N 4.
Public Health Care in Ukraine, Great Britain, the USA. Verbs. Auxiliary verbs
Health care or healthcare is the prevention, treatment, and management of
illness and the preservation of mental and physical well-being through the
services offered by the medical, nursing, and allied health
professions. According to the World Health Organization, health care
embraces all the goods and services designed to promote health, including
“preventive, curative and palliative interventions, whether directed to
individuals or to populations”. The organised provision of such services may
constitute a health care system. This can include a specific
governmental organisation such as, in the UK, the National Health Service or a cooperation across
the National Health Service and Social Services as in Shared Care.
Before the term "healthcare" became popular, English-speakers
referred to medicine
or to the health sector
and spoke of the treatment and prevention of illness
and disease.
The healthcare industry
The health care industry is
one of the world's largest and fastest-growing industries. Consuming over 10
percent of gross domestic product of most developed
nations, health care can form an enormous part of a country's economy.
In 2003,
health care costs paid to hospitals, physicians, nursing homes, diagnostic
laboratories, pharmacies,
medical device
manufacturers and other components of the health care system, consumed 15.3
percent of the GDP of
the United States,
the largest of any country in the world. For United States, the health share of
gross domestic product (GDP) is expected to hold steady in 2006 before resuming
its historical upward trend, reaching 19.6 percent of GDP by 2016. [2]
In 2001, for the OECD
countries the average was 8.4 percent [4] with the
According to Health Affairs,
USD$7,498 will be spent on every woman, man and
child in the
The healthcare industry
includes the delivery of health services by health care providers. Usually such services
receive payment from the patient or from the patient's insurance
company; although they may be government-financed (such as the National Health Service in the United Kingdom)
or delivered by charities or volunteers, particularly in poorer countries.
There are many ways of
providing healthcare in the modern world. The most common way is face-to-face
delivery, where care provider and patient see each other 'in the flesh'. This
is what occurs in general medicine in most countries. However, healthcare is
not always face-to-face; with modern telecommunications technology, in absentia health care
is becoming more common. This could be when practitioner and patient
communicate over the phone, video conferencing, the internet,
email, text messages,
or any other form of non-face-to-face communication.
Medical and social models of healthcare
A traditional view is that
improvements in health result from advancements in medical
science. The medical model of health focuses on the eradication of illness
through diagnosis
and effective treatment. In contrast, the social model of health places
emphasis on changes that can be made in society and in people's own lifestyles
to make the population healthier. It defines illness from the point of view of the individual's functioning
within their society rather than by monitoring for changes in biological
or physiological
signs.
To coincide with the 60th anniversary of
All high-tech extras - such as screws and rods - are paid for by the
patient. In a hospital in the Ukrainian capital, neurosurgeon Igor Kurylets, is
working on a patient's back. An 18-year-old woman lies face down on the
operating table, with about 30cm of spine exposed. The operation may look
somewhat primitive: there is a lot of rather violent bashing, scraping and
screwing going on. But this is in fact a state-of-the-art procedure. During the
four-hour operation, the patient's spine will be realigned from an inverted
S-shape to a straight, ordinary looking back.
All
high-tech extras - such as screws and rods - are paid for by the patient
Holding it all in place will be rods and screws, designed in the
It
used to be illegal to pay for medical services in a state hospital
All the basic medical provisions are supplied by the state-run hospital.
All the high-tech extras - the screws and rods, the specialised x-ray equipment
- are paid for separately by the patient. Dr Kurylets was one of the people who
pioneered this hybrid system in
Gratitude money
But the vast majority
of Ukrainians, when they fall ill, still use the system that the country
inherited from the
They are clean
though, and well maintained. But that is largely because the doctors themselves
contribute to the hospital's upkeep. We
pay for their hospital, so they have additional money to change windows and
doors, to redecorate the hospital - it is positive economic co-operation Dr
KuryletsOne surgeon on the urology ward agreed to speak to the BBC on condition
of anonymity. "Each of us puts in $100 or $200," he said. "And
with that money we pay to have the walls painted, replace some sanitary
facilities, varnish these floors, and so on." And it's not just cosmetic
improvements that the medical staff has to pay for. Reaching into his desk
draw, the doctor pulled out a handful of catheters and tubes wrapped in sterile
medical packaging: his own personal stash. "It's got to the stage now
where we are buying things we need in order to perform an operation." But
how does a doctor like this one, on a salary of about US$250 (£125) per
month, pay for all of this? It turns out that the free healthcare provided by
the state isn't entirely free after all. "A patient will come to me and
ask: 'Doctor, how much will this cost?' I leave it to the patient to thank me
as he sees fit in return for my work. "The level of gratitude can range
from 'thank you doctor', to a $4 bottle of cognac. Or it can be a certain sum
of money. A fairly large sum. Several times larger than my monthly
salary."
Hospital upkeep
Dr Kurylets believes
that his hybrid clinic maximises the potential of the immense but crumbling
state-run infrastructure. In return for the use of the SBU's medical
facilities, he treats security service personnel for free. And his clinic
contributes to the upkeep of their hospital. "We pay for their hospital,
so they have additional money to change windows and doors, to redecorate the
hospital. It is positive economic co-operation," Dr Kurylets said.
Patients who are not employees of the SBU do have to pay, though. The
18-year-old with the curved spine would be charged around $10,000. And while
that may seem like a lot of money, it is a fraction of what a similar operation
would cost in Western Europe or the
The healthcare system in
Ukraine
Ukrainian healthcare is run by the Ministry of Health, with all working
citizens contributing to the cost. In theory, healthcare is available free of
charge to all citizens of Ukraine, however, in practice, the free services only
cover basic provision and patients often have to pay for extras such as
specialist equipment required during surgery. Often, doctors and consultants
will also charge a fee for their time.
Ukrainian public healthcare is still in transition from the Soviet dictated
health system of the past. Under this system, capacity was everything,
resulting in high numbers of physicians and beds, among the best in
Fortunately, as is often the case in
Private cosmetic surgery and dental care in
Two particular specialties in
Medical tourism is growing rapidly in
The Institute for Reproductive Medicine: IVF and
infertility treatment in Kiev, Ukraine
The Institute for
Reproductive Medicine (IRM) in
About the Institute for Reproductive Medicine
in
The first successful in
vitro fertilisation programme in
IRM – the first IVF
clinic in
The first ICSI in
Cryotransfer – birth
of a child (2003)
The structure of the IRM Fertility Clinic in Kiev
1.
Infertility Unit
2.
Embryological Unit
3.
Surgical Unit: minimally
invasive endoscopic surgery (laparoscopy,hysteroscopy, fertiloscopy), wide
range of gynaecological, andrological, and urological operations
Polyclinic
1.
Gynaecological
endocrinologist
2.
Prenatal diagnosis and
pregnancy care: 4D ultrasound, prenatal painting
3.
Cervical pathology
specialist
4.
Urologist-andrologist
5.
Breast specialist
6.
Day patient department
Infertility treatments
available at the IRM Fertility Clinic in Ukraine
·
Male factor - cutting edge
diagnosis and treatment
·
Female factor -
comprehensive fertility assessment of the female partner
·
Combined factor - integrated
approach to both partners
·
ICSI
·
IMSI
·
PICSI
·
Egg donation
·
Sperm donation
·
Freezing of reproductive
cells
·
Embryo freezing
·
Selective transfer of 1-2
embryos
·
Treatment in non-stimulated
cycles with frozen-thawed embryo transfer
Fertility treatment packages
in Ukraine
Conventional IVF
Ist VISIT (1-2 hours
during one working day)
·
Initial consultation
·
Examination of a couple:
gynecological examination + sperm analysis + chromosome analysis of both
partners
·
Sperm collection
·
Consultation based on the
results of examination + personalised treatment algorithm work out
TREATMENT PROGRAMME (average
duration – 1-1½ months)
·
Controlled ovarian
stimulation
·
Ultrasound and hormone
monitoring of follicular growth
·
Oocyte pick up
·
Laboratory preparation and
selection of germ cells (sperm and oocytes)
·
Fertilisation via IVF (in a
Petri dish)
·
Embryo cultivation
·
Selection of quality embryos
·
Selective embryo transfer
·
Consultations during
programme
ICSI Package
Ist VISIT (1-2 hours during one working day)
·
Initial consultation
·
Examination of a couple: gynecological
examination + sperm analysis + chromosome analysis of both partners
·
Sperm collection
·
Consultation based on the
results of examination + personalised treatment algorithm work out
TREATMENT PROGRAMME (average
duration – 1-1½ months)
·
Controlled ovarian
stimulation
·
Ultrasound and hormone
monitoring of follicular growth
·
Oocyte pick up
·
Laboratory preparation and
selection of germ cells (sperm and oocytes)
·
Fertilisation via ICSI
·
Embryo cultivation
·
Selection of quality embryos
·
Selective embryo transfer
·
Consultations during
programme
·
On-line support till 12
weeks of pregnancy
·
Consultations during
programme
Egg donation
Ist VISIT (1-2 hours during one working day)
·
Initial consultation
·
Examination of a couple: gynecological
examination + sperm analysis + chromosome analysis of both partners
·
Sperm collection,
cryopreservation
·
Chromosome analysis of a
husband (karyotype of a donor was determined)
·
Donor matching from donor
database (taking into account phenotype and blood type)
TREATMENT PROGRAMME (average duration – 1-1½ months)
·
Controlled ovarian
stimulation of a donor
·
Synchronization of menstrual
cycles of a donor and a recipient
·
Ultrasound and hormone
monitoring of follicular growth
·
Oocyte pick up
·
Fertilisation via ICSI
·
Embryo cultivation
·
Selection of quality embryos
·
Selective embryo transfer
·
Consultations during
programme
·
On-line support till 12
weeks of pregnancy
·
Consultations during
programme
Health care
in the
Health
care in the
The
U.S. Census Bureau reported that 49.9 million residents, 16.3% of the
population, were uninsured in 2010 (up from 49.0 million residents, 16.1% of
the population, in 2009). According to the World Health Organization (WHO), the
Active
debate about health care reform in the
Life
expectancy at birth in the
A
2004 Institute of Medicine (IOM) report said: "The
On
March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) became
law, providing for major changes in health insurance.
Providers
Health
care providers in the
Facilities
In
the
The
non-profit hospitals share of total hospital capacity has remained relatively
stable (about 70%) for decades. There are also privately owned for-profit
hospitals as well as government hospitals in some locations, mainly owned by
county and city governments.
There
is no nationwide system of government-owned medical facilities open to the
general public but there are local government-owned medical facilities open to
the general public. The federal Department of Defense operates field hospitals
as well as permanent hospitals (the Military Health System), to provide
military-funded care to active military personnel.
The
federal Veterans Health Administration operates VA hospitals open only to
veterans, though veterans who seek medical care for conditions they did not
receive while serving in the military are charged for services. The Indian
Health Service operates facilities open only to Native Americans from
recognized tribes. These facilities, plus tribal facilities and privately
contracted services funded by IHS to increase system capacity and capabilities,
provide medical care to tribespeople beyond what can be paid for by any private
insurance or other government programs.
Hospitals
provide some outpatient care in their emergency rooms and specialty clinics,
but primarily exist to provide inpatient care. Hospital emergency departments
and urgent care centers are sources of sporadic problem-focused care.
"Surgicenters" are examples of specialty clinics. Hospice services
for the terminally ill who are expected to live six months or less are most
commonly subsidized by charities and government. Prenatal, family planning, and
"dysplasia" clinics are government-funded obstetric and gynecologic
specialty clinics respectively, and are usually staffed by nurse practitioners.
Physicians
(M.D. and D.O.)
Physicians
in the
The
Medical products, research and
development
As
in most other countries, the manufacture and production of pharmaceuticals and
medical devices is carried out by private companies. The research and
development of medical devices and pharmaceuticals is supported by both public
and private sources of funding. In 2003, research and development expenditures
were approximately $95 billion with $40 billion coming from public sources and
$55 billion coming from private sources. These investments into medical
research have made the
Spending
Total U.S. healthcare spending as a percent of
U.S. GDP (gross domestic product).
According
to the World Health Organization (WHO), total health care spending in the
The
Office of the Actuary (OACT) of the Centers for Medicare and Medicaid Services
publishes data on total health care spending in the
In
2009, the
U.S. healthcare costs exceed those of
other countries, relative to the size of the economy or GDP.
The
Congressional Budget Office has found that "about half of all growth in
health care spending in the past several decades was associated with changes in
medical care made possible by advances in technology." Other factors
included higher income levels, changes in insurance coverage, and rising
prices. Hospitals and physician spending take the largest share of the health
care dollar, while prescription drugs take about 10%. The use of prescription
drugs is increasing among adults who have drug coverage.
One
analysis of international spending levels in the year 2000 found that while the
Health
care spending in the
An
earlier study by AHRQ the found significant persistence in the level of health
care spending from year to year. Of the 1% of the population with the highest
health care spending in 2002, 24.3% maintained their ranking in the top 1% in
2003. Of the 5% with the highest spending in 2002, 34% maintained that ranking
in 2003. Individuals over age 45 were disproportionately represented among
those who were in the top decile of spending for both years.
Total
Health care cost rise based on total
expenditure on health as % of GDP. Countries are
Seniors
spend, on average, far more on health care costs than either working-age adults
or children. The pattern of spending by age was stable for most ages from 1987
through 2004, with the exception of spending for seniors age 85 and over.
Spending for this group grew less rapidly than that of other groups over this
period.
The
2008 edition of the Dartmouth Atlas of Health Care found that providing
Medicare beneficiaries with severe chronic illnesses with more intense health
care in the last two years of life—increased spending, more tests, more
procedures and longer hospital stays—is not associated with better patient
outcomes. There are significant geographic variations in the level of care
provided to chronically ill patients, only 4% of which are explained by differences
in the number of severely ill people in an area. Most of the differences are
explained by differences in the amount of "supply-sensitive" care
available in an area. Acute hospital care accounts for over half (55%) of the
spending for Medicare beneficiaries in the last two years of life, and
differences in the volume of services provided is more significant than
differences in price. The researchers found no evidence of
"substitution" of care, where increased use of hospital care would
reduce outpatient spending (or vice versa).
Health care cost rise based on total
expenditure on health as % of GDP. Countries are
Increased
spending on disease prevention is often suggested as a way of reducing health
care spending. Whether prevention saves or costs money depends on the
intervention. Childhood vaccinations, or contraceptives save much more than
they cost. Research suggests that in many cases prevention does not produce
significant long-term cost savings. Some interventions may be cost-effective by
providing health benefits, while others are not cost-effective. Preventive care
is typically provided to many people who would never become ill, and for those
who would have become ill is partially offset by the health care costs during
additional years of life.
In
September 2008 The Wall Street Journal reported that consumers were reducing
their health care spending in response to the current economic slow-down. Both
the number of prescriptions filled and the number of office visits dropped
between 2007 and
In
2009, the average private room in a nursing home cost $219 daily. Assisted
living costs averaged $3,131 monthly. Home health aides averaged $21 per hour.
Adult day care services averaged $67 daily.
Impact on
On
March 1, 2010, billionaire investor Warren Buffett said that the high costs
paid by
Allegations of waste
In
December 2011, the outgoing Administrator of the Centers for Medicare &
Medicaid Services, Dr. Donald Berwick, asserted that 20% to 30% of health care
spending is waste. He listed five causes for the waste: (1) overtreatment of
patients, (2) the failure to coordinate care, (3) the administrative complexity
of the health care system, (4) burdensome rules and (5) fraud.
Payment
Doctors
and hospitals are generally funded by payments from patients and insurance
plans in return for services rendered (fee-for-service or FFS).
