Health care reform

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Health care reform is "innovation and improvement of the health care system by reappraisal, amendment of services, and removal of faults and abuses in providing and distributing health services to patients. It includes a re-alignment of health services and health insurance to maximum demographic elements (the unemployed, indigent, uninsured, elderly, inner cities, rural areas) with reference to coverage, hospitalization, pricing and cost containment, insurers' and employers' costs, pre-existing medical conditions, prescribed drugs, equipment, and services."[1]

Individual states have not been able to reform health care.[2] Many proposals have been made in the United States of America at the national level for reform,[3] and the Patient Protection and Affordable Care Act, a major reform package, became law in March 2010 after a major political fight.

Health care cost

Health care costs are "the actual costs of providing services related to the delivery of health care, including the costs of procedures, therapies, and medications. It is differentiated from health expenditures, which refers to the amount of money paid for the services, and from fees, which refers to the amount charged, regardless of cost."[4]

Regarding the increases in cost of the health care sector in the United States of America, one cost-benefit analysis concluded, "on average, the increases in medical spending since 1960 have provided reasonable value."[5]

Sources of unnecessary costs

Administrative costs

The costs of administration of health care in the United States of America in higher than the costs in Canada.[6]

Conflict of interest

Doctors who receive income from referring patients for medical tests have been shown to refer more patients for medical tests presumably due to conflict of interest.[7]

Insufficient access to prior medical records

Sometimes diagnostic testing is redundant because of inadequate access to prior medical records.[8]

Unnecessary care

Unnecessary is common[9][10] and may be motivated by financial conflict of interest[7].

Problems in resource and cost allocation

Market forces

Large payers often negotiate significant discounts with providers. The discounted prices may not cover the cost of some services, but the payer sees an overall advantage from volume in the payer network.

Unfunded mandates

EMTALA requires U.S. emergency facilities to examine and stabilize patients, without checking ability to pay. This can be lifesaving, but, even in true emergencies, a hospital can easily accumulate hundreds of thousands of dollars in costs for stabilizing a gunshot wound victim. If that victim is uninsured, EMTALA provides no means of reimbursement.

Cost shifting

To cover actual costs, providers may increase their prices to providers with less market leverage, and charge the highest "list" prices to uninsured people who are "self-pay".

Proposed interventions

Increased preventive health care

Regarding the opportunity cost of primary prevention of diseases, one analysis concluded, "opportunities for efficient investment in health care programs are roughly equal for prevention and treatment."[11]

Patient-centered medical home

The patient-centered medical home as been described[12] and promoted by various organizations[13]

Improved availability of prior medical records

Having the results of prior tests available may reduce the need for repeating tests.[14] A randomized controlled trial has shown reduction in ordering of redundant tests.[15]

Public reporting of outcomes

See also: Health care quality assurance

Reimbursement changes

Financial risk sharing

Financial risk sharing may be implemented through accountable care organizations[16], global payments[17], capitation fees, or prospective payment systems.

Pay for performance
For more information, see: Pay for performance.

In one study, pay for performance did not improve the care of hypertension.[18] However, a systematic review of older studies suggested possible benefit.[19]

Place doctors on salary

Placing doctors on salary has been proposed to avoid the conflict of interest in the fee-for-service plans.[20][21][22] Similarly, abandonment of fee for service has been advocated.[23] Salaried physicians may be more receptive to clinical practice guidelines.[24]

Whether placing doctors on salary has only been studied in primary care.[19]

Health services accessibility

Health services accessibility is "the degree to which individuals are inhibited or facilitated in their ability to gain entry to and to receive care and services from the health care system. Factors influencing this ability include geographic, architectural, transportational, and financial considerations, among others."[25]

Proposed interventions

The 1993 Clinton health care plan proposed a mandate that employers pay 80 percent of the average premium of health care plans for their employees.[26]

In 1976, President Carter proposed comprehensive national health insurance system with universal and mandatory coverage.[27]

In 1965,President Johnson proposed and implemented Medicare and Medicaid.[28]

In 1949, President Truman proposed national health insurance.[29]

Malpractice reform

Reform of medical malpractice is sometimes included as a component of health care reform.[30][31][32][33][26][34]

Enterprise liability

The American College of Physicians has suggested demonstration projects test the feasibility of enterprise liability.[35][36]

Comprehensive proposals

Several alternatives are in the U.S. Congress, such as the Baucus bill introduced by the Gang of Six.

