The need is urgent to bring US health care costs into a sustainable range for both public and private payers. Commonly, programs to contain costs use cuts, such as reductions in payment levels, benefit structures, and eligibility. A less harmful strategy would reduce waste, not value-added care. The opportunity is immense. In just 6 categories of waste—overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse—the sum of the lowest available estimates exceeds 20% of total health care expenditures. The actual total may be far greater. The savings potentially achievable from systematic, comprehensive, and cooperative pursuit of even a fractional reduction in waste are far higher than from more direct and blunter cuts in care and coverage. The potential economic dislocations, however, are severe and require mitigation through careful transition strategies.

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Eliminating Waste in US Health Care

The United States has the highest per capita spending on health care of any industrialized nation but continually lags behind other nations in health care outcomes including life expectancy and infant mortality. National health expenditures are projected to exceed $2.5 trillion in 2009. Given healthcare's direct impact on the economy, there is a critical need to control health care spending. According to The Health Imperative: Lowering Costs and Improving Outcomes, the costs of health care have strained the federal budget, and negatively affected state governments, the private sector and individuals. Healthcare expenditures have restricted the ability of state and local governments to fund other priorities and have contributed to slowing growth in wages and jobs in the private sector. Moreover, the number of uninsured has risen from 45.7 million in 2007 to 46.3 million in 2008. The Health Imperative: Lowering Costs and Improving Outcomes identifies a number of factors driving expenditure growth including scientific uncertainty, perverse economic and practice incentives, system fragmentation, lack of patient involvement, and under-investment in population health. Experts discussed key levers for catalyzing transformation of the delivery system. A few included streamlined health insurance regulation, administrative simplification and clarification and quality and consistency in treatment. The book is an excellent guide for policymakers at all levels of government, as well as private sector healthcare workers.

The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary

ContextMore than 45 million individuals in the United States lack health insurance, potentially limiting their access to and use of appropriate health care services. Although the uninsured comprise a range of income levels, little attention has been directed at higher-income uninsured adults and their patterns of care.ObjectiveTo examine whether having higher income attenuates the association between being uninsured and using fewer recommended health care services.Design, Setting, and ParticipantsCross-sectional analysis of data from the 2002 Behavioral Risk Factor Surveillance System, drawn from a nationally representative sample of households. Participants were community-dwelling adults (n = 194 943; 50% women) aged 18 to 64 years in 2002.Main Outcome MeasuresSelf-reported use of screening for cervical, breast, and colorectal cancer; serum cholesterol screening and measurement, aspirin use, and tobacco cessation and weight loss counseling for cardiovascular risk reduction; and serum cholesterol and glycosylated hemoglobin measurement, eye and foot examination, and influenza and pneumococcal vaccination for diabetes management.ResultsAmong eligible adults, use of cancer prevention services ranged from 51% for colorectal cancer screening to 88% for cervical cancer screening, while use of cardiovascular risk reduction services ranged from 38% for weight loss counseling to 81% for aspirin use, and use of services for diabetes management ranged from 33% for pneumococcal vaccination to 88% for serum glycosylated hemoglobin measurement. In bivariate analyses, health insurance and annual household income were both strongly associated with use of nearly all examined health care services (P values .05).ConclusionsEven among higher-income adults, lack of health care insurance was associated with significantly decreased use of recommended health care services; increased income did not attenuate the difference in use between uninsured and insured adults. Efforts to improve the use of recommended health care services among the uninsured should focus on patient education and expanding insurance eligibility for both lower-income and higher-income adults.

https://jamanetwork.com/journals/jama/articlepdf/202791/JOC60050.pdf

Use of Health Care Services by Lower-Income and Higher-Income Uninsured Adults

BACKGROUND

Individuals without medical insurance or with limited insurance are less likely than those with broader insurance coverage to receive preventive services and to seek timely medical care. The authors examined the associations of insurance status with stage at diagnosis among women with breast cancer.



METHODS

This study included women age ≥40 years who were diagnosed with invasive breast cancer from 1998 to 2003 and who were reported to the National Cancer Data Base. Multivariable logistic regression analyses were used to examine the associations of insurance status with more advanced-stage breast cancer at diagnosis while controlling for other patient characteristics.



RESULTS

Among the 533,715 women with breast cancer who were included in the current analysis, the proportions with advanced-stage (III/IV) cancer at diagnosis ranged from 8% among privately insured patients to 18% among uninsured patients and 19% among Medicaid patients; differences in the proportions of women with advanced-stage cancer were statistically significant (P < .0001). Regression analyses indicated that, compared with privately insured patients, uninsured patients and Medicaid patients had a greater likelihood of diagnosis at stage II (odds ratio [OR], ∼≈1.5) or at stages III/IV (OR, 2.4) versus stage I (P < .001). Black and Hispanic patients also were significantly more likely than white patients to be diagnosed at a more advanced stage (P < .001).



CONCLUSIONS

The results from this study provided strong evidence that patients without health insurance or with Medicaid coverage, as well as black and Hispanic patients, were more likely to present with advanced-stage breast cancer. These results are consistent with other reports that have documented less use of preventive services, including mammography, among uninsured women and delays in diagnosis and treatment for black and Hispanic women. Cancer 2007. © 2007 American Cancer Society.

Insurance status and stage of cancer at diagnosis among women with breast cancer

This position paper concerns improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it with health care in other countries. The concluding section proposes lessons that the United States can learn from these countries and recommendations for achieving a high-performance health care system in the United States. The articles are based on a position paper developed by the American College of Physicians' Health and Public Policy Committee. This policy paper (not included in this article) also provides a detailed analysis of health care systems in 12 other industrialized countries. Although we can learn much from other health systems, the College recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. This caution notwithstanding, we have identified several approaches that have worked well for countries like ours and could probably be adapted to the unique circumstances in the United States.

Achieving a high-performance health care system with universal access: what the United States can learn from other countries.

Between 2000 and 2004, the number of uninsured Americans increased by six million, primarily because of a decline in employer-sponsored insurance. All of the increase occurred among adult...

Changes In Economic Conditions And Health Insurance Coverage, 2000–2004

The 2005 Current Population Survey (CPS) is used to estimate what share of uninsured Americans are eligible for coverage through Medicaid or the State Children's Health Insurance Program ...

The Uninsured And The Affordability Of Health Insurance Coverage

The number of uninsured Americans increased by 3.4 million between 2004 and 2006, despite improving economic conditions. In the first four years of the decade, during a period of economic recession, the number increased by 6.0 million. The dominant factor in both periods was a decline in employer-sponsored insurance coverage. Although the recent decline was less than that experienced from 2000 to 2004, growth in public coverage was small, and the number of uninsured people increased by 1.0 million children and 2.4 million adults. Employer coverage declined most for self-employed or small-firm workers, in the South, and among noncitizens.

Allison Cook

Papers

Changes In Economic Conditions And Health Insurance Coverage, 2000–2004

The Uninsured And The Affordability Of Health Insurance Coverage

The U.S. Economy And Changes In Health Insurance Coverage, 2000–2006

How We Can Pay for Health Care Reform