Around
84.7% of Americans have some form of health insurance; either through their
employer or the employer of their spouse or parent (59.3%), purchased
individually (8.9%), or provided by government programs (27.8%; there is some
overlap in these figures). All government health care programs have restricted
eligibility, and there is no government health insurance company which covers
all Americans. Americans without health insurance coverage in 2007 totaled
15.3% of the population, or 45.7 million people.
Among
those whose employer pays for health insurance, the employee may be required to
contribute part of the cost of this insurance, while the employer usually
chooses the insurance company and, for large groups, negotiates with the
insurance company.
In
2004, private insurance paid for 36% of personal health expenditures, private
out-of-pocket 15%, federal government 34%, state and local governments 11%, and
other private funds 4%. Due to "a dishonest and inefficient system"
that sometimes inflates bills to ten times the actual cost, even insured
patients can be billed more than the real cost of their care.
Insurance
for dental and vision care (except for visits to ophthalmologists, which are
covered by regular health insurance) is usually sold separately. Prescription
drugs are often handled differently than medical services, including by the
government programs. Major federal laws regulating the insurance industry
include COBRA and HIPAA.
Individuals
with private or government insurance are limited to medical facilities which
accept the particular type of medical insurance they carry. Visits to
facilities outside the insurance program's "network" are usually
either not covered or the patient must bear more of the cost. Hospitals
negotiate with insurance programs to set reimbursement rates; some rates for
government insurance programs are set by law. The sum paid to a doctor for a
service rendered to an insured patient is generally less than that paid
"out of pocket" by an uninsured patient. In return for this discount,
the insurance company includes the doctor as part of their "network",
which means more patients are eligible for lowest-cost treatment there. The
negotiated rate may not cover the cost of the service, but providers (hospitals
and doctors) can refuse to accept a given type of insurance, including Medicare
and Medicaid. Low reimbursement rates have generated complaints from providers,
and some patients with government insurance have difficulty finding nearby
providers for certain types of medical services.
Charity
care for those who cannot pay is sometimes available, and is usually funded by
non-profit foundations, religious orders, government subsidies, or services
donated by the employees.
The
Emergency Medical Treatment and Active Labor Act requires virtually all
hospitals to accept all patients, regardless of the ability to pay, for
emergency room care. The act does not provide access to non-emergency room care
for patients who cannot afford to pay for health care, nor does it provide the
benefit of preventive care and the continuity of a primary care physician.
Emergency health care is generally more expensive than an urgent care clinic or
a doctor's office visit, especially if a condition has worsened due to putting
off needed care. Emergency rooms are typically at, near, or over capacity. Long
wait times have become a problem nationally, and in urban areas some ERs are
put on "diversion" on a regular basis, meaning that ambulances are
directed to bring patients elsewhere.
Private This
section needs additional citations for verification. Please help improve this
article by adding citations to reliable sources. Unsourced material may be
challenged and removed. (January 2009)
Share by insurance coverage type, for those
under 65 years of age
Most
Americans under age 65 (59.3%) receive their health insurance coverage through
an employer (which includes both private as well as civilian public-sector
employers) under group coverage, although this percentage is declining. Costs
for employer-paid health insurance are rising rapidly: since 2001, premiums for
family coverage have increased 78%, while wages have risen 19% and inflation
has risen 17%, according to a 2007 study by the Kaiser Family Foundation.
Workers with employer-sponsored insurance also contribute; in 2007, the average
percentage of premium paid by covered workers is 16% for single coverage and
28% for family coverage. In addition to their premium contributions, most
covered workers face additional payments when they use health care services, in
the form of deductibles and copayments.
Just
less than 9% of the population purchases individual health care insurance.
Insurance payments are a form of cost-sharing and risk management where each
individual or their employer pays predictable monthly premiums. This
cost-spreading mechanism often picks up much of the cost of health care, but
individuals must often pay up-front a minimum part of the total cost (a
deductible), or a small part of the cost of every procedure (a copayment).
Private insurance accounts for 35% of total health spending in the
Share by insurance coverage type, for
those under 65 years of age
Provider
networks can be used to reduce costs by negotiating favorable fees from
providers, selecting cost effective providers, and creating financial incentives
for providers to practice more efficiently. A survey issued in 2009 by
Defying
many analysts' expectations, PPOs have gained market share at the expense of
HMOs over the past decade.
Just
as the more loosely managed PPOs have edged out HMOs, HMOs themselves have also
evolved towards less tightly managed models. The first HMOs in the
Public
Government
programs directly cover 27.8% of the population (83 million), including the
elderly, disabled, children, veterans, and some of the poor, and federal law
mandates public access to emergency services regardless of ability to pay.
Public spending accounts for between 45% and 56.1% of
However,
all government-funded healthcare programs exist only in the form of statutory
law, and accordingly can be amended or revoked like any other statute. There is
no constitutional right to healthcare. The U.S. Supreme Court explained in 1977
that "the Constitution imposes no obligation on the States to pay ... any
of the medical expenses of indigents."
Government funded programs include:
Medicare,
generally covering citizens and long-term residents 65 years and older and the
disabled.
Medicaid,
generally covering low income people in certain categories, including children,
pregnant women, and the disabled. (Administered by the states.)
State
Children's Health Insurance Program, which provides health insurance for
low-income children who do not qualify for Medicaid. (Administered by the
states, with matching state funds.)
Various
programs for federal employees, including TRICARE for military personnel (for
use in civilian facilities)
The
Veterans Administration, which provides care to veterans, their families, and
survivors through medical centers and clinics.
Title
X which funds reproductive health care
State
and local health department clinics
Indian
health service
National
Institutes of Health treats patients who enroll in research for free.
Medical
Corps of various branches of the military.
Certain
county and state hospitals
Government
run community clinics
The
exemption of employer-sponsored health benefits from federal income and payroll
taxes distorts the health care market. The
Health
insurance benefits are an attractive way for employers to increase the salary
of employees as they are nontaxable. As a result, 65% of the non-elderly
population and over 90% of the privately insured non-elderly population
receives health insurance at the workplace. Additionally, most economists agree
that this tax shelter increases individual demand for health insurance, leading
some to claim that it is largely responsible for the rise in health care
spending.
In
addition the government allows full tax shelter at the highest marginal rate to
investors in health savings accounts (HSAs). Some have argued that this tax
incentive adds little value to national health care as a whole because the most
wealthy in society tend also to be the most healthy. Also it has been argued,
HSAs segregate the insurance pools into those for the wealthy and those for the
less wealthy which thereby makes equivalent insurance cheaper for the rich and
more expensive for the poor. However, one advantage of health insurance
accounts is that funds can only be used towards certain HSA qualified expenses,
including medicine, doctor's fees, and Medicare Parts A and B. Funds cannot be
used towards expenses such as cosmetic surgery.
There
are also various state and local programs for the poor. In 2007, Medicaid
provided health care coverage for 39.6 million low-income Americans (although
Medicaid covers approximately 40% of
It
has been reported that the number of physicians accepting Medicaid has
decreased in recent years due to relatively high administrative costs and low
reimbursements. In 1997, the federal government also created the State
Children's Health Insurance Program (SCHIP), a joint federal-state program to
insure children in families that earn too much to qualify for Medicaid but
cannot afford health insurance. SCHIP covered 6.6 million children in 2006, but
the program is already facing funding shortfalls in many states. The government
has also mandated access to emergency care regardless of insurance status and
ability to pay through the Emergency Medical Treatment and Labor Act (EMTALA),
passed in 1986, but EMTALA is an unfunded mandate.
The uninsured
Some
Americans do not qualify for government-provided health insurance, are not
provided health insurance by an employer, and are unable to afford, cannot
qualify for, or choose not to purchase, private health insurance. When charity
or "uncompensated" care is not available, they sometimes simply go
without needed medical treatment. This problem has become a source of
considerable political controversy on a national level.
According
to the US Census Bureau, in 2007, 45.7 million people in the
Among
the uninsured population, the Census Bureau says, nearly 37 million were
employment-age adults (ages 18 to 64), and more than 27 million worked at least
part time. About 38% of the uninsured live in households with incomes of
$50,000 or more. According to the Census Bureau, nearly 36 million of the
uninsured are legal U.S citizens. Another 9.7 million are noncitizens, but the
Census Bureau does not distinguish in its estimate between legal noncitizens
and illegal immigrants. Nearly one fifth of the uninsured population is able to
afford insurance, almost one quarter is eligible for public coverage, and the
remaining 56% need financial assistance (8.9% of all Americans). Extending
coverage to all who are eligible remains a fiscal challenge.
A
2003 study in Health Affairs estimated that uninsured people in the
The
health insurance system in
From
2000 to 2004, the
The
reports concluded that the committee recommended that the nation should
implement a strategy to achieve universal health insurance coverage. As of
The
six reports created by the Institute of Medicine (IOM) found that the principal
consequences of uninsurance were the following: Children and Adults without
health insurance did not receive needed medical care; they typically live in
poorer health and die earlier than children or adults who have insurance. The
financial stability of a whole family can be put at risk if only one person is
uninsured and needs treatment for unexpected health care costs. The overall
health status of a community can be adversely affected by a higher percentage
of uninsured people within the community. The coverage gap between the insured
and the uninsured has not decreased even after the recent federal initiatives
to extend health insurance coverage.
The
last report was published in 2004 and was named Insuring America's Health:
Principles and Recommendations. This report recommended the following: The
President and Congress need to develop a strategy to achieve universal
insurance coverage and establish a firm schedule to reach this goal by the year
2010. The committee also recommended that the federal and state governments
provide sufficient resources for Medicaid and the State Children's Health
Insurance Program (SCHIP) to cover all persons currently eligible until the
universal coverage takes effect. They also warned that the federal and state
governments should prevent the erosion of outreach efforts, eligibility,
enrollment, and coverage of these specific programs.
Some
people think that not having health insurance will have adverse consequences
for the health of the uninsured. On the other hand, some people believe that
children and adults without health insurance have access to needed health care
services at hospital emergency rooms, community health centers, or other safety
net facilities offering charity care. Some observers note that there is a solid
body of evidence showing that a substantial proportion of
Children
in
The
same committee analyzed the effects of health insurance on adult's health
outcomes: adults who do not have health insurance coverage who acquire Medicare
coverage at age 65, experience substantially improved health and functional
status, particularly those who have cardiovascular disease or diabetes. Adults
who have cardiovascular disease or other cardiac risk factors that are
uninsured are less likely to be aware of their condition, which leads to worse
health outcomes for those individuals. Without health insurance, adults are
more likely to be diagnosed with certain cancers that would have been
detectable earlier by screening by a clinician if they had regularly visited a
doctor. As a consequence, these adults are more likely to die from their
diagnosed cancer or suffer poorer health outcomes.
Many
towns and cities in the
Estimates
for 2008 reported that the uninsured would spend $30 billion for healthcare and
receive $56 billion in uncompensated care, and that if everyone were covered by
insurance then overall costs would increase by $123 billion. A 2003 Institute
of Medicine (IOM) report estimated total cost of health care provided to the
uninsured at $98.9 billion in 2001, including $26.4 billion in out-of-pocket
spending by the uninsured, with $34.5 billion in "free"
"uncompensated" care covered by government subsidies of $30.6 billion
to hospitals and clinics and $5.1 billion in donated services by physicians.
Role of government in health care
market
Numerous
publicly funded health care programs help to provide for the elderly, disabled,
military service families and veterans, children, and the poor, and federal law
ensures public access to emergency services regardless of ability to pay;
however, a system of universal health care has not been implemented
nation-wide. However, as the OECD has pointed out, the total
In
July 2009,
Regulation and oversight
Involved organizations and
institutions
Healthcare
is subject to extensive regulation at both the federal and the state level,
much of which "arose haphazardly" Under this system, the federal
government cedes primary responsibility to the states under the
McCarran-Ferguson Act. Essential regulation includes the licensure of health
care providers at the state level and the testing and approval of
pharmaceuticals and medical devices by the Food and Drug Administration, and
laboratory testing. These regulations are designed to protect consumers from
ineffective or fraudulent healthcare. Additionally, states regulate the health
insurance market and they often have laws which require that health insurance companies
cover certain procedures, although state mandates generally do not apply to the
self-funded health care plans offered by large employers, which exempt from
state laws under preemption clause of the Employee Retirement Income Security
Act. In 2010, the Patient Protection and Affordable Care Act (PPACA) was
passed, and includes various new regulations, with one of the most notable
being a health insurance mandate which requires all citizens to purchase health
insurance. While not regulation per se, the federal government also has a major
influence on the healthcare market through its payments to providers under
Medicare and Medicaid, which in some cases are used as a reference point in the
negotiations between medical providers and insurance companies.
At
the federal level, United States Department of Health and Human Services
oversees the various federal agencies involved in health care. The health
agencies are a part of the United States Public Health Service, and include the
Food and Drug Administration, which certifies the safety of food, effectiveness
of drugs and medical products, the Centers for Disease Prevention, which
prevents disease, premature death, and disability, the Agency of Health Care
Research and Quality, the Agency Toxic Substances and Disease Registry, which
regulates hazardous spills of toxic substances, and the National Institutes of
Health, which conducts medical research.
State
governments maintain state health departments, and local governments (counties
and municipalities) often have their own health departments, usually branches
of the state health department. Regulations of a state board may have executive
and police strength to enforce state health laws. In some states, all members
of state boards must be health care professionals. Members of state boards may
be assigned by the governor or elected by the state committee. Members of local
boards may be elected by the mayor council. The McCarran–Ferguson Act, which
cedes regulation to the states, does not itself regulate insurance, nor does it
mandate that states regulate insurance. "Acts of Congress" that do
not expressly purport to regulate the "business of insurance" will
not preempt state laws or regulations that regulate the "business of
insurance." The Act also provides that federal anti-trust laws will not
apply to the "business of insurance" as long as the state regulates
in that area, but federal anti-trust laws will apply in cases of boycott,
coercion, and intimidation. By contrast, most other federal laws will not apply
to insurance whether the states regulate in that area or not.
Self-policing
of providers by providers is a major part of oversight. Many health care
organizations also voluntarily submit to inspection and certification by the
Joint Commission on Accreditation of Hospital Organizations, JCAHO. Providers
also undergo testing to obtain board certification attesting to their skills. A
report issued by Public Citizen in April 2008 found that, for the third year in
a row, the number of serious disciplinary actions against physicians by state
medical boards declined from 2006 to 2007, and called for more oversight of the
boards.
The
Centers for Medicare and Medicaid Services (CMS) publishes an on-line
searchable database of performance data on nursing homes.
The
regulation is controversial. In 2004, conservative think tank Cato Institute
published a study which concluded that regulation provides benefits in the
amount of $170 billion but costs the public up to $340 billion. The study
concluded that the majority of the cost differential arises from medical
malpractice, U.S. Food and Drug Administration (FDA) regulations, and
facilities regulations.
"Certificates of need" for hospitals
In
1978, the federal government required that all states implement Certificate of
Need (CON) programs for cardiac care, meaning that hospitals had to apply and
receive certificates prior to implementing the program; the intent was to
reduce cost by reducing duplicate investments in facilities. It has been
observed that these certificates could be used to increase costs through
weakened competition. Many states removed the CON programs after the federal
requirement expired in 1986, but some states still have these programs.
Empirical research looking at the costs in areas where these programs have been
discontinued have not found a clear effect on costs, and the CON programs could
decrease costs because of reduced facility construction or increase costs due
to reduced competition.
Licensing of providers
American
Medical Association (AMA) has lobbied the government to highly limit physician
education since 1910, currently at 100,000 doctors per year, which has led to a
shortage of doctors and physicians' wages in the
An
even bigger problem may be that the doctors are paid for procedures instead of
results.
