsibilities among multiple agencies,
• providers in the same community, caring for the same patients, often work independently
• primary care system is struggling
• Health care delivery in the United States has long been described as a “cottage industry,” characterized by fragmentation at the national, state, community, and practice levels. There is no single national entity or set of policies guiding the health care system; states divide their responsibilities among multiple agencies, while providers practicing in the same community and caring for the same patients often work independently from one another. Furthermore, the fragile primary care system is on the verge of collapse. This report from The Commonwealth Fund Commission on a High Performance Health System examines the problem of fragmentation in our health care delivery system, particularly at the community level, and offers policy recommendations to stimulate greater organization.

Question 6

US health care systems in the US

Answer 6

• Tend to follow a dispersed model
• With fragmented systems of care
• Only 1/3 physicians are generalists/PCP (PAs and NPs tend to be more likely to provide primary care)
• Many medium size hospitals offer a broad range of services.
• Fewer procedures -> higher complication rates
• High importance on patient autonomy, choice, convenience
• Proportion of PAs providing primary care services? NPs?

Question 7

The US fragmented system

Answer 7

• patients and families navigate unassisted
• poor communication and lack of clear accountability
• the absence of peer accountability,
• quality improvement infrastructure,
• clinical information systems
• high-cost, intensive medical intervention is rewarded more than higher-value primary care
• In our fragmented system:
  
  • patients and families navigate unassisted across different providers and care settings, fostering frustrating and dangerous patient experiences;
  • poor communication and lack of clear accountability for a patient among multiple providers lead to medical errors, waste, and duplication;
  • the absence of:
    
    • peer accountability,
    • quality improvement infrastructure,
    • clinical information systems
  • These deficiencies foster poor overall quality of care;
  • high-cost, intensive medical intervention is rewarded over higher-value primary care, including preventive medicine and the management of chronic illness

Question 8

How and why did health care develop as a “dispersed” model of care in the US?

Answer 8

• Biomedical model of health care (illnesses have discrete pathophysiological causes that can be treated and eradicated with specific treatments)
• Financial incentives (favoring specialist procedure oriented care, gov’t support of hospital expansion)
• Professionalism (sovereignty of physicians as pre-eminent authorities on health care, reliance on presumed responsibility for acting in patients’ best interests and self-regulation)
• Growing awareness of importance of PC in last few decades (1970s…) with inclusion of psychosocial, family, cultural, environmental contributions to health and disease. More than physiology and anatomy, pathogens, and genetic hiccups.
• -Burton-Hill Hospital Construction Act (1946) – to expand hospital capacity rather than development of ambulatory services. Also supported residency training. Medical AND nursing practice shifted to hospital rather than community base.
• Professionalism - US is unique in not having as much government regulation of health care resources, hospital resources, allocation and training of health care workers (specialists vs generalists), coordination of public health and medical care services.
• US has provided financing without as much oversight and control over health services.
• Physicians were relied on to determine need and development of facilities and services, which with the influence of the biomedical paradigm and financial incentives structured to favor specialist and hospital centered care led to emphasis of tertiary care over primary care base. The AMA exerted considerable power over the organization, financing, and delivery of medical in the US

Question 9

how much care is needed for 1000 adults in one month?

Answer 9

• 750 – sick or injured (one or more episodes/mo.)
• 250 – visited physician at least once
• 9 – admitted to hospital
• 1 – referred to university medical center

Question 10

“levels” of care

Answer 10

• Primary – common problems, preventive care (80-90% of patient visits)
• Secondary – specialized care, hospital care
• Tertiary – treatment of rare and complex disorders

Question 11

tertiary care

Answer 11

• Less common, but more costly problems
• Overemphasis on the tertiary care apex of the triangle creates a mismatch between resources and the prevalence and incidence of health problems.
• There is a direct relationship between the frequency with which a provider or facility performs a specialized procedure, and the quality of the outcome for the patient. (D.Barr; Health Policy)
• i.e. A rural hospital with 3 cases of _______ per year….