President Obama

President Obama summarized his plan.[37][30][32][38]

His House Bill is H.R. 3200 and includes an expansion of Medicaid.[39] The Congressional Budget Office has published their budgetary projections which states, "enacting H.R. 3200 would result in a net increase in the federal budget deficit of $239 billion over the 2010-2019 period."[40]

President Clinton

President Clinton summarized his plan.[26] The Clinton plan included mandatory:[41][42]

The Clinton plan was defeated, "the Senate Finance Committee did approve a bill in July 1994 that would have extended health insurance to 95 percent of the population by 2002, but the bill stalled in debate on the Senate floor and never came to a vote."[43] The defeat was interpreted as being "rejected by a public that came to see it as a bid to replace their family doctor with the Bureau of Motor Vehicles writ large."[43]


  1. Anonymous (2024), Health care reform (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Emanuel E, Wyden R (October 2008). "A new federal-state partnership in health care: real power for states". JAMA 300 (16): 1931–4. DOI:10.1001/jama.2008.536. PMID 18940982. Research Blogging.
  3. Goodridge E; Arnquist S. (2009) A History of Health Care Reform The New York Times
  4. Anonymous (2024), Health care costs (English). Medical Subject Headings. U.S. National Library of Medicine.
  5. Cutler DM, Rosen AB, Vijan S (August 2006). "The value of medical spending in the United States, 1960-2000". N. Engl. J. Med. 355 (9): 920–7. DOI:10.1056/NEJMsa054744. PMID 16943404. Research Blogging.
  6. Woolhandler S, Campbell T, Himmelstein DU (August 2003). "Costs of health care administration in the United States and Canada". N. Engl. J. Med. 349 (8): 768–75. DOI:10.1056/NEJMsa022033. PMID 12930930. Research Blogging.
  7. 7.0 7.1 Swedlow A et al. (1992). "Increased costs and rates of use in the California workers' compensation system as a result of self-referral by physicians". N Engl J Med 327: 1502-6. PMID 1406882.
  8. Bates DW, Boyle DL, Rittenberg E, et al (1998). "What proportion of common diagnostic tests appear redundant?". Am. J. Med. 104 (4): 361–8. PMID 9576410[e]
  9. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL (2003). "The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care.". Ann Intern Med 138 (4): 288-98. PMID 12585826[e]
  10. Ashton CM, Souchek J, Petersen NJ, Menke TJ, Collins TC, Kizer KW et al. (2003). "Hospital use and survival among Veterans Affairs beneficiaries.". N Engl J Med 349 (17): 1637-46. DOI:10.1056/NEJMsa003299. PMID 14573736. Research Blogging.
  11. Cohen JT, Neumann PJ, Weinstein MC (February 2008). "Does preventive care save money? Health economics and the presidential candidates". N. Engl. J. Med. 358 (7): 661–3. DOI:10.1056/NEJMp0708558. PMID 18272889. Research Blogging.
  12. Rogers JC (2007). "Assembling patient-centered medical homes--the care principles.". Fam Med 39 (10): 697-9. PMID 17987408[e]
  13. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home.
  14. Tierney WM, McDonald CJ, Martin DK, Rogers MP (1987). "Computerized display of past test results. Effect on outpatient testing". Ann. Intern. Med. 107 (4): 569–74. PMID 3631792[e]
  15. Bates DW, Kuperman GJ, Rittenberg E, et al (1999). "A randomized trial of a computer-based intervention to reduce utilization of redundant laboratory tests". Am. J. Med. 106 (2): 144–50. PMID 10230742[e]
  16. Berwick DM (2011). "Launching Accountable Care Organizations - The Proposed Rule for the Medicare Shared Savings Program.". N Engl J Med 364. DOI:10.1056/NEJMp1103602. PMID 21452999. Research Blogging.
  17. Song, Z (2011 [last update]). Health Care Spending and Quality in Year 1 of the Alternative Quality Contract | Health Policy and Reform. Retrieved on September 7, 2011.