AMA
has also aggressively lobbied for many restrictions that require doctors to carry
out operations that might be carried out by cheaper workforce. For example, in
1995, 36 states banned or restricted midwifery even though it delivers equally
safe care to that by doctors, according to studies [clarification needed] . The
regulation lobbied by AMA has decreased the amount and quality of health care,
according to the consensus of economist: the restrictions do not add to
quality, they decrease the supply of care. [clarification needed] Moreover,
psychologists, nurses and pharmacologists are not allowed to prescribe
medicines.[clarification needed] Previously nurses were not even allowed to
vaccinate the patients without direct supervision by doctors.
Emergency Medical Treatment and
Active Labor Act (EMTALA)
EMTALA,
enacted by the federal government in 1986, requires that hospital emergency
departments treat emergency conditions of all patients regardless of their
ability to pay and is considered a critical element in the "safety
net" for the uninsured, but established no direct payment mechanism for
such care. Indirect payments and reimbursements through federal and state
government programs have never fully compensated public and private hospitals
for the full cost of care mandated by EMTALA. In fact, more than half of all
emergency care in the
Mentally
ill patients present a unique challenge for emergency departments and
hospitals. In accordance with EMTALA, mentally ill patients who enter emergency
rooms are evaluated for emergency medical conditions. Once mentally ill
patients are medically stable, regional mental health agencies are contacted to
evaluate them. Patients are evaluated as to whether they are a danger to
themselves or others. Those meeting this criterion are admitted to a mental
health facility to be further evaluated by a psychiatrist. Typically, mentally
ill patients can be held for up to 72 hours, after which a court order is
required.[citation needed]
Quality assurance
Health
care quality assurance consists of the "activities and programs intended
to assure or improve the quality of care in either a defined medical setting or
a program. The concept includes the assessment or evaluation of the quality of
care; identification of problems or shortcomings in the delivery of care;
designing activities to overcome these deficiencies; and follow-up monitoring
to ensure effectiveness of corrective steps."
One
innovation in encouraging quality of health care is the public reporting of the
performance of hospitals, health professionals or providers, and healthcare
organizations. However, there is "no consistent evidence that the public
release of performance data changes consumer behaviour or improves care."
Overall system effectiveness compared
to other countries
Life expectancy compared to healthcare
spending from 1970 to
The
A
study found that between 1997 and 2003, preventable deaths declined more slowly
in the
The
Organisation for Economic Co-operation and Development (OECD) found that the
Recent
studies find growing gaps in life expectancy based on income and geography. In
Life expectancy compared to
healthcare spending from 1970 to
The
debate about
A
report released in April 2008 by the Foundation for Child Development, which studied
the period from 1994 through 2006, found mixed results for the health of
children in the U.S. Mortality rates for children ages 1 through 4 dropped by a
third, and the percentage of children with elevated blood lead levels dropped
by 84%. The percentage of mothers who smoked during pregnancy also declined. On
the other hand, both obesity and the percentage of low-birth weight babies
increased. The authors note that the increase in babies born with low birth
weights can be attributed to women delaying childbearing and the increased use
of fertility drugs.
System efficiency and equity
Variations
in the efficiency of health care 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
Lean
manufacturing techniques such as value stream mapping can help identify and
subsequently mitigate waste associated with costs of healthcare.
Efficiency
Preventable deaths
In
2009, lack of health insurance was responsible for about 45,000 excess
preventable deaths in the
Value for money
A
study of international health care spending levels published in the health
policy journal Health Affairs in the year 2000 found that the U.S. spends
substantially more on health care than any other country in the Organization
for Economic Co-operation and Development (OECD), and that the use of health
care services in the U.S. is below the OECD median by most measures. The
authors of the study conclude that the prices paid for health care services are
much higher in the U.S. than elsewhere.[37] While the 19 next most wealthy
countries by GDP all pay less than half what the US does for health care, they
have all gained about six years of life expectancy more than the U.S. since
1970.
Delays in seeking care and increased
use of emergency care
Uninsured
Americans are less likely to have regular health care 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.
Shared costs of the uninsured
The
costs of treating the uninsured must often be absorbed by providers as charity
care, passed on to the insured via cost shifting and higher health insurance
premiums, or paid by taxpayers through higher taxes. However, hospitals and
other providers are reimbursed for the cost of providing uncompensated care via
a federal matching fund program. Each state enacts legislation governing the
reimbursement of funds to providers. In
A
report published by the Kaiser Family Foundation in April 2008 found that
economic downturns place a significant strain on state Medicaid and SCHIP
programs. The authors estimated that a 1% increase in the unemployment rate
would increase Medicaid and SCHIP enrollment by 1 million, and increase the
number uninsured by 1.1 million. State spending on Medicaid and SCHIP would
increase by $1.4 billion (total spending on these programs would increase by
$3.4 billion). This increased spending would occur at the same time state
government revenues were declining. During the last downturn, the Jobs and
Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal
assistance to states, which helped states avoid tightening their Medicaid and
SCHIP eligibility rules. The authors conclude that Congress should consider
similar relief for the current economic downturn.
Variations in provider practices
The
treatment given to a patient can vary significantly depending on which health
care providers they use. Research suggests that some cost-effective treatments
are not used as often as they should be, while overutilization occurs with
other health care 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
health care. The way the Health care system tries to eliminate this problem is
through cost sharing tactics like co-pays and deductibles. If patients face
more of the economic burden they will then only consume health care when it is
necessary. According to the
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 health care system of the
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.
Many
primary care physicians no longer see their patients while they are in the
hospital. Instead, hospitalists are used, which fragments care because
hospitalists usually have had no previous relationship with the patient they
are treating and do not have a personal knowledge of the patient's medical
history. 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
The
health care system in the
According
to the insurance industry group
A
2003 study published by the Blue Cross and Blue Shield Association 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 12.9% to 11.6%
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 the Blue Cross and Blue Shield Association found that the average
administrative expense cost for all commercial health insurance products was
represented 9.18% of premiums in 2008. Administrative costs were 11.12% of
premiums for small group products and 16.35% in the individual market.
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
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. The lack of price information on medical services can
also distort incentives. The insurance which pays on behalf of insureds
negotiate with medical providers, sometimes using government-established prices
such as Medicaid billing rates as a reference point. This reasoning has led for
calls to reform the insurance system to create a consumer-driven health care
system whereby consumers pay more out-of-pocket. 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.
Overall costs
The
cost impact of the existing mixed public-private system is subject to debate.
The United States spends more as a percentage of GDP than similar countries,
and this can be explained either through higher prices for services themselves,
higher costs to administer the system, or more utilization of these services
(for example, due to the United States having a more sickly population), or to
a combination of these elements.
Free-market
advocates claim that the health care system is "dysfunctional"
because the system of third-party payments from insurers removes the patient as
a major participant in the financial and medical choices that affect costs.
Because government intervention has expanded insurance availability through
programs such as Medicare and Medicaid, this has exacerbated the problem.
According to a study paid for by
Health
care costs rising far faster than inflation have been a major driver for health
care reform in the
In
March 2010,
Equity
Coverage
Enrollment
rules in private and governmental programs result in millions of Americans
going without health care coverage, including children. The U.S. Census Bureau
estimated that 45.7 million Americans (15.3% of the total population) had no
health insurance coverage in 2007. However, statistics regarding the insured
population are difficult to pinpoint for a number of factors, with the Census
Bureau writing that "health insurance coverage is likely to be
underreported". Further, such statistics do not provide insight into the
reason a given person might be uninsured. For example, studies have shown that
approximately one third of this 45.7 million person population of uninsured persons
is actually eligible for government insurance programmes such as
Medicaid/Medicare, but has elected not to enroll. The largest proportion of the
population of uninsured Americans is persons earning in excess of $50,000 per
annum, with those earning over $75,000 p.a. comprising the fastest-growing
segment of the uninsured population. US Citizens who earn too much money to
qualify for government assistance with insurance programs but who do not earn
enough to purchase a private health insurance plan make up approxmiately 2.7%
percent of the total US population (8.2 million of approximately 300 million
total population, by 2003 figures).
Some
states (like
Coverage
gaps also occur among the insured population.
Coverage
gaps and affordability also surfaced in a 2007 international comparison by the
Commonwealth Fund. Among adults surveyed in the
Mental health
A
lack of mental health coverage for Americans bears significant ramifications to
the
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. Up to 2008 insurance
companies used loopholes and, though providing financial equity, they often
worked around the law by applying unequal co-payments or setting limits on the
number of days spent in in-patient or out-patient treatment facilities.
Medical underwriting and the
uninsurable
In
most states in the
Proponents
of medical underwriting argue that it ensures that individual health insurance
premiums are kept as low as possible. Critics of medical underwriting believe
that it unfairly prevents people with relatively minor and treatable
pre-existing conditions from obtaining health insurance.
One
large industry survey found that 13% of applicants for individual health
insurance who went through medical underwriting were denied coverage in 2004.
Declination rates increased significantly with age, rising from 5% for those
under 18 to just under one-third for those aged 60 to 64. Among those who were
offered coverage, the study found that 76% received offers at standard premium
rates, and 22% were offered higher rates. The frequency of increased premiums
also increased with age, so for applicants over 40, roughly half were affected
by medical underwriting, either in the form of denial or increased premiums. In
contrast, almost 90% of applicants in their 20s were offered coverage, and
three-quarters of those were offered standard rates. Seventy percent of
applicants age 60–64 were offered coverage, but almost half the time (40%) it
was at an increased premium. The study did not address how many applicants who
were offered coverage at increased rates chose to decline the policy. A study
conducted by the Commonwealth Fund in 2001 found that, among those aged 19 to
64 who sought individual health insurance during the previous three years, the
majority found it unaffordable, and less than a third ended up purchasing
insurance. This study did not distinguish between consumers who were quoted
increased rates due to medical underwriting and those who qualified for
standard or preferred premiums. Some states have outlawed medical underwriting
as a prerequisite for individually purchased health coverage. These states tend
to have the highest premiums for individual health insurance.
Demographic differences
In
the
Public
spending is highly correlated with age; average per capita public spending for
seniors was more than five times that for children ($6,921 versus $1,225).
Average public spending for non-Hispanic blacks ($2,973) was slightly higher
than that for whites ($2,675), while spending for Hispanics ($1,967) was
significantly lower than the population average ($2,612). Total public spending
is also strongly correlated with self-reported health status ($13,770 for those
reporting "poor" health versus $1,279 for those reporting
"excellent" health). Seniors comprise 13% of the population but take
1/3 of all prescription drugs. The average senior fills 38 prescriptions
annually. A new study has also found that older men and women in the South are
more often prescribed antibiotics than older Americans elsewhere, even though
there is no evidence that the South has higher rates of diseases requiring
antibiotics.
There
is a great deal of research into inequalities in health care. In some cases
these inequalities are caused by income disparities that result in lack of
health insurance and other barriers to receiving services. According to the
2009 National Healthcare Disparities Report, uninsured Americans are less
likely to receive preventive services in health care. 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 health care reflect a systemic bias in the way medical
procedures and treatments are prescribed for different ethnic groups. Raj
Drug efficacy and safety
The
Food and Drug Administration (FDA) is the primary institution tasked with the
safety and effectiveness of human and veterinary drugs. It also is responsible
for making sure drug information is accurately and informatively presented to
the public. The FDA reviews and approves products and establishes drug
labeling, drug standards, and medical device manufacturing standards. It sets
performance standards for radiation and ultrasonic equipment.
One
of the more contentious issues related to drug safety is immunity from
prosecution. In 2004, the FDA reversed a federal policy, arguing that FDA
premarket approval overrides most claims for damages under state law for
medical devices. In 2008 this was confirmed by the Supreme Court in Riegel v.
Medtronic.
On
30 June 2006, an FDA ruling went into effect extending protection from lawsuits
to pharmaceutical manufacturers, even if it was found that they submitted
fraudulent clinical trial data to the FDA in their quest for approval. This
left consumers who experience serious health consequences from drug use with
little recourse. In 2007, opposition was raised in the Congressional House to
the FDA ruling, but the Senate upheld the status quo. On 4 March 2009, an
important U.S. Supreme Court decision was handed down. In Wyeth v. Levine, the
court asserted that state-level rights of action could not be pre-empted by federal
immunity and could provide "appropriate relief for injured
consumers." In June 2009, under the Public Readiness and Emergency
Preparedness Act, Secretary of Health and Human Services Kathleen Sebelius
signed an order extending protection to vaccine makers and federal officials
from prosecution during a declared health emergency related to the
administration of the swine flu vaccine.
Impact of drug companies
The
When
health care legislation was being written in 2009, the drug companies were asked
to support the legislation in return for not allowing importation of drugs from
foreign countries.
Political issues
Prescription
drug prices The following text needs to be harmonized with text in Prescription
drug prices in the
During
the 1990s, the price of prescription drugs became a major issue in American
politics as the prices of many new drugs increased exponentially, and many
citizens discovered that neither the government nor their insurer would cover
the cost of such drugs. Per capita, the
The
United States government has taken the position (through the Office of the
United States Trade Representative) that U.S. drug prices are rising because
U.S. consumers are effectively subsidizing costs which drug companies cannot
recover from consumers in other countries (because many other countries use
their bulk-purchasing power to aggressively negotiate drug prices). The
Debate
A
poll released in March 2008 by the Harvard School of Public Health and Harris
Interactive found that Americans are divided in their views of the
A
2004 Institute of Medicine (IOM) report said: "The
An
impediment to implementing any
Advocates
for single-payer health care often point to other countries, where national
government-funded systems produce better health outcomes at lower cost.
Opponents deride this type of system as "socialized medicine", and it
has not been one of the favored reform options by Congress or the President in
both the Clinton and Obama reform efforts. It has been pointed out that
socialized medicine is a system in which the government owns the means of
providing medicine.
As
an example of how government intervention has had unintended consequences, in
1973, the federal government passed the Health Maintenance Organization Act,
which heavily subsidized the HMO business model — a model that was in decline
prior to such legislative intervention. The law was intended to create market
incentives that would lower health care costs, but HMOs have never achieved
their cost-reduction potential.
Piecemeal
market-based reform efforts are complex. One study evaluating current popular
market-based reform policy packages concluded that if market-oriented reforms
are not implemented on a systematic basis with appropriate safeguards, they
have the potential to cause more problems than they solve.
According
to economist and former
Reform
Healthcare
reform in the
The
Patient Protection and Affordable Care Act (Public Law 111-148) is a health
care reform bill that was signed into law in the
The
law includes a large number of health-related provisions to take effect over
the next four years, including expanding Medicaid eligibility for people making
up to 133% of FPL, subsidizing insurance premiums for peoples making up to 400%
of FPL ($88,000 for family of 4) so their maximum "out-of-pocket" pay
will be from 2% to 9.8% of income for annual premium, providing incentives for
businesses to provide health care benefits, prohibiting denial of coverage and
denial of claims based on pre-existing conditions, establishing health
insurance exchanges, prohibiting insurers from establishing annual spending
caps and support for medical research. The costs of these provisions are offset
by a variety of taxes, fees, and cost-saving measures, such as new Medicare
taxes for high-income brackets, taxes on indoor tanning, cuts to the Medicare
Advantage program in favor of traditional Medicare, and fees on medical devices
and pharmaceutical companies; there is also a tax penalty for citizens who do
not obtain health insurance (unless they are exempt due to low income or other
reasons). The Congressional Budget Office estimates that the net effect
(including the reconciliation act) will be a reduction in the federal deficit
by $143 billion over the first decade.
