In this final segment of the lecture, we will review the interactions between the building blocks that make up what we've called the polycentric unbounded health system in the United States. We'll review some of the intermediate outcomes, that is quality and access, and we will review population health outcomes, which are the ultimate measure of the outcomes produced by health system. Finally, we will review the possible future developments in the United States. To begin, the emergence of the health care system out of the interactions between the building blocks, one can describe the US health system as unbounded polycentric system of health care. There are multiple interactions between different health subsystems, there are multiple sources of insurance, and there are both public and private insurance. There are multiple providers who work with these insurers. Patients access to healthcare is dependent upon the particular insurance system that they are reliant upon. The service delivery building block acts as an integrator between the systems of payment and different regulatory arrangements. This has immediate consequences for the complexity of the service delivery healthcare building block. There are difficulties in accessing, effectively, and timely care and there are problems for providers, patients, and insurers in having access to and making effective use of relevant timely information. Finally, there are high levels of administrative costs produced by the interactions between service delivery, finance, governance, information, and pharmaceuticals building blocks. There are many complex interactions between payers, public and private providers, hospitals, patients and doctors, and a large and influential pharmaceutical industry. Finally, there's reliance upon competition, markets, and innovation to regulate and govern these interactions between payers, providers, pharmaceutical corporations and patients. In deed, it is one of the goals of regulation to establish a framework for competition. In conclusion, I want to be clear about defining the terminology of an unbounded system of care in the United States. Each subsystem of health care in the United States is bounded. Each subsystem is supported by a particular flow of funds and it's measured by reference to the outcomes that are producers. By the term unbounded, I'm referring to the interaction between the various subsystems that make up the USL system. Competition between multiple systems of insurance, multiple systems of health care providers, and moving populations of patients ensures that each part of the system works within a given set of parameters. However, it is the interactions between these subsystems that is left unbounded. It is the lack of any governmental body with over site and responsibility for guiding the system as a whole that leaves the system as a whole unbounded. This unboundedness of the US health system in the US is arguably it's single most important characteristic. We noted at the beginning of this lecture, there's a very high priority given to health in the United States and that there's a very high level of spending on health care. However, we also noted that there's much less of a priority for achieving improvements in outcomes for the population as a whole. So let's move to look at the achievements of the US health care system in respect to access and quality of care. In respective access, we've noted that in 2017, around 10 percent or 27 million people did not have health insurance and therefore had limited access to health care. The uninsured have access to a limited form of safety-net provided by the Emergency Medical Treatment and Active Labor Act. But they also tend to be billed for services provided at the highest price levels in the US health system. There was a big problem in measuring the quality of health care produced by a healthcare system. There are many different measures of quality and much variation in those measures. I want to focus on just one which is generally regarded as an important measure of quality. This measures the number of deaths that are amenable to healthcare treatment. This is the number of deaths that could have been prevented by more effective timely healthcare treatment. This can either be because health care was unsafe, because by since it didn't receive the best or recommended form of health care, or because I received unnecessary care. When you review this graph, it's important to note the relatively low numbers of deaths that are amenable to safe, effective timely health care. In this graph in 2014, the United States had one of the highest levels of deaths amenable to health care. But this still unranges at below 120 deaths per 100,000. That said, this graph does reflect an important measure of quality. The blue bar on this diagram is a 2004 figure, the gray bar is a 2014 figure. Each high-income country in this graph reflects an improvement on this measure of quality. In particular, note the amount of reduction in the number of deaths amenable to health care in the United Kingdom between 2004 and 2014. By contrast, the improvement in the United States is at a much slower rate than in the United Kingdom and in other high income countries. So in this particular graph, we say that the United States has one of the highest levels of deaths that are amenable to health care. But in addition, it is a relatively slow rate of improvement on this measure of quality that makes the United States one of the lower performance on this measure. The performance by the United States on this measure of quality of health care may be indicative of the difficulty of mobilizing a polycentric, unbounded system of health care to improve the quality and safety of healthcare. The following analysis of changes in measures of population health suggests a similar problem in mobilizing the health system