The US healthcare "system," and reform thereof, almost defies characterization,
except perhaps as an elusive moving target. It is immensely complicated, almost
inexplicable, costly beyond belief, seriously discriminatory, and often unsafe. It is
responsive, if at all, to multiple regionally and demographically varied forces. These
include patients (also known as consumers), providers (a term generally loathed by
physicians), purchasers (of health insurance), payers (for healthcare products and
services), and the various controllers of these players, such as the federal and state
governments, professional associations, industry, and academia -- especially the
education and research enterprises. Myriad groups function as connectors at
interfaces, such as communications and computer companies, and as scavengers at
the fringes, such as liability attorneys. One overriding element is crystal-clear. The
money expended from all sources in American healthcare is extraordinarily
large, some $1.7 trillion in 2004, one seventh of the total US economy, and
larger than the total economies of most countries of the world. This cost is in
excess of that of any other country, when measured in total, as a percentage
of the gross domestic product (GDP), per capita, or by outcomes. Worse yet,
even though awash in money spent, over 45,000,000 Americans (about 15%)
are without health insurance.
Who is in charge of the US healthcare system? No one and everyone. Anarchy and
chaos stand side by side. There is nothing remotely akin to a "US healthcare czar."
"The marketplace" determines how much money is spent on what and how many
people of what types work in healthcare. Yet, it is by no means a "free market." It is
constantly reshaped by numerous forces, none truly predominant, although
government of all kinds, including Medicare, Medicaid, the Veterans Administration,
the Public Health Service, and the 50 states and many local health departments --
plus the military, government in aggregate constituting comprise nearly 50% of all
US healthcare expenditures. Who can "order" that patient safety measures be
put into effect? No one. Who can require compatible computerized medical
records in the home, the doctor's office, the pharmacy, the emergency room,
and the hospital? No one can, even if such an implementation would provably
save lives and money. Who can ensure that the quality of care provided in the
physician's office, where the most care is given, is above a certain standard?
No one. Who can even require that it be measured? No one can. You may ask
why we spend so much and get so little. Actually, we get a lot, not a little, of testing,
technology, medications, surgeries, hospitalizations, and all the rest -- (which is)
often a lot of what we need...(but sometimes) only a little.
Dr. George Lundberg, Editor of Medscape General Medicine (Web MD website)