In
May 2011, the state of
Health Insurance Coverage of
Immigrants
Of
the 26.2 million foreign immigrants living in the
VIDEO
Healthcare in
Healthcare
in the
Taken
together, the World Health Organization, in 2000, ranked the provision of
healthcare in the
Healthcare in
Most
healthcare in
Norfolk and Norwich University
Hospital, a National Health Service hospital.
The
two main kinds of trusts in the NHS, reflecting purchaser/provider roles, are
commissioning trusts such as Primary Care Trusts which examine local needs and
negotiate with providers (that may be public or private entities) to provide
health care services to the local population, and provider trusts which are NHS
bodies delivering health care service. They will be involved in agreeing major
capital and other health care spending projects in their region. Services
commissioned include general practice physician services (most of whom are
private businesses working under exclusive contract to the NHS), community
nursing, local clinics and mental health service. For most people, the majority
of health care is delivered in a primary health care setting. Provider trusts
are care deliverers, the main examples being the hospital trusts and the
ambulance trusts which spend the money allocated to them by the commissioning trusts.
Hospitals, as they tend to provide more complex and specialized care, receive
the lion's share of NHS funding. The hospital trusts own assets (such as
hospitals and the equipment in them) purchased for the nation and held in trust
for them. Commissioning has also been extended to the very lowest level
enabling ordinary doctors who identify a need in their community to commission
services to meet that need. Primary care is delivered by a wide range of
independent contractors such as GPs, dentists, pharmacists and optometrists and
is the first point of contact for most people. Secondary care (sometimes termed
acute health care) can be either elective care or emergency care and providers
may be in the public or private sector, though the majority of secondary care
happens in NHS owned facilities. There are also (as of 2009) 246 Memory clinics
in the
The
NHS Constitution covers the rights and obligations of patients and staff, many
of which are legally enforceable. The NHS has a high level of popular public
support within the country: an independent survey conducted in 2004 found that
users of the NHS often expressed very high levels satisfaction about their
personal experience of the medical services they received: 92% of hospital
in-patients, 87% of GP users, 87% of hospital outpatients, and 70% of Accident
and Emergency department users. However, only 67% of those surveyed agreed with
the statement "My local NHS is providing me with a good service”, and only
51% agreed with the statement “The NHS is providing a good service.
Satisfaction in successive surveys has noted high satisfaction across all
patient groups, especially recent inpatients, and user satisfaction is notably
higher than that of the general public. The report found that most highly
recalled sources of information on the NHS are perceived to be the most
critical. The national press was seen to be the most critical (64%), followed
by local press (54%) and TV or radio (51%) compared to just 13% saying the
national press is favourable). The national press was reported as being the
least reliable source of information (50% reporting it to be not very or not at
all reliable, compared to 36% believing the press was reliable). Newspapers
were reported as being less favourable and also less reliable than the
broadcast media. The most reliable sources of information were considered to be
leaflets from GPs and information from friends (both 77% reported as reliable)
and medical professionals (75% considered reliable).
Healthcare in
The
majority of healthcare in
Healthcare in
The
majority of healthcare in
Healthcare in
The
majority of healthcare in
Comparisons between the public health
systems in the United Kingdom
The reduction in infant mortality between 1960
to 2008 for the United Kingdom in comparison with France, Ireland, Sweden,
Switzerland, and the United States. The overall trend has meant a large
improvement in health inside the
Common
features
Each
NHS system uses General Practitioners (GPs) to provide primary healthcare and
to make referrals to further services as necessary. Hospitals then provide more
specialist services, including care for patients with psychiatric illnesses, as
well as direct access to Accident and Emergency (A&E) departments.
Pharmacies (other than those within hospitals) are privately owned but have
contracts with the relevant health service to supply prescription drugs.
Each
public healthcare system also provides free ambulance services for emergencies,
when patients need the specialist transport only available from ambulance crews
or when patients are not fit to travel home by public transport. These services
are generally supplemented when necessary by the voluntary ambulance services
(British Red Cross, St Andrews Ambulance Association and St John Ambulance). In
addition, patient transport services by air are provided by the Scottish
Ambulance Service in
Each
NHS system also provides dental services through private dental practices and
dentists can only charge NHS patients at the set rates for each country.
Patients opting to be treated privately do not receive any NHS funding for the
treatment. About half of the income of dentists in
The reduction in infant mortality
between 1960 to 2008 for the United Kingdom in comparison with France, Ireland,
Sweden, Switzerland, and the United States. The overall trend has meant a large
improvement in health inside the
Differences
Advice services
Each
NHS system has its own 24-hour telephone advisory service:
Best practice and cost effectiveness
In
In
Cost control
The
National Audit Office reports annually on the summarised consolidated accounts
of the NHS, and Audit
Parking charges
Parking
charges at hospitals have been abolished in
Prescription charges
Policlinics
Policlinics
are being trialled in
Role of private sector in public
healthcare
Whereas
the United Kingdom Government is expanding the role of the private sector
within the NHS in
Funding and performance of healthcare
since devolution
In
January 2010 the Nuffield Trust published a comparative study of NHS
performance in England and the devolved administrations since devolution,
concluding that while Scotland, Wales and Northern Ireland have had higher
levels of funding per capita than England, with the latter having fewer
doctors, nurses and managers per head of population, the English NHS is making
better use of the resources by delivering relatively higher levels of activity,
crude productivity of its staff, and lower waiting times. However, the Nuffield
Trust quickly issued a clarifying statement in which they admitted that the
figures they used to make comparisons between
What is a Verb?
The verb is perhaps the most
important part of the sentence.
A verb or compound verb
asserts something about the subject
of the sentence and express actions, events, or states of being. The verb or
compound verb is the critical element of the predicate
of a sentence.
In each of the following
sentences, the verb or compound verb is highlighted:
Dracula bites
his victims on the neck.
The verb "bites"
describes the action Dracula takes.
N 4.
Public Health Care in Ukraine, Great Britain, the USA. Verbs. Auxiliary verbs Health care or healthcare is the prevention, treatment, and management of
illness and the preservation of mental and physical well-being through the
services offered by the medical, nursing, and allied health
professions. According to the World Health Organization, health care
embraces all the goods and services designed to promote health, including
“preventive, curative and palliative interventions, whether directed to
individuals or to populations”. The organised provision of such services may
constitute a health care system. This can include a specific
governmental organisation such as, in the UK, the National Health Service or a cooperation across
the National Health Service and Social Services as in Shared Care.
Before the term "healthcare" became popular, English-speakers
referred to medicine
or to the health sector
and spoke of the treatment and prevention of illness
and disease. The health care industry is
one of the world's largest and fastest-growing industries. Consuming over 10
percent of gross domestic product of most developed
nations, health care can form an enormous part of a country's economy.
In 2003,
health care costs paid to hospitals, physicians, nursing homes, diagnostic
laboratories, pharmacies,
medical device
manufacturers and other components of the health care system, consumed 15.3
percent of the GDP of
the United States,
the largest of any country in the world. For United States, the health share of
gross domestic product (GDP) is expected to hold steady in 2006 before resuming
its historical upward trend, reaching 19.6 percent of GDP by 2016. [2]
In 2001, for the OECD
countries the average was 8.4 percent [4] with the According to Health Affairs,
USD$7,498 will be spent on every woman, man and
child in the The healthcare industry
includes the delivery of health services by health care providers. Usually such services
receive payment from the patient or from the patient's insurance
company; although they may be government-financed (such as the National Health Service in the United Kingdom)
or delivered by charities or volunteers, particularly in poorer countries. There are many ways of
providing healthcare in the modern world. The most common way is face-to-face
delivery, where care provider and patient see each other 'in the flesh'. This
is what occurs in general medicine in most countries. However, healthcare is
not always face-to-face; with modern telecommunications technology, in absentia health care
is becoming more common. This could be when practitioner and patient
communicate over the phone, video conferencing, the internet,
email, text messages,
or any other form of non-face-to-face communication. A traditional view is that
improvements in health result from advancements in medical
science. The medical model of health focuses on the eradication of illness
through diagnosis
and effective treatment. In contrast, the social model of health places
emphasis on changes that can be made in society and in people's own lifestyles
to make the population healthier. It defines illness from the point of view of the individual's functioning
within their society rather than by monitoring for changes in biological
or physiological
signs. To coincide with the 60th anniversary of All high-tech extras - such as screws and rods - are paid for by the
patient. In a hospital in the Ukrainian capital, neurosurgeon Igor Kurylets, is
working on a patient's back. An 18-year-old woman lies face down on the
operating table, with about 30cm of spine exposed. The operation may look
somewhat primitive: there is a lot of rather violent bashing, scraping and
screwing going on. But this is in fact a state-of-the-art procedure. During the
four-hour operation, the patient's spine will be realigned from an inverted
S-shape to a straight, ordinary looking back. All
high-tech extras - such as screws and rods - are paid for by the patient Holding it all in place will be rods and screws, designed in the It
used to be illegal to pay for medical services in a state hospital All the basic medical provisions are supplied by the state-run hospital.
All the high-tech extras - the screws and rods, the specialised x-ray equipment
- are paid for separately by the patient. Dr Kurylets was one of the people who
pioneered this hybrid system in Gratitude money But the vast majority
of Ukrainians, when they fall ill, still use the system that the country
inherited from the They are clean
though, and well maintained. But that is largely because the doctors themselves
contribute to the hospital's upkeep. We
pay for their hospital, so they have additional money to change windows and
doors, to redecorate the hospital - it is positive economic co-operation Dr
KuryletsOne surgeon on the urology ward agreed to speak to the BBC on condition
of anonymity. "Each of us puts in $100 or $200," he said. "And
with that money we pay to have the walls painted, replace some sanitary
facilities, varnish these floors, and so on." And it's not just cosmetic
improvements that the medical staff has to pay for. Reaching into his desk
draw, the doctor pulled out a handful of catheters and tubes wrapped in sterile
medical packaging: his own personal stash. "It's got to the stage now
where we are buying things we need in order to perform an operation." But
how does a doctor like this one, on a salary of about US$250 (£125) per
month, pay for all of this? It turns out that the free healthcare provided by
the state isn't entirely free after all. "A patient will come to me and
ask: 'Doctor, how much will this cost?' I leave it to the patient to thank me
as he sees fit in return for my work. "The level of gratitude can range
from 'thank you doctor', to a $4 bottle of cognac. Or it can be a certain sum
of money. A fairly large sum. Several times larger than my monthly
salary." Hospital upkeep Dr Kurylets believes
that his hybrid clinic maximises the potential of the immense but crumbling
state-run infrastructure. In return for the use of the SBU's medical
facilities, he treats security service personnel for free. And his clinic
contributes to the upkeep of their hospital. "We pay for their hospital,
so they have additional money to change windows and doors, to redecorate the
hospital. It is positive economic co-operation," Dr Kurylets said.
Patients who are not employees of the SBU do have to pay, though. The
18-year-old with the curved spine would be charged around $10,000. And while
that may seem like a lot of money, it is a fraction of what a similar operation
would cost in Western Europe or the The healthcare system in
Ukraine Ukrainian healthcare is run by the Ministry of Health, with all working
citizens contributing to the cost. In theory, healthcare is available free of
charge to all citizens of Ukraine, however, in practice, the free services only
cover basic provision and patients often have to pay for extras such as
specialist equipment required during surgery. Often, doctors and consultants
will also charge a fee for their time. Ukrainian public healthcare is still in transition from the Soviet dictated
health system of the past. Under this system, capacity was everything,
resulting in high numbers of physicians and beds, among the best in Fortunately, as is often the case in Private cosmetic surgery and dental care in Two particular specialties in Medical tourism is growing rapidly in The Institute for Reproductive Medicine: IVF and
infertility treatment in Kiev, Ukraine The Institute for
Reproductive Medicine (IRM) in About the Institute for Reproductive Medicine
in The first successful in
vitro fertilisation programme in IRM – the first IVF
clinic in The first ICSI in Cryotransfer – birth
of a child (2003) The structure of the IRM Fertility Clinic in Kiev 1.
Infertility Unit 2.
Embryological Unit 3.
Surgical Unit: minimally
invasive endoscopic surgery (laparoscopy,hysteroscopy, fertiloscopy), wide
range of gynaecological, andrological, and urological operations Polyclinic 1.
Gynaecological
endocrinologist 2.
Prenatal diagnosis and
pregnancy care: 4D ultrasound, prenatal painting 3.
Cervical pathology
specialist 4.
Urologist-andrologist 5.
Breast specialist 6.
Day patient department Infertility treatments
available at the IRM Fertility Clinic in Ukraine ·
Male factor - cutting edge
diagnosis and treatment ·
Female factor -
comprehensive fertility assessment of the female partner ·
Combined factor - integrated
approach to both partners ·
ICSI ·
IMSI ·
PICSI ·
Egg donation ·
Sperm donation ·
Freezing of reproductive
cells ·
Embryo freezing ·
Selective transfer of 1-2
embryos ·
Treatment in non-stimulated
cycles with frozen-thawed embryo transfer Fertility treatment packages
in Ukraine Conventional IVF Ist VISIT (1-2 hours
during one working day) ·
Initial consultation ·
Examination of a couple:
gynecological examination + sperm analysis + chromosome analysis of both
partners ·
Sperm collection ·
Consultation based on the
results of examination + personalised treatment algorithm work out TREATMENT PROGRAMME (average
duration – 1-1½ months) ·
Controlled ovarian
stimulation ·
Ultrasound and hormone
monitoring of follicular growth ·
Oocyte pick up ·
Laboratory preparation and
selection of germ cells (sperm and oocytes) ·
Fertilisation via IVF (in a
Petri dish) ·
Embryo cultivation ·
Selection of quality embryos ·
Selective embryo transfer ·
Consultations during
programme ICSI Package Ist VISIT (1-2 hours during one working day) ·
Initial consultation ·
Examination of a couple: gynecological
examination + sperm analysis + chromosome analysis of both partners ·
Sperm collection ·
Consultation based on the
results of examination + personalised treatment algorithm work out TREATMENT PROGRAMME (average
duration – 1-1½ months) ·
Controlled ovarian
stimulation ·
Ultrasound and hormone
monitoring of follicular growth ·
Oocyte pick up ·
Laboratory preparation and
selection of germ cells (sperm and oocytes) ·
Fertilisation via ICSI ·
Embryo cultivation ·
Selection of quality embryos ·
Selective embryo transfer ·
Consultations during
programme ·
On-line support till 12
weeks of pregnancy ·
Consultations during
programme Egg donation Ist VISIT (1-2 hours during one working day) ·
Initial consultation ·
Examination of a couple: gynecological
examination + sperm analysis + chromosome analysis of both partners ·
Sperm collection,
cryopreservation ·
Chromosome analysis of a
husband (karyotype of a donor was determined) ·
Donor matching from donor
database (taking into account phenotype and blood type) TREATMENT PROGRAMME (average duration – 1-1½ months) ·
Controlled ovarian
stimulation of a donor ·
Synchronization of menstrual
cycles of a donor and a recipient ·
Ultrasound and hormone
monitoring of follicular growth ·
Oocyte pick up ·
Fertilisation via ICSI ·
Embryo cultivation ·
Selection of quality embryos ·
Selective embryo transfer ·
Consultations during
programme ·
On-line support till 12
weeks of pregnancy ·
Consultations during
programme Health care
in the Health
care in the The
U.S. Census Bureau reported that 49.9 million residents, 16.3% of the
population, were uninsured in 2010 (up from 49.0 million residents, 16.1% of
the population, in 2009). According to the World Health Organization (WHO), the
Active
debate about health care reform in the Life
expectancy at birth in the A
2004 Institute of Medicine (IOM) report said: "The On
March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) became
law, providing for major changes in health insurance. Providers Health
care providers in the Facilities In
the The
non-profit hospitals share of total hospital capacity has remained relatively
stable (about 70%) for decades. There are also privately owned for-profit
hospitals as well as government hospitals in some locations, mainly owned by
county and city governments. There
is no nationwide system of government-owned medical facilities open to the
general public but there are local government-owned medical facilities open to
the general public. The federal Department of Defense operates field hospitals
as well as permanent hospitals (the Military Health System), to provide
military-funded care to active military personnel. The
federal Veterans Health Administration operates VA hospitals open only to
veterans, though veterans who seek medical care for conditions they did not
receive while serving in the military are charged for services. The Indian
Health Service operates facilities open only to Native Americans from
recognized tribes. These facilities, plus tribal facilities and privately
contracted services funded by IHS to increase system capacity and capabilities,
provide medical care to tribespeople beyond what can be paid for by any private
insurance or other government programs. Hospitals
provide some outpatient care in their emergency rooms and specialty clinics,
but primarily exist to provide inpatient care. Hospital emergency departments
and urgent care centers are sources of sporadic problem-focused care.