in the United States to improve population health. We now turn to analyzing interactions between the health care system and population health outcomes. As we've noted, population outcomes or improving the health of the population as a whole is not one of the primary goals of the health system in United States, and it's therefore, unsurprising defined the United States does not achieve highly on this measure. This graph is a measure of life expectancy. It provides a comparison between life expectancy in the United States and in other members of the OECD in 2015. What we see here is that life expectancy in the United States in 2015 is below the OECD average of 80.9 years, at approximately 78.8 years. It is well below Japan, which has the highest life expectancy of 83.9 years. This graph is a measure of infant mortality and as with life expectancy of the measures, it shows two things. First of all, the United States in measuring infant mortality is below the OECD median. So the number of infant deaths per 1,000 live births in the United States is 4.2. By contrast, the number of infant deaths per 1,000 live births in Germany is 2.8. The graph, however, also reveals a second feature, which is the rate of improvement in infant deaths. That is, as with life expectancy, any infant mortality, there's been an improvement in the United States. It is just that this improvement is below or less than that in many other high-income countries and this is a significant pattern. It's not just the absolute level of outcomes is less than the US, but it is that these outcomes are improving at a slower rate. Nowhere is this more relevant or more telling than in relation to maternal mortality in the United States. Where unlike many other high-income countries, there is an increasing rate of maternal mortality. As we noted in the first module, there are particular segments of the US population, which have very high levels of mortality that are increasing, particularly the levels of maternal mortality for African American women. So in summary, what we note is that unsurprisingly, the United States has population outcomes which place it below other high-income countries. As we've also noted, this is hardly surprising given that the US health system is not directed improving the health of the population as a whole. The final question is relevant for the United States is, what is the future? What are the potential future developments? In particular, was the passing of the Affordable Care Act a step towards the adoption of universal health care coverage, or more generally, what was the importance of the Affordable Care Act? Universal health coverage and the movement towards universal health coverage is important, not merely because it would reduce the number of people who are uninsured, but also because universal health coverage acts as a discipline for directing the system towards improving the health of the population as a whole. So the question is, is there any likelihood of the United States moving towards a system of universal health coverage? In here I want to go back to a graphic that we looked at earlier in this lecture which reflects the piecemeal nature of the insurance system. It reflects the interlocking system of insurance between Medicare, employer-provided health insurance, the marketplaces for individuals who are seeking to purchase private insurance other than through their employer, and Medicaid. Now, the Affordable Care Act achieve many things. It created this system of exchanges on the private market, which had a profound effect on the accessibility of private health insurance for those people who do not have insurance through their employers. It also expanded Medicaid for those states that chose to expand Medicaid coverage. It's also important to note that the Affordable Care Act imposed a penalty on employers, particularly large employers, for failing to provide health insurance for their employees. Looked at as a whole, one can perhaps see the impact of the Affordable Care Act in a different light. In this diagram, you can see the impact of the Affordable Care Act in expanding employer-based insurance, expanding the market for insurance, and expanding Medicaid. What one can see is a picture of a gradual movement towards this health system that is directed towards achieving universal health coverage. In addition to these changes, the Affordable Care Act also introduced a mandate for all persons to take out health insurance. This requirement, which was introduced by the Affordable Care Act and which has been subsequently zeroed out, was for every person to take out health insurance. This is perhaps one of the reasons that the Affordable Care Act was extremely controversial, because it marked the emergence of a system of health care directed at achieving universal health coverage. There is one important qualification to make about this. The Affordable Care Act achieved a movement towards universal health coverage in a piecemeal fashion. It expanded the coverage of insurance by each of these particular subsystems. There are currently proposals supported by many Democratic presidential candidates to introduce a system that's described as a single-payer system or Medicare for all. What is important to note about all of the proposals for reform of the US health system is that they each share in common the movement towards having the goal of government being accountable for guiding the system as a whole. Perhaps, the most important feature of all the proposals for reform of the health care system is a question about whether the government moves towards this role, a bounding the health system or being responsible for guiding the system as a whole, or whether the US health system reverts to being a polycentric unbounded system of care, which provides coverage for particular sub-populations in the United States.
