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United States Health Care System Edits -Marswanson

"Certificates of need" for hospitals

The concept of the Certificates Of Needs (CON) first appeared in the field of health care and was passed in New York, in 1964 and then into federal law during the Richard Nixon administration in 1974, alongside the National Health Planning and Resources Development Act. Certificates of need were necessary for the construction of medical facilities in 35 states and are issued by state health care agencies:

The CON requirement was originally based on state law. New York passed the first certificate-of-need law in 1964, the Metcalf–McCloskey Act. From that time to the passage of Section 1122 of the Social Security Act in 1972, another 18 states passed certificate-of-need legislation. Section 1122 was enacted because many states resisted any form of regulation dealing with health facilities and services.

In 1978, the federal government required that all states implement Certificate of Need (CON) programs for cardiac care, meaning that hospitals had to apply and receive certificates prior to implementing the program; the intent was to reduce cost by reducing duplicate investments in facilities. It has been observed that these certificates could be used to increase costs through weakened competition. Many states removed the CON programs after the federal requirement expired in 1986, but some states still have these programs. Empirical research looking at the costs in areas where these programs have been discontinued have not found a clear effect on costs, and the CON programs could decrease costs because of reduced facility construction or increase costs due to reduced competition.

Affordable Care Act

The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act (PPACA) and colloquially as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the enactment of Medicare and Medicaid in 1965.

Financial summary of Affordable Care Act. Jan-Feb 2011

Source of Funds	$ Billions
Taxes and fines	$517
Reduced payments to providers	368
Use of initial CLASS premiums	70
Other revenue and savings	133
Total source of funds	$1,088
New Expenditures
Medicaid expansion (with CHIP *)	$434
Exchange subsidies	465
Small-employer tax credits	37
Overhead and other	47
Total New Expenditures	$983
Expansion-related “deficit reduction”	$105

The table shows the source funding the United States Congressional Budget Office planned on allocating and implementing in the first years of of the ACA.

In less developed nations those on low income in need of treatment will often avail themselves of whatever help they can from either the state or NGOs without going into debt, and in most developed countries public coverage of healthcare costs are comprehensive. But in the US, even when the patient has insurance coverage, including coverage under the Patient Protection and Affordable Care Act of 2010, considerable medical costs remain the patient's responsibility. Consequently, medical debt has been found by a 2009 study to be the primary cause of personal bankruptcy.

System efficiency and equity

Medical debt is an especially notable phenomenon in the United States. According to a 2019 poll from the Pew Research center, American citizens are much more worried about health care issues as a top public matter and concern, especially medical expenses, rather than the economy and terrorism.

A 2007 survey found about 70 million Americans either have difficulty paying for medical treatment or have medical debt. According to research done in 2019, especially adults who are between 18–64 years and those lacking health insurance coverage are familiar with medical financial hardship in the US. It is estimated that up to 200 billion dollars of medical debt is owed in the United States; the state that owes the lowest amount of medical debt is Hawaii at 2.3%

Studies have found people are most likely to accumulate large medical debts when they do not have health insurance to cover the costs of necessary medications, treatments, or procedures—in 2009 about 50 million Americans had no health coverage. However, about 60% of those found to have medical debt were insured. Health insurance plans rarely cover all health-related expenses; for insured people, the gap between insurance coverage and the affordability of health care manifests as medical debt. As with any type of debt, medical debt can lead to an array of personal and financial problems—including having to go without food and heat plus a reluctance to seek further medical treatment. Aggressive debt collecting has been highlighted as an aggravating factor. A study has found about 63% of adults with medical debt avoided further medical treatment, compared with only 19% of adults who had no such debt.

Potential Future Impact of Climate Change on Health

Climate change poses many threats to the health and well-being of all Americans. Climate change affects the food we eat, the air we breathe, the water we drink, and the places that provide us with shelter. Climate change can also impact people’s health and well-being by altering the frequency or intensity of extreme weather events and spread of certain pests and diseases.

Climate change affects people’s health in two main ways:

• By changing the seriousness or frequency of health problems that people already face.

1. Exposure. People will encounter climate hazards differently. Exposure will depend on where and how long people spend time and what they do. For example, people who spend a lot of time outdoors may be more exposed to extreme heat.
2. Sensitivity. Some people are more sensitive than others to climate hazards due to factors like age and health condition. For example, children and adults with asthma are particularly sensitive to air pollutants and wildfire smoke.
3. Adaptive capacity. People can adjust to, take advantage of, or respond to climate change hazards. A person’s ability to adapt may depend upon their income, age, living situation, access to health care, and many other factors

This figure shows the average number of heating and cooling degree days per year across the contiguous 48 states.

This map shows how the average number of heating degree days per year has changed in each state over time. The map was created by comparing the first 65 years of available data (1895–1959) with the most recent 64 years (1960–2023). “Warmer” colors indicate an increase in temperatures between the two periods, leading to less of a need to turn on the heat—that is, fewer heating degree days. “Cooler” colors indicate a decrease in temperatures, leading to more of a need to turn on the heat—that is, more heating degree days. Click on a state to reveal the trend in a line graph.

The health effects of climate change include respiratory and heart diseases, pest-related diseases like Lyme disease and West Nile Virus, water- and food-related illnesses, and injuries and deaths. Climate change has also been linked to increases in violent crime and overall poor mental health.

People can face multiple climate change effects at the same time, at different stages of their life, or over the course of their lifetime. A person’s vulnerability to climate change impacts depends on three key factors:

1. Exposure. People will encounter climate hazards differently. Exposure will depend on where and how long people spend time and what they do. For example, people who spend a lot of time outdoors may be more exposed to extreme heat.
2. Sensitivity. Some people are more sensitive than others to climate hazards due to factors like age and health condition. For example, children and adults with asthma are particularly sensitive to air pollutants and wildfire smoke.
3. Adaptive capacity. People can adjust to, take advantage of, or respond to climate change hazards. A person’s ability to adapt may depend upon their income, age, living situation, access to health care, and many other factors