Delivering Health Care in America: A Systems Approach 7th Edition

Book Preface

With this Seventh Edition, we celebrate 20 years of serving instructors, students, pol-icymakers, and others, both at home and overseas, with up-to-date information on the dynamic U.S. health care delivery system. Much has changed, and much will continue to change in the future, as the nation grapples with critical issues of access, cost, and quality. Indeed, much of the developing and developed world will also be contending with similar issues.
People in the United States, in particular, have just gotten a taste of a far-reaching health care reform through President Barack Obama’s signature Affordable Care Act (ACA), nick-named “Obamacare.” To date, this law has pro-duced mixed results that are documented in this new edition.

At the time this edition went to press, we were left with promises of another reform under the slogan “Repeal and replace Obamacare,” a move championed by President Donald Trump, who had made it one of the centerpieces of his presidential campaign. Much remains to be seen as to how this promise will play out.
On May 4, 2017, the U.S. House of Rep-resentatives passed the American Health Care Act (AHCA) by a vote of 217 to 213, with Republican support. The bill is likely to undergo significant changes in the U.S. Sen-ate. Hence, what the new law may eventually look like was unknown at the time this man-uscript went to press. As was the case with the ACA, for which the Democratic Party played an exclusive role in its passage, contentious debates, partisanship, and deal making among both Republicans and Democrats have marked the progress in moving the new law through Congress.

Although we have chosen to sidestep any premature speculation about the fate of the ACA and the shape of its replacement, wher-ever possible, we have presented trends and facts that support certain conclusions. Mainly, experiences and outcomes under the ACA have been highlighted in this edition.
On his first day in office in January 2017, President Trump signed an executive order to “waive, defer, grant exemptions from, or delay the implementation of any provision or require-ment of the [Affordable Care] Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individu-als, families, health care providers, health insur-ers, patients, recipients of health care services, purchasers of health insurance, or makers of medical devices, products, or medications.” This executive order effectively repealed small por-tions of the ACA that deal with taxation and fees.

Going forward, the issues of universal cover-age and affordability of insurance and health care will be critical. Under the ACA, approximately 27 million people remained uninsured, even though the uninsurance rate in the United States dropped from 13.3% to 10.9% between 2013 and 2016. The majority of the newly insured individ-uals were covered under Medicaid, the nation’s safety net health insurance program for the poor.
Another thorny issue will be how to provide health care for the millions of illegal immigrants who obtain services mainly through hospital emergency departments, and through char-itable sources to some extent. Is there a better, more cost-effective way to address their needs?

The affordability of health insurance in the non-employment-based private market was severely eroded under the ACA, mainly for those who did not qualify for federal subsi-dies to buy insurance. The reason for the rate hikes in this segment was that few young and healthy people enrolled in health care plans under the ACA. Consequently, for many peo-ple, premium costs rose to unaffordable lev-els in 2016. People who really needed to use health care enrolled in much larger numbers than healthier individuals. Such an adverse selection prompted the chief executive of Aetna Insurance, Mark Bertolini, to remark that the marketplace for individual health insurance coverage was in a “death spiral.” Some large insurance companies either pulled out of the government-sponsored health care exchanges or were planning to do so because of financial losses sustained under the ACA.