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Canada:

Single payer system (universal healthcare)

Moderate/high healthcare expenditures

>90% of healthcare is financed by the government

Whereas, United States:

Multiple payer system (public & private)

High healthcare expenditures

~44% of healthcare is financed by the government

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Life Expectancy:

Women: 79.3

Men: 73.5

Infant Mortality:

5.44 deaths per 1,000 live births

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Life Expectancy:

Women: 83.9

Men: 79.8

Infant Mortality:

5.00 deaths per 1,000 live births

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Leading Cause of Death & Major Health Issues: U.S.

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Leading Cause of Death & Major Health Issues: U.S.

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Both U.S and Canada:

Heart disease

Chronic diseases (diabetes)

Cerebrovascular disease (strokes)

Cancer (breast, colorectal, prostate, lung)

11.3% diagnosed with Type I and II diabetes; 12.5% smoke

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Leading Cause of Death & Major Health Issues: Canada

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Leading Cause of Death & Major Health Issues: Canada

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Both U.S and Canada:

Heart disease

Chronic diseases (diabetes)

Cerebrovascular disease (strokes)

Cancer (breast, colorectal, prostate, lung)

10% diagnosed with Type I and II diabetes; 10.3% smoke.

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OVERALL

$4.3 trillion/yr

$12,914 per person

BREAKDOWN

Medicare: $900.8 billion

Medicaid: $734 billion

Private: $1,211.4 billion

Out of Pocket: $433.2 billion

Hospital: $1323.9 billion

Physician: $864.8 billion

Drug: $378 billion

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OVERALL

$331 billion/yr

$8563 per person

BREAKDOWN

Hospital: 24.34%

Physicians: 13.6%

Drugs: 13.5%

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OVERALL

Highe rates leave many uninsured.

Not universal.

PUBLIC

Government funded Medicare and Medicaid.

Federal taxes fund health care costs.

Lower costs, less flexible.

PRIVATE

Around ⅔ oFf Americans have private insurance.

Dominant form of coverage.

Provided via employers.

Higher costs, more flexible.

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OVERALL

“Single-payer” system

Government funded

PUBLIC

Funded by personal incomes and taxes.

Each province has its own insurance plan that is cash assisted by the government.

Each insurnace plan has coverage for medically necessary services.

Extra services are privately funded.

PRIVATE

Around ⅔ of Canadians have private insurance.

Services like dental, vision, etc.

Private plans are paid via employers, unions, or other contracted organizations.

Vast majority of insurers are for-profit.

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Benefits and Limitations of Health Care System: Canada

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Benefits and Limitations of Health Care System: Canada

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Limitations:
- Funding crisis
- Less technology-driven system
- Less innovation in preventative medicine
Benefits:
- Publicly-funded healthcare
- Easy access to hospitals and physicians services
- Equal access to healthcare

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Learn about Canada's health care system, including Medicare, funding, accessing health care services and delivery.

On this page

About Medicare

Medicare is a term that refers to Canada's publicly funded health care system. Instead of having a single national plan, we have 13 provincial and territorial health care insurance plans. Under this system, all Canadian residents have reasonable access to medically necessary hospital and physician services without paying out-of-pocket.

Roles and responsibilities for health care services are shared between provincial and territorial governments and the federal government.

The provincial and territorial governments are responsible for the management, organization and delivery of health care services for their residents.

The federal government is responsible for:

Canada Health Act

Provincial and territorial health care insurance plans must meet the standards described in the Canada Health Act. This is necessary to get their full payment under the Canada Health Transfer.

These standards include:

public administration

comprehensiveness

universality

portability

accessibility

Public administration

The provincial and territorial plans must be administered and operated on a non profit basis by a public authority.

Comprehensiveness

The provincial and territorial plans must insure all medically necessary services provided by:

hospitals

physicians

dentists, when the service must be performed in a hospital

Medically necessary services are not defined in the Canada Health Act. The provincial and territorial health care insurance plans consult with their respective physician colleges or groups. Together, they decide which services are medically necessary for health care insurance purposes.

If a service is considered medically necessary, the full cost must be covered by the public health care insurance plan.

Universality

The provincial and territorial plans must cover all residents.

Portability

The provincial and territorial plans must cover all residents when they travel within Canada. Limited coverage is also required for travel outside the country.

When a resident moves to another province, they can continue to use their original health care insurance card for 3 months. This gives them enough time to register for the new plan and receive their new health insurance card.

Accessibility

The provincial and territorial plans must provide all residents reasonable access to medically necessary services. Access must be based on medical need and not the ability to pay.

Federal funding for health care

The federal government provides health care funding to the provinces and territories through the Canada Health Transfer.

Provinces and territories receive additional federal funding support through other fiscal transfers.

Delivering health care services to specific groups

We provide certain direct health care services to some population groups, including:

First Nations people living on reserves

Inuit

serving members of the Canadian Forces

eligible veterans

inmates in federal penitentiaries

some groups of refugee claimants

Other federal health-related functions

We are responsible for the regulation of products, such as:

food

consumer products

pharmaceuticals

cosmetics

chemicals

pesticides

medical devices

radiation-emitting devices like cellphones

The federal government also supports:

health research

health promotion and protection

disease monitoring and prevention

The government also provides tax support for health-related costs:

tax credits for:

disability

medical expenses

caregivers and disabled dependents

tax rebates to public institutions for health services

deductions for private health insurance premiums for the self-employed

Accessing health care services

Canadians most often turn to primary health care services as their first point of contact with the health care system.