Question 12

characteristics of “primary care”

Answer 12

• Initial contact
• Continuous care
• Comprehensive
• Coordination of care
• In the US -> Primary Care includes family practice, general internists, general pediatricians, PAs, generalist nurse practitioners
• Integrated, accessible health care
• Maintain sustained relationship with patients, in context of family and community.

Question 13

benefits of primary care

Answer 13

• Preventive care
• Adherence to treatment
• Appropriate treatment per indications
• Reduced hospitalizations
• Patient satisfaction with care
• Improved indicators (IMR, LE, $)

Question 14

Care coordination

Answer 14

• “Gatekeeping” preventing inappropriate visits to specialists or for unnecessary procedures
• Tracking and follow-up – making sure that acute and specialty care is followed up on, that high risk pts get the recommended screening and management, etc
• Advocate for patient – assist pt (with hospitals, specialists, insurers) in getting the needed care
• Provide assistance with navigating health care systems – educate and advise pts how to get the care they need

Question 15

How can we fix fragmented care?

Answer 15

• Patient incentives. Patients should be given incentives to choose to receive care from high-quality, high-value delivery systems. This requires performance measurement systems that adequately distinguish among delivery systems. Payment…
• Regulatory changes. The regulatory environment should be modified to facilitate clinical integration among providers. Limit unnecessary duplication of facilities and services
• Accreditation. There should be accreditation programs that focus on the six attributes of an ideal delivery system we have identified. Payers and consumers should be encouraged to base decisions on payment and provider networks on such information, in tandem with performance measurement data.
• Provider training. Current training programs for physicians and other health professionals do not adequately prepare providers to practice in an organized delivery system or team-based environment. Provider training programs should be required to teach systems-based skills and competencies, including population health, and be encouraged to include clinical training in organized delivery systems.
• Government infrastructure support. We recognize that in certain regions or for specific populations, formal organized delivery systems may not develop on their own. In such instances, we propose that the government play a greater role in facilitating or establishing the infrastructure for an organized delivery system, for example through assistance in establishing care coordination networks, care management services, after-hours coverage, health information technology, and performance improvement activities.
• Health information technology. Health information technology provides critical infrastructure for an organized delivery system. Providers should be required to implement and utilize certified electronic health records that meet functionality, interoperability, and security standards, and to participate in health information exchange across providers and care settings within five years.

Question 16

Payment reform

Answer 16

• fee-for-service payment fuels fragmentation
• bundled payments reward coordinated, high-value care.
• pay-for-performance rewards high-quality, patient-centered care.
• The more organization in delivery systems, the more feasible these payment reforms become. These payment reforms also could spur organization, since they reward optimal care over the continuum of services.
• No single policy will fix the fragmentation of our health care system. Rather, a comprehensive approach is required—one that might lead progressively to greater organization and better performance. We recommend the following strategies:
• Payment reform. Provider payment reform offers the opportunity to stimulate greater organization as well as higher performance. The predominant fee-for-service payment system fuels the fragmentation of our delivery system. We recommend that payers move away from fee-for-service toward bundled payment systems that reward coordinated, high-value care. In addition, we recommend expanding pay-for-performance programs to reward high-quality, patient-centered care. The more organization in delivery systems, the more feasible these payment reforms become. These payment reforms also could spur organization, since they reward optimal care over the continuum of services. Specifically, we believe that:
• Full population prepayment—a single payment for the full continuum of services for a given patient population and period of time—should be encouraged. Such payments should be adequately risk-adjusted to avoid adverse patient selection. If full population prepayment is not feasible, payers should encourage:
• Global case payments for acute hospitalizations. Ideally, such payments should bundle all related medical services from the initial hospitalization to a defined period post-hospitalization (including preventable re-hospitalizations). These payments also should be risk-adjusted to avoid adverse patient selection.
• Alternative payment structures for primary care. Primary care practices that provide comprehensive, coordinated, patient-centered care (e.g., certified medical homes) should be offered an alternative to fee-for-service payment. Promising alternatives include comprehensive prepayment for primary care services or fee-for-service payments plus a per-patient care management fee.
• Pay-for-performance should be expanded. The more bundled the payment mechanism, the higher proportion of the payment should be tied to performance. These programs should migrate away from measures that focus on individual processes in a single provider setting (e.g., hemoglobin A1C testing rates for patients with diabetes) toward broader measures of quality, such as clinical outcomes (e.g., blood pressure control or hospital readmission rates), care coordination, or patient experiences.
• Medicare should support further demonstration projects that test innovations in o payment design and care delivery.