"Surgicenters" are examples of specialty clinics. Hospice services
for the terminally ill who are expected to live six months or less are most
commonly subsidized by charities and government. Prenatal, family planning, and
"dysplasia" clinics are government-funded obstetric and gynecologic
specialty clinics respectively, and are usually staffed by nurse practitioners. Physicians
(M.D. and D.O.) Physicians
in the The
Medical products, research and
development As
in most other countries, the manufacture and production of pharmaceuticals and
medical devices is carried out by private companies. The research and
development of medical devices and pharmaceuticals is supported by both public
and private sources of funding. In 2003, research and development expenditures
were approximately $95 billion with $40 billion coming from public sources and
$55 billion coming from private sources. These investments into medical
research have made the Spending Total U.S. healthcare spending as a percent of
U.S. GDP (gross domestic product). According
to the World Health Organization (WHO), total health care spending in the The
Office of the Actuary (OACT) of the Centers for Medicare and Medicaid Services
publishes data on total health care spending in the In
2009, the U.S. healthcare costs exceed those of
other countries, relative to the size of the economy or GDP. The
Congressional Budget Office has found that "about half of all growth in
health care spending in the past several decades was associated with changes in
medical care made possible by advances in technology." Other factors
included higher income levels, changes in insurance coverage, and rising
prices. Hospitals and physician spending take the largest share of the health
care dollar, while prescription drugs take about 10%. The use of prescription
drugs is increasing among adults who have drug coverage. One
analysis of international spending levels in the year 2000 found that while the
Health
care spending in the An
earlier study by AHRQ the found significant persistence in the level of health
care spending from year to year. Of the 1% of the population with the highest
health care spending in 2002, 24.3% maintained their ranking in the top 1% in
2003. Of the 5% with the highest spending in 2002, 34% maintained that ranking
in 2003. Individuals over age 45 were disproportionately represented among
those who were in the top decile of spending for both years. Total Health care cost rise based on total
expenditure on health as % of GDP. Countries are Seniors
spend, on average, far more on health care costs than either working-age adults
or children. The pattern of spending by age was stable for most ages from 1987
through 2004, with the exception of spending for seniors age 85 and over.
Spending for this group grew less rapidly than that of other groups over this
period. The
2008 edition of the Dartmouth Atlas of Health Care found that providing
Medicare beneficiaries with severe chronic illnesses with more intense health
care in the last two years of life—increased spending, more tests, more
procedures and longer hospital stays—is not associated with better patient
outcomes. There are significant geographic variations in the level of care
provided to chronically ill patients, only 4% of which are explained by differences
in the number of severely ill people in an area. Most of the differences are
explained by differences in the amount of "supply-sensitive" care
available in an area. Acute hospital care accounts for over half (55%) of the
spending for Medicare beneficiaries in the last two years of life, and
differences in the volume of services provided is more significant than
differences in price. The researchers found no evidence of
"substitution" of care, where increased use of hospital care would
reduce outpatient spending (or vice versa). Health care cost rise based on total
expenditure on health as % of GDP. Countries are Increased
spending on disease prevention is often suggested as a way of reducing health
care spending. Whether prevention saves or costs money depends on the
intervention. Childhood vaccinations, or contraceptives save much more than
they cost. Research suggests that in many cases prevention does not produce
significant long-term cost savings. Some interventions may be cost-effective by
providing health benefits, while others are not cost-effective. Preventive care
is typically provided to many people who would never become ill, and for those
who would have become ill is partially offset by the health care costs during
additional years of life. In
September 2008 The Wall Street Journal reported that consumers were reducing
their health care spending in response to the current economic slow-down. Both
the number of prescriptions filled and the number of office visits dropped
between 2007 and In
2009, the average private room in a nursing home cost $219 daily. Assisted
living costs averaged $3,131 monthly. Home health aides averaged $21 per hour.
Adult day care services averaged $67 daily. Impact on On
March 1, 2010, billionaire investor Warren Buffett said that the high costs
paid by Allegations of waste In
December 2011, the outgoing Administrator of the Centers for Medicare &
Medicaid Services, Dr. Donald Berwick, asserted that 20% to 30% of health care
spending is waste. He listed five causes for the waste: (1) overtreatment of
patients, (2) the failure to coordinate care, (3) the administrative complexity
of the health care system, (4) burdensome rules and (5) fraud. Payment Doctors
and hospitals are generally funded by payments from patients and insurance
plans in return for services rendered (fee-for-service or FFS). Around
84.7% of Americans have some form of health insurance; either through their
employer or the employer of their spouse or parent (59.3%), purchased
individually (8.9%), or provided by government programs (27.8%; there is some
overlap in these figures). All government health care programs have restricted
eligibility, and there is no government health insurance company which covers
all Americans. Americans without health insurance coverage in 2007 totaled
15.3% of the population, or 45.7 million people. Among
those whose employer pays for health insurance, the employee may be required to
contribute part of the cost of this insurance, while the employer usually
chooses the insurance company and, for large groups, negotiates with the
insurance company. In
2004, private insurance paid for 36% of personal health expenditures, private
out-of-pocket 15%, federal government 34%, state and local governments 11%, and
other private funds 4%. Due to "a dishonest and inefficient system"
that sometimes inflates bills to ten times the actual cost, even insured
patients can be billed more than the real cost of their care. Insurance
for dental and vision care (except for visits to ophthalmologists, which are
covered by regular health insurance) is usually sold separately. Prescription
drugs are often handled differently than medical services, including by the
government programs. Major federal laws regulating the insurance industry
include COBRA and HIPAA. Individuals
with private or government insurance are limited to medical facilities which
accept the particular type of medical insurance they carry. Visits to
facilities outside the insurance program's "network" are usually
either not covered or the patient must bear more of the cost. Hospitals
negotiate with insurance programs to set reimbursement rates; some rates for
government insurance programs are set by law. The sum paid to a doctor for a
service rendered to an insured patient is generally less than that paid
"out of pocket" by an uninsured patient. In return for this discount,
the insurance company includes the doctor as part of their "network",
which means more patients are eligible for lowest-cost treatment there. The
negotiated rate may not cover the cost of the service, but providers (hospitals
and doctors) can refuse to accept a given type of insurance, including Medicare
and Medicaid. Low reimbursement rates have generated complaints from providers,
and some patients with government insurance have difficulty finding nearby
providers for certain types of medical services. Charity
care for those who cannot pay is sometimes available, and is usually funded by
non-profit foundations, religious orders, government subsidies, or services
donated by the employees. The
Emergency Medical Treatment and Active Labor Act requires virtually all
hospitals to accept all patients, regardless of the ability to pay, for
emergency room care. The act does not provide access to non-emergency room care
for patients who cannot afford to pay for health care, nor does it provide the
benefit of preventive care and the continuity of a primary care physician.
Emergency health care is generally more expensive than an urgent care clinic or
a doctor's office visit, especially if a condition has worsened due to putting
off needed care. Emergency rooms are typically at, near, or over capacity. Long
wait times have become a problem nationally, and in urban areas some ERs are
put on "diversion" on a regular basis, meaning that ambulances are
directed to bring patients elsewhere. Private This
section needs additional citations for verification. Please help improve this
article by adding citations to reliable sources. Unsourced material may be
challenged and removed. (January 2009) Share by insurance coverage type, for those
under 65 years of age Most
Americans under age 65 (59.3%) receive their health insurance coverage through
an employer (which includes both private as well as civilian public-sector
employers) under group coverage, although this percentage is declining. Costs
for employer-paid health insurance are rising rapidly: since 2001, premiums for
family coverage have increased 78%, while wages have risen 19% and inflation
has risen 17%, according to a 2007 study by the Kaiser Family Foundation.
Workers with employer-sponsored insurance also contribute; in 2007, the average
percentage of premium paid by covered workers is 16% for single coverage and
28% for family coverage. In addition to their premium contributions, most
covered workers face additional payments when they use health care services, in
the form of deductibles and copayments. Just
less than 9% of the population purchases individual health care insurance.
Insurance payments are a form of cost-sharing and risk management where each
individual or their employer pays predictable monthly premiums. This
cost-spreading mechanism often picks up much of the cost of health care, but
individuals must often pay up-front a minimum part of the total cost (a
deductible), or a small part of the cost of every procedure (a copayment).
Private insurance accounts for 35% of total health spending in the Share by insurance coverage type, for
those under 65 years of age Provider
networks can be used to reduce costs by negotiating favorable fees from
providers, selecting cost effective providers, and creating financial incentives
for providers to practice more efficiently. A survey issued in 2009 by Defying
many analysts' expectations, PPOs have gained market share at the expense of
HMOs over the past decade. Just
as the more loosely managed PPOs have edged out HMOs, HMOs themselves have also
evolved towards less tightly managed models. The first HMOs in the Public Government
programs directly cover 27.8% of the population (83 million), including the
elderly, disabled, children, veterans, and some of the poor, and federal law
mandates public access to emergency services regardless of ability to pay.
Public spending accounts for between 45% and 56.1% of However,
all government-funded healthcare programs exist only in the form of statutory
law, and accordingly can be amended or revoked like any other statute. There is
no constitutional right to healthcare. The U.S. Supreme Court explained in 1977
that "the Constitution imposes no obligation on the States to pay ... any
of the medical expenses of indigents." Government funded programs include: Medicare,
generally covering citizens and long-term residents 65 years and older and the
disabled. Medicaid,
generally covering low income people in certain categories, including children,
pregnant women, and the disabled. (Administered by the states.) State
Children's Health Insurance Program, which provides health insurance for
low-income children who do not qualify for Medicaid. (Administered by the
states, with matching state funds.) Various
programs for federal employees, including TRICARE for military personnel (for
use in civilian facilities) The
Veterans Administration, which provides care to veterans, their families, and
survivors through medical centers and clinics. Title
X which funds reproductive health care State
and local health department clinics Indian
health service National
Institutes of Health treats patients who enroll in research for free. Medical
Corps of various branches of the military. Certain
county and state hospitals Government
run community clinics The
exemption of employer-sponsored health benefits from federal income and payroll
taxes distorts the health care market. The Health
insurance benefits are an attractive way for employers to increase the salary
of employees as they are nontaxable. As a result, 65% of the non-elderly
population and over 90% of the privately insured non-elderly population
receives health insurance at the workplace. Additionally, most economists agree
that this tax shelter increases individual demand for health insurance, leading
some to claim that it is largely responsible for the rise in health care
spending. In
addition the government allows full tax shelter at the highest marginal rate to
investors in health savings accounts (HSAs). Some have argued that this tax
incentive adds little value to national health care as a whole because the most
wealthy in society tend also to be the most healthy. Also it has been argued,
HSAs segregate the insurance pools into those for the wealthy and those for the
less wealthy which thereby makes equivalent insurance cheaper for the rich and
more expensive for the poor. However, one advantage of health insurance
accounts is that funds can only be used towards certain HSA qualified expenses,
including medicine, doctor's fees, and Medicare Parts A and B. Funds cannot be
used towards expenses such as cosmetic surgery. There
are also various state and local programs for the poor. In 2007, Medicaid
provided health care coverage for 39.6 million low-income Americans (although
Medicaid covers approximately 40% of It
has been reported that the number of physicians accepting Medicaid has
decreased in recent years due to relatively high administrative costs and low
reimbursements. In 1997, the federal government also created the State
Children's Health Insurance Program (SCHIP), a joint federal-state program to
insure children in families that earn too much to qualify for Medicaid but
cannot afford health insurance. SCHIP covered 6.6 million children in 2006, but
the program is already facing funding shortfalls in many states. The government
has also mandated access to emergency care regardless of insurance status and
ability to pay through the Emergency Medical Treatment and Labor Act (EMTALA),
passed in 1986, but EMTALA is an unfunded mandate. The uninsured Some
Americans do not qualify for government-provided health insurance, are not
provided health insurance by an employer, and are unable to afford, cannot
qualify for, or choose not to purchase, private health insurance. When charity
or "uncompensated" care is not available, they sometimes simply go
without needed medical treatment. This problem has become a source of
considerable political controversy on a national level. According
to the US Census Bureau, in 2007, 45.7 million people in the Among
the uninsured population, the Census Bureau says, nearly 37 million were
employment-age adults (ages 18 to 64), and more than 27 million worked at least
part time. About 38% of the uninsured live in households with incomes of
$50,000 or more. According to the Census Bureau, nearly 36 million of the
uninsured are legal U.S citizens. Another 9.7 million are noncitizens, but the
Census Bureau does not distinguish in its estimate between legal noncitizens
and illegal immigrants. Nearly one fifth of the uninsured population is able to
afford insurance, almost one quarter is eligible for public coverage, and the
remaining 56% need financial assistance (8.9% of all Americans). Extending
coverage to all who are eligible remains a fiscal challenge. A
2003 study in Health Affairs estimated that uninsured people in the The
health insurance system in From
2000 to 2004, the The
reports concluded that the committee recommended that the nation should
implement a strategy to achieve universal health insurance coverage. As of The
six reports created by the Institute of Medicine (IOM) found that the principal
consequences of uninsurance were the following: Children and Adults without
health insurance did not receive needed medical care; they typically live in
poorer health and die earlier than children or adults who have insurance. The
financial stability of a whole family can be put at risk if only one person is
uninsured and needs treatment for unexpected health care costs. The overall
health status of a community can be adversely affected by a higher percentage
of uninsured people within the community. The coverage gap between the insured
and the uninsured has not decreased even after the recent federal initiatives
to extend health insurance coverage. The
last report was published in 2004 and was named Insuring America's Health:
Principles and Recommendations. This report recommended the following: The
President and Congress need to develop a strategy to achieve universal
insurance coverage and establish a firm schedule to reach this goal by the year
2010. The committee also recommended that the federal and state governments
provide sufficient resources for Medicaid and the State Children's Health
Insurance Program (SCHIP) to cover all persons currently eligible until the
universal coverage takes effect. They also warned that the federal and state
governments should prevent the erosion of outreach efforts, eligibility,
enrollment, and coverage of these specific programs. Some
people think that not having health insurance will have adverse consequences
for the health of the uninsured. On the other hand, some people believe that
children and adults without health insurance have access to needed health care
services at hospital emergency rooms, community health centers, or other safety
net facilities offering charity care. Some observers note that there is a solid
body of evidence showing that a substantial proportion of Children
in The
same committee analyzed the effects of health insurance on adult's health
outcomes: adults who do not have health insurance coverage who acquire Medicare
coverage at age 65, experience substantially improved health and functional
status, particularly those who have cardiovascular disease or diabetes. Adults
who have cardiovascular disease or other cardiac risk factors that are
uninsured are less likely to be aware of their condition, which leads to worse
health outcomes for those individuals. Without health insurance, adults are
more likely to be diagnosed with certain cancers that would have been
detectable earlier by screening by a clinician if they had regularly visited a
doctor. As a consequence, these adults are more likely to die from their
diagnosed cancer or suffer poorer health outcomes. Many
towns and cities in the Estimates
for 2008 reported that the uninsured would spend $30 billion for healthcare and
receive $56 billion in uncompensated care, and that if everyone were covered by
insurance then overall costs would increase by $123 billion. A 2003 Institute
of Medicine (IOM) report estimated total cost of health care provided to the
uninsured at $98.9 billion in 2001, including $26.4 billion in out-of-pocket