  18. Serumaga B, Ross-Degnan D, Avery AJ, Elliott RA, Majumdar SR, Zhang F et al. (2011). "Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study.". BMJ 342: d108. DOI:10.1136/bmj.d108. PMID 21266440. PMC PMC3026849. Research Blogging.
  19. 19.0 19.1 Gosden T, Sibbald B, Williams J, Petchey R, Leese B (2003). "Paying doctors by salary: a controlled study of general practitioner behaviour in England.". Health Policy 64 (3): 415-23. PMID 12745177[e]
  20. Relman AS. (2009) Doctors as the Key to Health Care Reform. New Engl J Med
  21. Harris G (2009) Hospital Savings: Salaries for Doctors, Not Fees. New York Times
  22. (2009) Doctors Weigh in on Healthcare Reform CNBC
  23. Relman AS (2010). Medical Guidelines and Malpractice. New York Times.
  24. Tunis SR, Hayward RS, Wilson MC, Rubin HR, Bass EB, Johnston M et al. (1994). "Internists' attitudes about clinical practice guidelines.". Ann Intern Med 120 (11): 956-63. PMID 8172440.
  25. Anonymous (2024), Health services accessibility (English). Medical Subject Headings. U.S. National Library of Medicine.
  26. 26.0 26.1 26.2 Clinton B (September 1992). "The Clinton health care plan". N. Engl. J. Med. 327 (11): 804–7. PMID 1501657[e] Cite error: Invalid <ref> tag; name "pmid1501657" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid1501657" defined multiple times with different content
  27. (June 9, 1977) National Health Insurance: The Dream Whose Time Has Come? The New York Times
  28. Blumenthal D, Morone J (November 2008). "The lessons of success--revisiting the Medicare story". N. Engl. J. Med. 359 (22): 2384–9. DOI:10.1056/NEJMhpr0806879. PMID 19038885. Research Blogging.
  29. Toner, Robin. Ideas & Trends: Government Health Insurance; An Idea Whose Time Has Come? It Came in 1965.. The New York Times.
  30. 30.0 30.1 Obama B (October 2008). "Modern health care for all Americans". N. Engl. J. Med. 359 (15): 1537–41. DOI:10.1056/NEJMp0807677. PMID 18815388. Research Blogging.
  31. McCain JS. (2008) Access to quality and affordable health care for every American. New Engl J Med PMID 18815389
  32. 32.0 32.1 Obama B (October 2008). "Affordable health care for all Americans: the Obama-Biden plan". JAMA 300 (16): 1927–8. DOI:10.1001/jama.2008.515. PMID 18940980. Research Blogging.
  33. McCain JS (October 2008). "Making access to quality and affordable health care a reality for every American". JAMA 300 (16): 1925–6. DOI:10.1001/jama.2008.514. PMID 18940979. Research Blogging.
  34. Sullivan LW (September 1992). "The Bush administration's health care plan". N. Engl. J. Med. 327 (11): 801–4. PMID 1501656[e]
  35. (March 1995) "Beyond MICRA: new ideas for liability reform. American College of Physicians". Ann. Intern. Med. 122 (6): 466–73. PMID 7856998[e]
  36. Petersen SK (March 1995). "No-fault and enterprise liability: the view from Utah". Ann. Intern. Med. 122 (6): 462–3. PMID 7856996[e]
  37. Obama, B (August 16, 2009). Op-Ed Contributor - Why We Need Health Care Reform. The New York Times.
  38. Obama B (November 2007). "My cure for an ailing system. How I, as president, would achieve affordable, universal health coverage". Mod Healthc 37 (47): 21. PMID 18159809[e]
  39. America’s Affordable Health Choices Act of 2009
  40. Congressional Budget Office - H.R. 3200, America's Affordable Health Choices Act of 2009.
  41. Angell M (November 1993). "The beginning of health care reform: the Clinton plan". N. Engl. J. Med. 329 (21): 1569–70. PMID 8413480[e]
  42. Relman AS (November 1993). "Medical practice under the Clinton reforms--avoiding domination by business". N. Engl. J. Med. 329 (21): 1574–6. PMID 8204139[e]
  43. 43.0 43.1 Wines, Michael; Pear, Robert (July 30, 1996). President Finds Benefits In Defeat on Health Care -. The New York Times. Retrieved on 2009-08-16.