Question 17

Full population prepayment

Answer 17

• “Full population prepayment”—a single payment for the full continuum of services for a given patient population and period of time.
• Full population prepayment—a single payment for the full continuum of services for a given patient population and period of time—should be encouraged. Such payments should be adequately risk-adjusted to avoid adverse patient selection.

Question 18

global case payments

Answer 18

• Global case payments for acute hospitalizations. Ideally, such payments should bundle all related medical services from the initial hospitalization to a defined period post-hospitalization (including preventable re-hospitalizations). These payments also should be risk-adjusted to avoid adverse patient selection.
• Global case payments for acute hospitalizations. Ideally, such payments should bundle all related medical services from the initial hospitalization to a defined period post-hospitalization (including preventable re-hospitalizations). These payments also should be risk-adjusted to avoid adverse patient selection.

Question 19

alternative payment models (APMs) or structures for primary care

Answer 19

• Primary care practices that provide comprehensive, coordinated, patient-centered care (e.g., certified medical homes) as an alternative to fee-for-service payment.
• Promising alternatives include comprehensive prepayment for primary care services or fee-for-service payments plus a per-patient care management fee.
• Alternative payment structures for primary care. Primary care practices that provide comprehensive, coordinated, patient-centered care (e.g., certified medical homes) should be offered an alternative to fee-for-service payment. Promising alternatives include comprehensive prepayment for primary care services or fee-for-service payments plus a per-patient care management fee.
• HHS has set a goal of tying 30 percent of Medicare fee-for-service payments to quality or value through alternative payment models by 2016 and 50 percent by 2018. HHS has also set a goal of tying 85 percent of all Medicare fee-for-service to quality or value by 2016 and 90 percent by 2018. To support these efforts, HHS has launched the Health Care Payment Learning and Action Network to help advance the work being done across sectors to increase the adoption of value-based payments and alternative payment models.

Question 20

Prospective payment system

Answer 20

• A payment mechanism for reimbursing hospitals for inpatient health care services in which a predetermined rate is set for treatment of specific illnesses.
• The payment amount for a particular service is derived based on the classification system of that service - for example, diagnosis-related groups (DRGs)for inpatient hospital services.\
• The Medicare Prospective Payment System (PPS) was introduced by the federal government in October, 1 1983, as a way to change hospital behavior through financial incentives that encourage more cost-efficient management of medical care. Under PPS, hospitals are paid a pre-determined rate for each Medicare admission. Each patient was classified into a diagnosis-related group (DRG) on the basis of clinical information. Except for certain patients with exceptionally high costs (“outliers”), the hospital is paid a flat rate for the DRG, regardless of the actual services provided.
• Enter the DRGs
• Each Medicare patient is classified into a DRG according to information from the medical record that appears on the bill:
  
  • •principal diagnosis (why the patient was admitted);
  • •complications and co-morbidities (other secondary diagnoses);
  • •surgical procedures;
  • •age and patient gender; and
  • •discharge disposition (routine, transferred, or expired).

Question 21

Structures of medical practice

Answer 21

• Physician offices – dispersed independent fee-for-service. Physicians admitted and cared for patients in hospitals - supporting hospital services.
• Multispecialty Group Practices. Physicians salaried, practice collected fees-for-services.
• Community Health Centers – team approach, comprehensive medical and public health care, targeting low-income populations.
• Prepaid Group Practice/Health Maintenance Organizations (HMOs). Kaiser.
  