spending by the uninsured, with $34.5 billion in "free"
"uncompensated" care covered by government subsidies of $30.6 billion
to hospitals and clinics and $5.1 billion in donated services by physicians. Role of government in health care
market Numerous
publicly funded health care programs help to provide for the elderly, disabled,
military service families and veterans, children, and the poor, and federal law
ensures public access to emergency services regardless of ability to pay;
however, a system of universal health care has not been implemented
nation-wide. However, as the OECD has pointed out, the total In
July 2009, Regulation and oversight Involved organizations and
institutions Healthcare
is subject to extensive regulation at both the federal and the state level,
much of which "arose haphazardly" Under this system, the federal
government cedes primary responsibility to the states under the
McCarran-Ferguson Act. Essential regulation includes the licensure of health
care providers at the state level and the testing and approval of
pharmaceuticals and medical devices by the Food and Drug Administration, and
laboratory testing. These regulations are designed to protect consumers from
ineffective or fraudulent healthcare. Additionally, states regulate the health
insurance market and they often have laws which require that health insurance companies
cover certain procedures, although state mandates generally do not apply to the
self-funded health care plans offered by large employers, which exempt from
state laws under preemption clause of the Employee Retirement Income Security
Act. In 2010, the Patient Protection and Affordable Care Act (PPACA) was
passed, and includes various new regulations, with one of the most notable
being a health insurance mandate which requires all citizens to purchase health
insurance. While not regulation per se, the federal government also has a major
influence on the healthcare market through its payments to providers under
Medicare and Medicaid, which in some cases are used as a reference point in the
negotiations between medical providers and insurance companies. At
the federal level, United States Department of Health and Human Services
oversees the various federal agencies involved in health care. The health
agencies are a part of the United States Public Health Service, and include the
Food and Drug Administration, which certifies the safety of food, effectiveness
of drugs and medical products, the Centers for Disease Prevention, which
prevents disease, premature death, and disability, the Agency of Health Care
Research and Quality, the Agency Toxic Substances and Disease Registry, which
regulates hazardous spills of toxic substances, and the National Institutes of
Health, which conducts medical research. State
governments maintain state health departments, and local governments (counties
and municipalities) often have their own health departments, usually branches
of the state health department. Regulations of a state board may have executive
and police strength to enforce state health laws. In some states, all members
of state boards must be health care professionals. Members of state boards may
be assigned by the governor or elected by the state committee. Members of local
boards may be elected by the mayor council. The McCarran–Ferguson Act, which
cedes regulation to the states, does not itself regulate insurance, nor does it
mandate that states regulate insurance. "Acts of Congress" that do
not expressly purport to regulate the "business of insurance" will
not preempt state laws or regulations that regulate the "business of
insurance." The Act also provides that federal anti-trust laws will not
apply to the "business of insurance" as long as the state regulates
in that area, but federal anti-trust laws will apply in cases of boycott,
coercion, and intimidation. By contrast, most other federal laws will not apply
to insurance whether the states regulate in that area or not. Self-policing
of providers by providers is a major part of oversight. Many health care
organizations also voluntarily submit to inspection and certification by the
Joint Commission on Accreditation of Hospital Organizations, JCAHO. Providers
also undergo testing to obtain board certification attesting to their skills. A
report issued by Public Citizen in April 2008 found that, for the third year in
a row, the number of serious disciplinary actions against physicians by state
medical boards declined from 2006 to 2007, and called for more oversight of the
boards. The
Centers for Medicare and Medicaid Services (CMS) publishes an on-line
searchable database of performance data on nursing homes. The
regulation is controversial. In 2004, conservative think tank Cato Institute
published a study which concluded that regulation provides benefits in the
amount of $170 billion but costs the public up to $340 billion. The study
concluded that the majority of the cost differential arises from medical
malpractice, U.S. Food and Drug Administration (FDA) regulations, and
facilities regulations. "Certificates of need" for hospitals In
1978, the federal government required that all states implement Certificate of
Need (CON) programs for cardiac care, meaning that hospitals had to apply and
receive certificates prior to implementing the program; the intent was to
reduce cost by reducing duplicate investments in facilities. It has been
observed that these certificates could be used to increase costs through
weakened competition. Many states removed the CON programs after the federal
requirement expired in 1986, but some states still have these programs.
Empirical research looking at the costs in areas where these programs have been
discontinued have not found a clear effect on costs, and the CON programs could
decrease costs because of reduced facility construction or increase costs due
to reduced competition. Licensing of providers American
Medical Association (AMA) has lobbied the government to highly limit physician
education since 1910, currently at 100,000 doctors per year, which has led to a
shortage of doctors and physicians' wages in the An
even bigger problem may be that the doctors are paid for procedures instead of
results. AMA
has also aggressively lobbied for many restrictions that require doctors to carry
out operations that might be carried out by cheaper workforce. For example, in
1995, 36 states banned or restricted midwifery even though it delivers equally
safe care to that by doctors, according to studies [clarification needed] . The
regulation lobbied by AMA has decreased the amount and quality of health care,
according to the consensus of economist: the restrictions do not add to
quality, they decrease the supply of care. [clarification needed] Moreover,
psychologists, nurses and pharmacologists are not allowed to prescribe
medicines.[clarification needed] Previously nurses were not even allowed to
vaccinate the patients without direct supervision by doctors. Emergency Medical Treatment and
Active Labor Act (EMTALA) EMTALA,
enacted by the federal government in 1986, requires that hospital emergency
departments treat emergency conditions of all patients regardless of their
ability to pay and is considered a critical element in the "safety
net" for the uninsured, but established no direct payment mechanism for
such care. Indirect payments and reimbursements through federal and state
government programs have never fully compensated public and private hospitals
for the full cost of care mandated by EMTALA. In fact, more than half of all
emergency care in the Mentally
ill patients present a unique challenge for emergency departments and
hospitals. In accordance with EMTALA, mentally ill patients who enter emergency
rooms are evaluated for emergency medical conditions. Once mentally ill
patients are medically stable, regional mental health agencies are contacted to
evaluate them. Patients are evaluated as to whether they are a danger to
themselves or others. Those meeting this criterion are admitted to a mental
health facility to be further evaluated by a psychiatrist. Typically, mentally
ill patients can be held for up to 72 hours, after which a court order is
required.[citation needed] Quality assurance Health
care quality assurance consists of the "activities and programs intended
to assure or improve the quality of care in either a defined medical setting or
a program. The concept includes the assessment or evaluation of the quality of
care; identification of problems or shortcomings in the delivery of care;
designing activities to overcome these deficiencies; and follow-up monitoring
to ensure effectiveness of corrective steps." One
innovation in encouraging quality of health care is the public reporting of the
performance of hospitals, health professionals or providers, and healthcare
organizations. However, there is "no consistent evidence that the public
release of performance data changes consumer behaviour or improves care." Overall system effectiveness compared
to other countries Life expectancy compared to healthcare
spending from 1970 to The
A
study found that between 1997 and 2003, preventable deaths declined more slowly
in the The
Organisation for Economic Co-operation and Development (OECD) found that the Recent
studies find growing gaps in life expectancy based on income and geography. In Life expectancy compared to
healthcare spending from 1970 to The
debate about A
report released in April 2008 by the Foundation for Child Development, which studied
the period from 1994 through 2006, found mixed results for the health of
children in the U.S. Mortality rates for children ages 1 through 4 dropped by a
third, and the percentage of children with elevated blood lead levels dropped
by 84%. The percentage of mothers who smoked during pregnancy also declined. On
the other hand, both obesity and the percentage of low-birth weight babies
increased. The authors note that the increase in babies born with low birth
weights can be attributed to women delaying childbearing and the increased use
of fertility drugs. System efficiency and equity Variations
in the efficiency of health care 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 Lean
manufacturing techniques such as value stream mapping can help identify and
subsequently mitigate waste associated with costs of healthcare. Efficiency Preventable deaths In
2009, lack of health insurance was responsible for about 45,000 excess
preventable deaths in the Value for money A
study of international health care spending levels published in the health
policy journal Health Affairs in the year 2000 found that the U.S. spends
substantially more on health care than any other country in the Organization
for Economic Co-operation and Development (OECD), and that the use of health
care services in the U.S. is below the OECD median by most measures. The
authors of the study conclude that the prices paid for health care services are
much higher in the U.S. than elsewhere.[37] While the 19 next most wealthy
countries by GDP all pay less than half what the US does for health care, they
have all gained about six years of life expectancy more than the U.S. since
1970. Delays in seeking care and increased
use of emergency care Uninsured
Americans are less likely to have regular health care 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. Shared costs of the uninsured The
costs of treating the uninsured must often be absorbed by providers as charity
care, passed on to the insured via cost shifting and higher health insurance
premiums, or paid by taxpayers through higher taxes. However, hospitals and
other providers are reimbursed for the cost of providing uncompensated care via
a federal matching fund program. Each state enacts legislation governing the
reimbursement of funds to providers. In A
report published by the Kaiser Family Foundation in April 2008 found that
economic downturns place a significant strain on state Medicaid and SCHIP
programs. The authors estimated that a 1% increase in the unemployment rate
would increase Medicaid and SCHIP enrollment by 1 million, and increase the
number uninsured by 1.1 million. State spending on Medicaid and SCHIP would
increase by $1.4 billion (total spending on these programs would increase by
$3.4 billion). This increased spending would occur at the same time state
government revenues were declining. During the last downturn, the Jobs and
Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal
assistance to states, which helped states avoid tightening their Medicaid and
SCHIP eligibility rules. The authors conclude that Congress should consider
similar relief for the current economic downturn. Variations in provider practices The
treatment given to a patient can vary significantly depending on which health
care providers they use. Research suggests that some cost-effective treatments
are not used as often as they should be, while overutilization occurs with
other health care 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
health care. The way the Health care system tries to eliminate this problem is
through cost sharing tactics like co-pays and deductibles. If patients face
more of the economic burden they will then only consume health care when it is
necessary. According to the 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 health care system of the 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. Many
primary care physicians no longer see their patients while they are in the
hospital. Instead, hospitalists are used, which fragments care because
hospitalists usually have had no previous relationship with the patient they
are treating and do not have a personal knowledge of the patient's medical
history. 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 The
health care system in the According
to the insurance industry group A
2003 study published by the Blue Cross and Blue Shield Association 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 12.9% to 11.6%
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 the Blue Cross and Blue Shield Association found that the average
administrative expense cost for all commercial health insurance products was
represented 9.18% of premiums in 2008. Administrative costs were 11.12% of
premiums for small group products and 16.35% in the individual market. 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 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. The lack of price information on medical services can
also distort incentives. The insurance which pays on behalf of insureds
negotiate with medical providers, sometimes using government-established prices
such as Medicaid billing rates as a reference point. This reasoning has led for
calls to reform the insurance system to create a consumer-driven health care
system whereby consumers pay more out-of-pocket. 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. Overall costs The
cost impact of the existing mixed public-private system is subject to debate.
The United States spends more as a percentage of GDP than similar countries,
and this can be explained either through higher prices for services themselves,
higher costs to administer the system, or more utilization of these services
(for example, due to the United States having a more sickly population), or to
a combination of these elements. Free-market
advocates claim that the health care system is "dysfunctional"
because the system of third-party payments from insurers removes the patient as
a major participant in the financial and medical choices that affect costs.
Because government intervention has expanded insurance availability through
programs such as Medicare and Medicaid, this has exacerbated the problem.
According to a study paid for by Health
care costs rising far faster than inflation have been a major driver for health
care reform in the In
March 2010, Equity Coverage Enrollment
rules in private and governmental programs result in millions of Americans
going without health care coverage, including children. The U.S. Census Bureau
estimated that 45.7 million Americans (15.3% of the total population) had no
health insurance coverage in 2007. However, statistics regarding the insured
population are difficult to pinpoint for a number of factors, with the Census
Bureau writing that "health insurance coverage is likely to be
underreported". Further, such statistics do not provide insight into the
reason a given person might be uninsured. For example, studies have shown that
approximately one third of this 45.7 million person population of uninsured persons
is actually eligible for government insurance programmes such as
Medicaid/Medicare, but has elected not to enroll. The largest proportion of the
population of uninsured Americans is persons earning in excess of $50,000 per
annum, with those earning over $75,000 p.a. comprising the fastest-growing
segment of the uninsured population. US Citizens who earn too much money to
qualify for government assistance with insurance programs but who do not earn
enough to purchase a private health insurance plan make up approxmiately 2.7%
percent of the total US population (8.2 million of approximately 300 million
total population, by 2003 figures). Some
states (like Coverage
gaps also occur among the insured population. Coverage
gaps and affordability also surfaced in a 2007 international comparison by the
Commonwealth Fund. Among adults surveyed in the Mental health A
lack of mental health coverage for Americans bears significant ramifications to
the 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. Up to 2008 insurance
companies used loopholes and, though providing financial equity, they often
worked around the law by applying unequal co-payments or setting limits on the
number of days spent in in-patient or out-patient treatment facilities. Medical underwriting and the
uninsurable In
most states in the Proponents
of medical underwriting argue that it ensures that individual health insurance
premiums are kept as low as possible. Critics of medical underwriting believe
that it unfairly prevents people with relatively minor and treatable
pre-existing conditions from obtaining health insurance. One
large industry survey found that 13% of applicants for individual health
insurance who went through medical underwriting were denied coverage in 2004.
Declination rates increased significantly with age, rising from 5% for those
under 18 to just under one-third for those aged 60 to 64. Among those who were
offered coverage, the study found that 76% received offers at standard premium
rates, and 22% were offered higher rates. The frequency of increased premiums
also increased with age, so for applicants over 40, roughly half were affected
by medical underwriting, either in the form of denial or increased premiums. In
contrast, almost 90% of applicants in their 20s were offered coverage, and
three-quarters of those were offered standard rates. Seventy percent of
applicants age 60–64 were offered coverage, but almost half the time (40%) it
was at an increased premium. The study did not address how many applicants who
were offered coverage at increased rates chose to decline the policy. A study
conducted by the Commonwealth Fund in 2001 found that, among those aged 19 to
64 who sought individual health insurance during the previous three years, the
majority found it unaffordable, and less than a third ended up purchasing
insurance. This study did not distinguish between consumers who were quoted
increased rates due to medical underwriting and those who qualified for
standard or preferred premiums. Some states have outlawed medical underwriting
as a prerequisite for individually purchased health coverage. These states tend
to have the highest premiums for individual health insurance. Demographic differences In
the Public
spending is highly correlated with age; average per capita public spending for
seniors was more than five times that for children ($6,921 versus $1,225).