  • Vertical integration – “under one roof”
  • Virtual integration – networks, Independent Practice Associations (IPAs).
• Preferred Provider Organization (PPO)
• Will talk about this next week as well, but will introduce some of the structure of provision of hc services today…
• In the past, primary MDs also worked in hospitals , admitting and caring for their patients there. Symbiotic relationship with hospitals – brought in patients, for medical wards, surgery, ICU, other services that hospitals could bill for.
• Dispersed independent fee-for-service.
• Multispecialty Group Practices. Physicians salaried, practice collected fees-for-services.
• Opposed by AMA and others.
• Kaiser-Permanente – Medical Care Program – largest HMO
  
  • 1.Kaiser Foundation Health Plan – insurer
  • 2.Kaiser Foundation Hospitals Corporation – owns and administers hospitals
  • 3.Permanente Medical Group – physician organizations that administer group practices and provide medical services to Kaiser plan members under capitated contract.
• PPOs – pts can see any providers, but lower costs if using in-network. Providers agree to accept payment as set by insurer.
• Vertical HMOs tend to rank higher in measures of quality of care. Virtual models offfer some benefits in coordination, but less different from FFS.
• Prepaid Group Practice name change to HMOs in 70s partly to avoid the socialism accusations from AMA and others.

Question 22

Accountable care organizations (ACOs)

Answer 22

• “…groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients…”
• What is risk adjustment in the context of ACOs?
• Risk adjustment helps to determine if a particular population of patients is sicker than another similar group. We have all heard physicians say, “My patients are sicker, and that is why they cost more.” Risk adjustment is an objective way to determine the illness burden of a group of patients.
• A simple example of risk adjustment might be differential payment levels based on age and gender. Proper risk adjustment should discourage ACOs or providers from shunning sicker patients or “cherry picking.”

Question 23

Patient-centered medical home (PCMH)

Answer 23

• The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.
• The medical home encompasses five functions and attributes:
• 1. Comprehensive Care
     * The primary care medical home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities.
     
     • More about Comprehensive Care
• 2. Patient-Centered
     * The primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. Recognizing that patients and families are core members of the care team, medical home practices ensure that they are fully informed partners in establishing care plans.
     * More about Patient-Centered Care
• 3. Coordinated Care
     * The primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team.
     * More about Coordinated Care
• 4. Accessible Services
     * The primary care medical home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care. The medical home practice is responsive to patients’ preferences regarding access.
     * More about Accessible Services
• 5.Quality and Safety
  
  • The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.
  • More about Quality and Safety
• Physician-led practice
  
  • Whole-person orientation, comprehensive care, including acute care, chronic care, preventive services, and end-of-life care, at all stages of life.
  • Integrated and coordinated care, culturally and linguistically appropriate.
  • Focus on quality and safety, quality improvement process and evidence-based medicine to continually improve patient outcomes.
  • Access, enhancing patients’ access to care.
  • A number of nationwide PCMH recognition and accreditation programs exist.

Question 24

Halth care systems - four basic national models

Answer 24

• Three basic goals of a country’s health care system:
  
  • keeping people healthy,
  • treating the sick,
  • protecting families against financial ruin from medical bills.
• Health Care Systems – Four Basic Models
• There are about 200 countries on our planet, and each country devises its own set of arrangements for meeting the three basic goals of a health care system: keeping people healthy, treating the sick, and protecting families against financial ruin from medical bills.
• But we don’t have to study 200 different systems to get a picture of how other countries manage health care. For all the local variations, health care systems tend to follow general patterns. There are four basic systems:

Question 25

Socialized Medicine or “beveridge” model

Answer 25

• “Single payer national health service”
• Government financed and controlled, with varying degrees of private services
• Most hospitals and clinics owned by government
• Most providers paid by the government
  
  • (i.e. Great Britain, Cuba, Scandinavian countries)
• 1. THE BEVERIDGE MODEL (“single payer national health service”)
     * Named after William Beveridge, the social reformer who designed Britain’s National Health Service. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library.
     * Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge.
     * Countries using the Beveridge plan or variations on it include its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong still has its own Beveridge-style health care, because the populace simply refused to give it up when the Chinese took over that former British colony in 1997. Cuba represents the extreme application of the Beveridge approach; it is probably the world’s purest example of total government control.
     * While the model is implemented differently in each country, it operates on the basis of a set of one or more common characteristics:
     