Average public spending for non-Hispanic blacks ($2,973) was slightly higher
than that for whites ($2,675), while spending for Hispanics ($1,967) was
significantly lower than the population average ($2,612). Total public spending
is also strongly correlated with self-reported health status ($13,770 for those
reporting "poor" health versus $1,279 for those reporting
"excellent" health). Seniors comprise 13% of the population but take
1/3 of all prescription drugs. The average senior fills 38 prescriptions
annually. A new study has also found that older men and women in the South are
more often prescribed antibiotics than older Americans elsewhere, even though
there is no evidence that the South has higher rates of diseases requiring
antibiotics. There
is a great deal of research into inequalities in health care. In some cases
these inequalities are caused by income disparities that result in lack of
health insurance and other barriers to receiving services. According to the
2009 National Healthcare Disparities Report, uninsured Americans are less
likely to receive preventive services in health care. 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 health care reflect a systemic bias in the way medical
procedures and treatments are prescribed for different ethnic groups. Raj Drug efficacy and safety The
Food and Drug Administration (FDA) is the primary institution tasked with the
safety and effectiveness of human and veterinary drugs. It also is responsible
for making sure drug information is accurately and informatively presented to
the public. The FDA reviews and approves products and establishes drug
labeling, drug standards, and medical device manufacturing standards. It sets
performance standards for radiation and ultrasonic equipment. One
of the more contentious issues related to drug safety is immunity from
prosecution. In 2004, the FDA reversed a federal policy, arguing that FDA
premarket approval overrides most claims for damages under state law for
medical devices. In 2008 this was confirmed by the Supreme Court in Riegel v.
Medtronic. On
30 June 2006, an FDA ruling went into effect extending protection from lawsuits
to pharmaceutical manufacturers, even if it was found that they submitted
fraudulent clinical trial data to the FDA in their quest for approval. This
left consumers who experience serious health consequences from drug use with
little recourse. In 2007, opposition was raised in the Congressional House to
the FDA ruling, but the Senate upheld the status quo. On 4 March 2009, an
important U.S. Supreme Court decision was handed down. In Wyeth v. Levine, the
court asserted that state-level rights of action could not be pre-empted by federal
immunity and could provide "appropriate relief for injured
consumers." In June 2009, under the Public Readiness and Emergency
Preparedness Act, Secretary of Health and Human Services Kathleen Sebelius
signed an order extending protection to vaccine makers and federal officials
from prosecution during a declared health emergency related to the
administration of the swine flu vaccine. Impact of drug companies The
When
health care legislation was being written in 2009, the drug companies were asked
to support the legislation in return for not allowing importation of drugs from
foreign countries. Political issues Prescription
drug prices The following text needs to be harmonized with text in Prescription
drug prices in the During
the 1990s, the price of prescription drugs became a major issue in American
politics as the prices of many new drugs increased exponentially, and many
citizens discovered that neither the government nor their insurer would cover
the cost of such drugs. Per capita, the The
United States government has taken the position (through the Office of the
United States Trade Representative) that U.S. drug prices are rising because
U.S. consumers are effectively subsidizing costs which drug companies cannot
recover from consumers in other countries (because many other countries use
their bulk-purchasing power to aggressively negotiate drug prices). The Debate A
poll released in March 2008 by the Harvard School of Public Health and Harris
Interactive found that Americans are divided in their views of the A
2004 Institute of Medicine (IOM) report said: "The An
impediment to implementing any Advocates
for single-payer health care often point to other countries, where national
government-funded systems produce better health outcomes at lower cost.
Opponents deride this type of system as "socialized medicine", and it
has not been one of the favored reform options by Congress or the President in
both the Clinton and Obama reform efforts. It has been pointed out that
socialized medicine is a system in which the government owns the means of
providing medicine. As
an example of how government intervention has had unintended consequences, in
1973, the federal government passed the Health Maintenance Organization Act,
which heavily subsidized the HMO business model — a model that was in decline
prior to such legislative intervention. The law was intended to create market
incentives that would lower health care costs, but HMOs have never achieved
their cost-reduction potential. Piecemeal
market-based reform efforts are complex. One study evaluating current popular
market-based reform policy packages concluded that if market-oriented reforms
are not implemented on a systematic basis with appropriate safeguards, they
have the potential to cause more problems than they solve. According
to economist and former Reform Healthcare
reform in the The
Patient Protection and Affordable Care Act (Public Law 111-148) is a health
care reform bill that was signed into law in the The
law includes a large number of health-related provisions to take effect over
the next four years, including expanding Medicaid eligibility for people making
up to 133% of FPL, subsidizing insurance premiums for peoples making up to 400%
of FPL ($88,000 for family of 4) so their maximum "out-of-pocket" pay
will be from 2% to 9.8% of income for annual premium, providing incentives for
businesses to provide health care benefits, prohibiting denial of coverage and
denial of claims based on pre-existing conditions, establishing health
insurance exchanges, prohibiting insurers from establishing annual spending
caps and support for medical research. The costs of these provisions are offset
by a variety of taxes, fees, and cost-saving measures, such as new Medicare
taxes for high-income brackets, taxes on indoor tanning, cuts to the Medicare
Advantage program in favor of traditional Medicare, and fees on medical devices
and pharmaceutical companies; there is also a tax penalty for citizens who do
not obtain health insurance (unless they are exempt due to low income or other
reasons). The Congressional Budget Office estimates that the net effect
(including the reconciliation act) will be a reduction in the federal deficit
by $143 billion over the first decade. In
May 2011, the state of Health Insurance Coverage of
Immigrants Of
the 26.2 million foreign immigrants living in the VIDEO Healthcare in
Healthcare
in the Taken
together, the World Health Organization, in 2000, ranked the provision of
healthcare in the Healthcare in
Most
healthcare in Norfolk and Norwich University
Hospital, a National Health Service hospital. The
two main kinds of trusts in the NHS, reflecting purchaser/provider roles, are
commissioning trusts such as Primary Care Trusts which examine local needs and
negotiate with providers (that may be public or private entities) to provide
health care services to the local population, and provider trusts which are NHS
bodies delivering health care service. They will be involved in agreeing major
capital and other health care spending projects in their region. Services
commissioned include general practice physician services (most of whom are
private businesses working under exclusive contract to the NHS), community
nursing, local clinics and mental health service. For most people, the majority
of health care is delivered in a primary health care setting. Provider trusts
are care deliverers, the main examples being the hospital trusts and the
ambulance trusts which spend the money allocated to them by the commissioning trusts.
Hospitals, as they tend to provide more complex and specialized care, receive
the lion's share of NHS funding. The hospital trusts own assets (such as
hospitals and the equipment in them) purchased for the nation and held in trust
for them. Commissioning has also been extended to the very lowest level
enabling ordinary doctors who identify a need in their community to commission
services to meet that need. Primary care is delivered by a wide range of
independent contractors such as GPs, dentists, pharmacists and optometrists and
is the first point of contact for most people. Secondary care (sometimes termed
acute health care) can be either elective care or emergency care and providers
may be in the public or private sector, though the majority of secondary care
happens in NHS owned facilities. There are also (as of 2009) 246 Memory clinics
in the The
NHS Constitution covers the rights and obligations of patients and staff, many
of which are legally enforceable. The NHS has a high level of popular public
support within the country: an independent survey conducted in 2004 found that
users of the NHS often expressed very high levels satisfaction about their
personal experience of the medical services they received: 92% of hospital
in-patients, 87% of GP users, 87% of hospital outpatients, and 70% of Accident
and Emergency department users. However, only 67% of those surveyed agreed with
the statement "My local NHS is providing me with a good service”, and only
51% agreed with the statement “The NHS is providing a good service.
Satisfaction in successive surveys has noted high satisfaction across all
patient groups, especially recent inpatients, and user satisfaction is notably
higher than that of the general public. The report found that most highly
recalled sources of information on the NHS are perceived to be the most
critical. The national press was seen to be the most critical (64%), followed
by local press (54%) and TV or radio (51%) compared to just 13% saying the
national press is favourable). The national press was reported as being the
least reliable source of information (50% reporting it to be not very or not at
all reliable, compared to 36% believing the press was reliable). Newspapers
were reported as being less favourable and also less reliable than the
broadcast media. The most reliable sources of information were considered to be
leaflets from GPs and information from friends (both 77% reported as reliable)
and medical professionals (75% considered reliable). Healthcare in
The
majority of healthcare in Healthcare in
The
majority of healthcare in Healthcare in
The
majority of healthcare in Comparisons between the public health
systems in the United Kingdom The reduction in infant mortality between 1960
to 2008 for the United Kingdom in comparison with France, Ireland, Sweden,
Switzerland, and the United States. The overall trend has meant a large
improvement in health inside the Common
features Each
NHS system uses General Practitioners (GPs) to provide primary healthcare and
to make referrals to further services as necessary. Hospitals then provide more
specialist services, including care for patients with psychiatric illnesses, as
well as direct access to Accident and Emergency (A&E) departments.
Pharmacies (other than those within hospitals) are privately owned but have
contracts with the relevant health service to supply prescription drugs. Each
public healthcare system also provides free ambulance services for emergencies,
when patients need the specialist transport only available from ambulance crews
or when patients are not fit to travel home by public transport. These services
are generally supplemented when necessary by the voluntary ambulance services
(British Red Cross, St Andrews Ambulance Association and St John Ambulance). In
addition, patient transport services by air are provided by the Scottish
Ambulance Service in Each
NHS system also provides dental services through private dental practices and
dentists can only charge NHS patients at the set rates for each country.
Patients opting to be treated privately do not receive any NHS funding for the
treatment. About half of the income of dentists in The reduction in infant mortality
between 1960 to 2008 for the United Kingdom in comparison with France, Ireland,
Sweden, Switzerland, and the United States. The overall trend has meant a large
improvement in health inside the Differences Advice services Each
NHS system has its own 24-hour telephone advisory service: Best practice and cost effectiveness In
In
Cost control The
National Audit Office reports annually on the summarised consolidated accounts
of the NHS, and Audit Parking charges Parking
charges at hospitals have been abolished in Prescription charges Policlinics Policlinics
are being trialled in Role of private sector in public
healthcare Whereas
the United Kingdom Government is expanding the role of the private sector
within the NHS in Funding and performance of healthcare
since devolution In
January 2010 the Nuffield Trust published a comparative study of NHS
performance in England and the devolved administrations since devolution,
concluding that while Scotland, Wales and Northern Ireland have had higher
levels of funding per capita than England, with the latter having fewer
doctors, nurses and managers per head of population, the English NHS is making
better use of the resources by delivering relatively higher levels of activity,
crude productivity of its staff, and lower waiting times. However, the Nuffield
Trust quickly issued a clarifying statement in which they admitted that the
figures they used to make comparisons between The verb is perhaps the most
important part of the sentence.
A verb or compound verb
asserts something about the subject
of the sentence and express actions, events, or states of being. The verb or
compound verb is the critical element of the predicate
of a sentence. In each of the following
sentences, the verb or compound verb is highlighted: Dracula bites
his victims on the neck. The verb "bites"
describes the action Dracula takes. In early October,
Giselle will plant twenty tulip bulbs. Here the compound verb
"will plant" describes an action that will take place in the future. My first teacher was
Miss Crawford, but I remember the janitor Mr. Weatherbee more vividly. In this sentence, the verb
"was" (the simple past
tense
of "is") identifies a particular person and the verb "remembered"
describes a mental action. Karl Creelman
bicycled around the world in 1899, but his diaries and his bicycle were
destroyed. In this sentence, the
compound verb "were destroyed" describes an action which took place
in the past. Verbs in the English language
are a lexically
and morphologically distinct part of speech
which describes an action, an event, or a state. While English has many irregular verbs,
for the regular
ones the conjugation rules are quite straightforward.
Being part of an analytic language, English regular verbs are
not very much inflected; all tenses, aspects and moods except the simple
present and the simple past are periphrastic,
formed with auxiliary verbs and modals. A regular English verb has
only one principal part, the infinitive or dictionary
form (which is identical to the simple present tense for all persons and
numbers except the third person singular). All other forms of a regular verb
can be derived straightforwardly from the infinitive, for a total of four forms
(e.g. exist, exists, existed, existing) English irregular verbs
(except to be) have at most three principal parts: Part Example: 1 write 2 wrote 3 written Strong verbs like write have all three
distinct parts, for a total of five forms (e. g. write, writes, wrote,
written, writing). The more irregular weak verbs also require up to three forms to be
learned. The highly irregular copular verb to
be has eight forms: be, am, is, are, being, was, were, been, of
which only one is derivable from a principal part (being is derived from
be). On the history of this verb, see Indo-European copula. Verbs had more forms when
the pronoun thou
was still in regular use and there was a number distinction in the second
person. To be, for instance, had art, wast and wert. Most of the strong verbs
that survive in modern English are considered irregular.
Irregular verbs in English come from several historical sources; some are
technically strong verbs (i. e. their forms display specific vowel changes of
the type known as ablaut in linguistics); others have had various
phonetic changes or contractions added to them over the history of English. The infinitive in
English is the naked root form of the word. When it is being used as a verbal noun,
the particle to is usually prefixed to it. When the infinitive stands as
the predicate of an auxiliary verb, to may be omitted, depending on the
requirements of the idiom. ·
The infinitive, in English,
is one of two verbal nouns: To write is to learn.
·
The infinitive, either
marked with to or unmarked, is used as the complement of many auxiliary
verbs: I will write a novel about talking beavers; I am really going to
write it. ·
The basic form also forms
the English imperative mood: Write these
words! ·
The basic form makes the
English subjunctive mood: If you write it,
they will read. The third person singular
in regular verbs
in English is distinguished by the suffix
-s. In English spelling, this -s is added to
the stem of the infinitive form: run → runs. If the base ends in a sibilant
sound like /s/,
/z/, /ʃ/, /tʃ/
(see IPA) that is not followed
by a silent E,
the suffix is written -es: buzz → buzzes; catch →
catches. If the base ends in a
consonant plus y, the y changes to an i and -es is
affixed to the end: cry → cries. Verbs ending in o
typically add -es: veto → vetoes. In Early Modern English, some dialects
distinguished the third person singular with the suffix -th; after
consonants this was written -eth, and some consonants were doubled when
this was added: run → runneth. ·
The third person singular is
used exclusively in the third person form of the English simple "present
tense", which often has other uses besides the simple present: He writes
airport novels
about anthropomorphic rodents. English preserves a number
of preterite-present verbs, such as can and
may. These verbs lack a separate form for the third person singular: she
can, she may. All surviving preterite-present verbs in modern English are
auxiliary verbs. The verb will, although historically not a
preterite-present verb, has come to be inflected like one when used as an
auxiliary; it adds -s in the third person singular only when it is a
full verb: Whatever she wills to happen will make life
annoying for everyone else. The present participle
is made by the suffix -ing: go → going. If the base ends in silent e,
it is dropped before adding the suffix: believe → believing. If the e is not
silent, it is retained: agree → agreeing. If the base ends in -ie,
change the ie to y and add -ing: lie → lying. If: ·
the base form ends in a
single consonant; and ·
a single vowel precedes that
consonant; and ·
the last syllable of the
base form is stressed then the final consonant is
doubled before adding the suffix: set → setting; occur
→ occurring. In British English,
as an exception, the final <l> is subject to doubling even when the last
syllable is not stressed: yodel → yodelling, travel →
travelling; in American English, these follow the rule: yodeling,
traveling. Similarly focus → focussing (AE focusing). Irregular forms include: ·
singeing, where the e is (sometimes) not dropped to avoid confusion with singing;
·
ageing, in British English, where the expected form aging
is ambiguous as to whether it has a hard or soft g; ·
words ending in -c,
which add k before the -ing, for example, panicking, frolicking,
and bivouacking. ·
a number of words that are
subject to the doubling rule even though they do not fall squarely within its
terms, such as diagramming, kidnapping, programming, and worshipping.
·
The present participle is
another English verbal noun: Writing is learning
(see gerund
for this sense). ·
It is used as an adjective:
a writing desk; building beavers. ·
It is used to form a past,
present or future tense with progressive or imperfective force: He is writing
another long book about beavers. ·
It is used with
quasi-auxiliaries to form verb phrases: He tried writing about
opossums instead, but his muse deserted him. In weak verbs, the preterite is formed with
the suffix -ed: work → worked. If the base ends in e,
-d is simply added to it: hone → honed; dye
> dyed. Where the base ends in a
consonant plus y, the y changes to i before the -ed
is added; deny → denied. Where the base ends in a
vowel plus y, the y is retained: alloy → alloyed. The rule for doubling the
final consonant in regular weak verbs for the preterite is the same as the rule
for doubling in the present participle; see above. Many strong verbs and other irregular verbs
form the preterite differently, for which see that article. ·
The preterite is used for
the English simple (non-iterative or progressive) past tense. He wrote
two more chapters about the dam at Kashawigamog Lake. In regular weak verbs, the past participle is
always the same as the preterite. Irregular verbs may have
separate preterites and past participles; see Wiktionary appendix: Irregular
English verbs. ·
The past participle is used
with the auxiliary have for the English perfect tenses: They have
written about the slap of tails on water, about the scent of the lodge...
(With verbs of motion, an archaic form with be may be found in older
texts: he is come.) ·
With be, it forms the
passive voice:
It is written so well, you can feel what it's like to gnaw down
trees! ·
It is used as an adjective: the
written word; a broken dam. ·
It is used with
quasi-auxiliaries to form verb phrases: 500,000 words got written in
record time. English verbs, like those in
many other western European languages, have more tenses
than forms; tenses beyond the ones possible with the five forms listed above
are formed with auxiliary verbs, as are the passive voice
forms of these verbs. Important auxiliary verbs in English include will,
used to form the future tense; shall, formerly used mainly for the
future tense, but now used mainly for commands and directives; be, have,
and do, which are used to form the supplementary tenses of the English
verb, to add aspect to the actions they describe, or for
negation. English verbs display
complex forms of negation. While simple negation was used well into the period
of early Modern English (Touch not the royal person!) in contemporary
English negation almost always requires that the negative particle be attached
to an auxiliary verb such as do or be. I go not is
archaic; I don't go or I am not going are what the contemporary
idiom requires. English exhibits similar idiomatic
complexity with the interrogative mood, which in Indo-European
languages is not, strictly speaking, a mood. Like many other Western European
languages, English historically allowed questions to be asked by inverting the
position of verb and subject: Whither goest thou? Now, in English,
questions are trickily idiomatic, and require the use of auxiliary verbs. In English grammar, tense
refers to any conjugated form expressing time, aspect or mood. The large number
of different composite verb forms means that English has the richest and
subtlest system of tense and aspect of any Germanic language. This can be
confusing for foreign learners; however, the English verb is in fact very
systematic once one understands that in each of the three time spheres - past,
present and future - English has a basic tense which can then be made either
perfect or progressive (continuous) or both. Simple Progressive Perfect Perfect progressive I will write I will be writing I will have written I will have been
writing I write I am writing I have written I have been writing I wrote I was writing I had written I had been writing Because of the neatness of
this system, modern textbooks on English generally use the terminology in this
table. What was traditionally called the "perfect" is here called
"present perfect" and the "pluperfect" becomes "past perfect",
in order to show the relationships of the perfect forms to their respective
simple forms. Whereas in other Germanic languages, or in Old English, the
"perfect" is just a past tense, the English "present
perfect" has a present reference; it is both a past tense and a present
tense, describing the connection between a past event and a present state. However, historical
linguists sometimes prefer terminology which applies to all Germanic languages
and is more helpful for comparative purposes; when describing wrote as a
historical form, for example, we would say "preterite" rather than
"past simple". This table, of course, omits
a number of forms which can be regarded as additional to the basic system: ·
the intensive present I
do write ·
the intensive past I did
write ·
the habitual past I used
to write ·
the "shall future"
I shall write ·
the "going-to
future" I am going to write ·
the "future in the
past" I was going to write ·
the conditional I would
write ·
the perfect conditional I
would have written ·
the (increasingly seldom
used) subjunctives, if I be, if I were. Some systems of English
grammar eliminate the future tense altogether, treating will/would simply as modal verbs, in the same category as other
modal verbs such as can/could and may/might. See Grammatical tense
for a more technical discussion of this subject. A full inventory of verb
forms follows. Or simple present. ·
Affirmative: I write;
He writes ·
Negative: He does not
(doesn't) write ·
Interrogative: Does he
write? ·
Negative interrogative: Does
he not write? (Doesn't he write?) Note that the "simple
present" in idiomatic English often identifies habitual or customary
action: He writes about
beavers (understanding that he does so all the
time.) It is used with stative
verbs: She thinks beavers
are remarkable It can also have a future
meaning (though much less commonly than in many other languages): She goes to Milwaukee
on Tuesday. Put Tuesday in the
plural, and She goes to Milwaukee on Tuesdays means that she goes to
Milwaukee every Tuesday. The present simple has an
intensive or emphatic form with "do": He does write. In the
negative and interrogative forms, of course, this is identical to the
non-emphatic forms. It is typically used as a response to the question Does
he write, whether that question is expressed or implied, and says that
indeed, he does write. The idiomatic use of the negative
particles not and -n't in the interrogative form is also worth
noting. In formal literary English of the sort in which
contractions are avoided, not attaches itself to the main verb: Does
he not write? When the colloquial contraction -n't is used, this
attaches itself to the auxiliary do: Doesn't he write? This in
fact is a contraction of a more archaic word order, still occasionally found in
poetry: *Does not he write? Or present continuous. ·
Affirmative: He is
writing ·
Negative: He is not
writing ·
Interrogative: Is he
writing? ·
Negative interrogative: Is
he not writing? (Isn't he writing?) This form describes the
simple engagement in a present activity, with the focus on action in progress
"at this very moment". It too can indicate a future, particularly
when discussing plans already in place: I am flying to Paris tomorrow.
Used with "always" it suggests irritation; compare He always does
that (neutral) with He's always doing that. Word order differs here
in the negative interrogative between the hyperformal is he not writing
and the usual isn't he writing? Traditionally just called
the perfect. ·
Affirmative: He has
written ·
Negative: He has not
written ·
Interrogative: Has he
written? ·
Negative interrogative: Has
he not written? (Hasn't he written?) This indicates that a past
event has one of a range of possible relationships to the present. This may be
a focus on present result: He has written a very fine book (and look,
here it is, we have it now). Or it may indicate a time-frame which includes the
present. I have lived here since my youth (and I still do). Compare: Have
you written a letter this morning? (it is still morning) with Did you
write a letter this morning? (it is now afternoon). The perfect tenses are
frequently used with the adverbs already or recently or with since
clauses. Although the label “perfect tense” implies a completed action, the
present perfect can identify habitual (I have written letters since I was
ten years old.) or continuous (I have lived here for fifteen years.)
action: In addition to these normal
uses where the time frame either is the present or includes the present, the
“have done” construct is used in temporal clauses to define a future time: When
you have written it, show it to me. It also forms a past infinitive, used
when infinitive constructions require a past perspective: Mozart is said to
have written his first symphony at the age of eight. (Notice that if not
for the need of an infinitive, the simple past would have been used here: He
wrote it at age eight.) The past infinitive is also used in the conditional
perfect. Or continuous. · Affirmative: He has been writing · Negative: He has not been writing · Interrogative: Has he been writing? · Negative interrogative: Has he not been writing? (Hasn't he been
writing?) Used for unbroken action in
the past which continues right up to the present. I have been writing this
paper all morning (and still am). Or preterite. ·
Affirmative: He wrote
·
Negative: He did not
write ·
Interrogative: Did he
write? ·
Negative interrogative: Did
he not write? (Didn't he write?) The same change of word order
in the negative interrogative that distinguishes the formal and informal
register also applies to the preterite. Note also that the preterite form is
also used only in the affirmative. When the sentence is recast as a negative or
interrogative, he wrote not and wrote he? are archaic and not
used in modern English. They must instead be supplied by periphrastic forms. This tense is used for a
single event in the past, sometimes for past habitual action, and in
chronological narration. Like the present simple, it has emphatic forms with
"do": he did write. Although it is sometimes
taught that the difference between the present perfect and the simple past is
that the perfect denotes a completed action whereas the past denotes an
incomplete action, this theory is clearly false. Both forms are normally used
for completed actions. (Indeed the English preterite comes from the Proto-Indo-European perfect.) And either
can be used for incomplete actions. The real distinction is that the present
perfect is used when the time frame either is the present or includes the
present, whereas the simple past is used when the time frame is in the absolute
past. The "used to" past
tense for habitual actions is probably best included under the bracket of the
past simple. Compare: When I was young I
played football every Saturday. When I was young I
used to play football every Saturday. The difference is slight,
but "used to" stresses the regularity, and the fact that the action
has been discontinued. Or imperfect or past
progressive. ·
Affirmative: He was
writing ·
Negative: He was not
writing ·
Interrogative: Was he
writing? ·
Negative interrogative: Was
he not writing? (Wasn't he writing?) This is typically used for
two events in parallel: While I was washing
the dishes my wife was walking the dog. Or for an interrupted action
(the past simple being used for the interruption): While I was washing the
dishes I heard a loud noise. Or when we are focussing on
a point in the middle of a longer action: At three o'clock
yesterday I was working in the garden.
(Contrast: I worked in the garden all day yesterday.) Or the
"pluperfect" ·
Affirmative: He had
written ·
Negative: He had not /
hadn't written ·
Interrogative: Had he
written? ·
Negative interrogative: Had
he not written? (Hadn't he written?) Or "pluperfect
progressive" or "continuous" ·
Affirmative: He had been writing
·
Negative: He had not been
/ hadn't been writing ·
Interrogative: Had he
been writing? ·
Negative interrogative: Had
he not been writing? (Hadn't he been writing?) Relates to the past perfect
much as the present perfect progressive relates to the present perfect, but
tends to be used with less precision. ·
Affirmative: He will
write ·
Negative: He will not /
won't write ·
Interrogative: Will he
write? ·
Negative interrogative: Will
he not write? (Won't he write?) See the article Shall and Will
for a discussion of the two auxiliary verbs used to form the simple future in
English. There is also a future with "go" which is used especially
for intended actions, and for the weather, and generally is more common in
colloquial speech: I'm going to write a
book some day. I think it's going to
rain. But the will future is
preferred for spontaneous decisions: Jack: "I think
we should have a barbeque!" Jill: "Good
idea! I'll go get the coal." ·
Affirmative: He will be
writing ·
Negative: He will not /
won't be writing ·
Interrogative: Will he be
writing? ·
Negative interrogative: Will
he not be writing? (Won't he be writing?) Used especially to indicate
that an event will be in progress at a particular point in the future: This
time tomorrow I will be taking my driving test. ·
Affirmative: He will have
written ·
Negative: He will not /
won't have written ·
Interrogative: Will he
have written? ·
Negative interrogative: Will
he not have written? (Won't he have written?) Used for something which
will be completed by a certain time (perfect in the literal sense) or which
leads up to a point in the future which is being focused on. I will have finished
my essay by Thursday. By then she will have
been there for three weeks. Or future perfect
continuous. ·
Affirmative: He will have
been writing ·
Negative: He will not /
won't have been writing ·
Interrogative: Will he
have been writing? ·
Negative interrogative: Will
he not have been writing? (Won't he have been writing?) Or past subjunctive. ·
Affirmative: He would
write ·
Negative: He would not /
wouldn't write ·
Interrogative: Would he
write? ·
Negative interrogative: Would
he not write? Used principally in a main
clause accompanied by an implicit or explicit doubt or "if-clause";
may refer to conditional statements in present or future time: I would like to pay
now if it's not too much trouble. (in present time;
doubt of possibility is explicit) I would like to pay
now. (in present time; doubt is implicit) I would do it if she
asked me to. (in future time; doubt is explicit) I would do it. (in future time; doubt is implicit) (A very common error by
foreign learners is to put the would into the if-clause itself. A
humorous formulation of the rule for the EFL classroom runs: "If
and would you never should, if and will makes teacher
ill!" But of course, both will and would CAN occur in an
if-clause when expressing volition. A student of English may rarely encounter
the incorrect construction as it can occur as an archaic form.) Or pluperfect
subjunctive/past-perfect subjunctive. ·
Affirmative: He would
have written ·
Negative: He would not /
wouldn't have written ·
Interrogative: Would he
have written? ·
Negative interrogative: Would
he not have written? Used as the past tense of
the conditional form; expresses thoughts which are or may be contrary to
present fact: I would have set an
extra place if I had known you were coming.
(fact that an extra place was not set is implicit; conditional statement is
explicit) I would have set an
extra place, but I didn't because Mother said you weren't coming. (fact that a place was not set is explicit; conditional is implicit) I would have set an
extra place. (fact that a place was not set is implicit,
conditional is implicit) The form is always identical
to the infinitive. This means that, apart from the verb "to be", it
is distinct only in the third person singular and the obsolete second person
singular. ·
Indicative: I write, thou
writest, he writes, I am ·
Subjunctive: I write,
thou write, he write, I be Used to refer to situations
which are or may be contrary to fact in the present or future; the infactuality
is rarely explicit: I insist that he come
at once. (present time; fact that the action is not
currently occuring is implicit) I insist that he come
when I call. (future time; fact that the action may or
may not occur is implicit) (The present subjunctive is
often interchangeable with the past subjunctive like so: I insist that he
must come at once.) The use of the old term
"imperfect" shows that this form is so rare that it has not been
integrated into the modern system of English tense classification. The
imperfect subjunctive is identical to the past simple in every verb except the
verb "to be". With this verb, there is an option, but no longer a
necessity, of using were throughout ALL forms (i.e., I wish I were an
Oscar Meyer
weiner, vs. I wish I was a girl). ·
Indicative: I was ·
Subjunctive: traditionally I
were but now more commonly I was. ·
If I were rich, I would
retire to the South of France. An auxiliary verb is a verb that
accompanies a main verb to indicate the tense, voice, mood, number, or person where this is not indicated by
inflection: The concert was enjoyed by all. You will drown in a sea of homework
if you do not work The auxiliary verb is also known as the helping verb. Literature: 1. Адамчик М.В.
Великий англо-український словник. – Київ, 2007. 2. Англійська
мова за професійним спрямуванням: Медицина: навч. посіб. для студ. вищ. навч.
закл. IV рівня акредитації / І. А. Прокоп, В. Я. Рахлецька, Г. Я. Павлишин ;
Терноп. держ. мед. ун-т ім. І. Я. Горбачевського. – Тернопіль: ТДМУ : Укрмедкнига, 2010. – 576 с. 3. Балла М.І.,
Подвезько М.Л. Англо-український словник. – Київ: Освіта, 2006. – Т. 1,2. 4.
Hansen J. T. Netter’s Anatomy Coloring Book. –
Saunders Elsevier, 2010. – 121 p. 5. Henderson B., Dorsey J. L. Medical Terminology for Dummies. – Willey
Publishing, 2009. – P. 189-211.The healthcare industry
Medical and social models of healthcare
What is a Verb?
Principal parts
Infinitive and basic form
Formation
Uses
Third person singular
Formation
Use
Exception
Present participle
Formation
Uses
Preterite
Formation
Use
Past participle
Formation
Uses
Tenses of the English verb
Overview of tenses
Present simple
Present progressive
Present perfect
Present
perfect progressive
Past simple
Past continuous
Past perfect
Past perfect progressive
Future simple
Future progressive
Future perfect
Future
perfect progressive
Conditional
Conditional perfect
Present subjunctive
Imperfect subjunctive
Auxilliary Verbs
harder.