     • 1. Health care is a human right, not a privilege
     • 2. Government ownership and operation of health care
     • 3. National government responsibility for delivery of equitable and efficient health care
     • 4. Full access to all regardless of ability to pay
     • 5. Primary care physician as gatekeeper to the rest of the system

Question 26

Social insurance or “bismarck” model

Answer 26

• uses a health insurance system
• usually financed jointly by employers and employees through payroll deduction.
• insurance plans are nonprofit and must include all citizens.
• providers and hospitals tend to be private
• (i.e. Germany, France, Belgium, the Netherlands, Japan)
• 2. THE BISMARCK MODEL (“social insurance model”)
     * Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Despite its European heritage, this system of providing health care would look fairly familiar to Americans. It uses an insurance system – the insurers are called “sickness funds” – usually financed jointly by employers and employees through payroll deduction.
     * Unlike the U.S. insurance industry, though, Bismarck-type health insurance plans have to cover everybody, and they don’t make a profit. Doctors and hospitals tend to be private in Bismarck countries; Japan has more private hospitals than the U.S. Although this is a multi-payer model – Germany has about 240 different funds – tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides.
     * The Bismarck model is found in Germany, of course, and France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in Latin America.

Question 27

National Health Insurance Model (beveridge plus bismarck)

Answer 27

• elements of both the Beveridge and Bismarck
• private-sector providers
• payment comes from government-run insurance program that all citizens fund through a premium or tax.
• (i.e. Canada’s National Health Insurance, Taiwan, South Korea)
• 3. THE NATIONAL HEALTH INSURANCE MODEL (“single payer national health insurance”)
     * This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance.
     * The single payer tends to have considerable market power to negotiate for lower prices; Canada’s system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated.
     * The classic NHI system is found in Canada, but some newly industrialized countries – Taiwan and South Korea, for example – have also adopted the NHI model.

Question 28

the out-of-pocket model

Answer 28

• Health care paid directly by patient
• Those that have money and can pay for health care get it, and those that do not stay sick or die.
• Generally used in countries too poor or disorganized to provide any kind of national health care system.
• (i.e. Most developing countries of the world - to varying degrees)
• 4. THE OUT-OF-POCKET MODEL (“market driven” health care)
     * Only the developed, industrialized countries – perhaps 40 of the world’s 200 countries – have established health care systems. Most of the nations on the planet are too poor and too disorganized to provide any kind of mass medical care. The basic rule in such countries is that the rich get medical care; the poor stay sick or die.
     * In rural regions of Africa, India, China and South America, hundreds of millions of people go their whole lives without ever seeing a doctor. They may have access, though, to a village healer using home-brewed remedies that may or not be effective against disease.
     * In the poor world, patients can sometimes scratch together enough money to pay a doctor bill; otherwise, they pay in potatoes or goat’s milk or child care or whatever else they may have to give. If they have nothing, they don’t get medical care.

Question 29

the US model

Answer 29

• Fragmented – has elements of all four models:
• Beveredge –socialized medicine for veterans, military, Native Americans.
• Bismark – social insurance for most people with jobs
• National Health Insurance - for Americans over the age of 65, some who are poor or disabled
• Out of Pocket – for those who don’t qualify or have health insurance
• Pre- ACA, which is an attempt to at least move in the direction of universal coverage…
• in 2010 (pre-ACA):
  
  • 27% of U.S. residents were covered under public programs (both Beveridge and National Health Insurance models)
  • 56% received primary coverage through private insurers
  • 16% lacked health insurance entirely.
• When it comes to treating veterans, we’re like Britain or Cuba.
• For Americans over the age of 65 on Medicare, we’re like Canada.
• For working Americans who get insurance on the job, we’re like Germany.
• For the 15 percent of the population who have no health insurance, we are like most of the developing countries, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you’re sick enough to be admitted to the emergency ward at the public hospital.
• The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it’s fairer and cheaper, too.