In general, primary health care:

delivers first-contact health care services

coordinates patients' health care services to support:

continuity of care, which means receiving high quality care from diagnosis to recovery

ease of movement across the health care system when more specialized services are needed from specialists or in hospitals

The provinces and territories also provide supplemental coverage to certain groups of people, such as:

seniors

children

social assistance recipients

This helps pay for health care services that are not generally covered under the publicly funded health care system. These services include:

vision care

dental care

prescription drugs

ambulance services

independent living (home care)

Those who do not qualify for supplementary benefits under government plans pay for these services through:

out-of-pocket payments

private health insurance plans

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Learn about Canada's health care system, including Medicare, funding, accessing health care services and delivery.

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Benefits and Limitations of Health Care System: U.S.

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Benefits and Limitations of Health Care System: U.S.

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Limitations:
- Preventable medical errors
- High costs of healthcare
- Lack of equal insurance
Benefits:
- Preventative cancer screenings
- Best chronic disease treatment
- Most advanced in research

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With all the squabbling in Washington and the media, it's easy to lose track of the facts about US health care.

There's a lot of things wrong with health care.

But there's also a lot of things right.

Photo: Screenshot of the original cast of ER

1. Most preemptive cancer screening

American women are most likely to have received a Pap smear or a mammogram in the past two years, according to the Commonwealth Fund.

We're also beating Canada on nearly all measures of preventive cancer screening, according to NBER.

2. Highest rate of cancer survival

America has the best survival rates for colon, rectum, lung, breast, and prostate cancer, according to various studies cited by the Robert Wood Johnson Foundation.

This has to do with high GDP-per-capita in the U.S., which provides for expensive cancer treatments.

3. Best treatment of chronic disease

A German study in 2002 found that Americans administered more state-of-the-art medicine than Europeans.

56 percent of Americans with high cholesterol were taking statins in 2002. Only 17-36 percent in Europe were taking them.

Moreover, 60 percent of antipsychotic drugs prescribed in the U.S. were of the newest generation. Only 10 percent in Germany were new.

4. Most identification and treatment of psychological disease

American kids are the most likely to be prescribed psychotropic medication. American women are the most likely to be prescribed antidepressants.

You can call it too thorough, but that's a problem every country in the world would like to have.

Source: ScienceDaily.com and Scientific American

5. Most advanced equipment per capita

America is kicking the world's ass in MRI units per million population (25.9) and CT scanners per million (34.3).

Source: OECD

6. Highest pay attracts the best doctors

Source: NYT

7. Most advanced research

American hospitals perform far-and-away the most clinical tests, according to the NYT. There's also this chart of the most important recent medical innovations floating around the internet.

The payoff for patients in America is immediate access to advanced information and medicine.

If you have the money, US health care is nonpareil

America embraces the idea that you get what you pay for.

If you are in the upper-middle class and can afford good health insurance, then you have access to the biggest network of World's biggest network hospitals, specialists, and technology.

Photo: Screenshot of the original cast of ER

If you are injured by malpractice, you can sue like mad

America's tort liability system lets patients pursue in court the full value of injury that results from malpractice. With the possibility of a huge (albeit capped in many states) settlement, patients can worry little about medical errors.

In countries that use a no-fault system -- most of the OECD -- patients automatically receive care for medical complication. However, they are more limited in their ability to pursue damages in court.

Source: World Bank

Health care reform will be even harder in countries that take excellent coverage for granted

Like France.

France has been pursuing cuts to their heath care system since the 1970s and massively failed. For instance, last summer public outcry stopped their government from considering cuts to the extensive coverage granted to people with chronic diseases, according to the WSJ.

But don't call us one-sided...

More: Features Health Care Reform

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10 Reasons Why The US Health Care System Is The Envy Of The World

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With all the squabbling in Washington and the media, it's easy to lose track of the facts about US health care. There's a lot of things wrong with health care. But there's also a lot of things right. Photo: Screenshot of the original cast of ER 1.

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- High infant mortality rates
- Patients that are admitted to the hospital are the sickest
- Two or more chronic diseases for adults aged 18-64 years

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KEY POINTS

Health care in Canada is ranked poorly relative to other high-income countries by the 2017 Commonwealth Fund Report.

Both the health-adjusted life expectancy tables from the World Health Organization and the Healthcare Access and Quality Index from the Global Burden of Disease Study place Canada in the top 10% of countries, above several comparators that were included in the Commonwealth Fund Report.

There are many potential reasons for discrepancies between different international rankings, including different definitions of health system boundaries, different sources of data, and different methodologies and limitations.

The latest Commonwealth Fund Report ranked Canada's health care system ninth out of 11 high-income countries. Its findings have been widely reported in the media. However, two other international comparisons, a comparison by the World Health Organization (WHO) on health-adjusted life expectancy (HALE) and the Global Burden of Disease study reach quite different conclusions about the relative quality of Canadian health care., What is the truth? We may find the answer by examining the data behind the headlines.

The Commonwealth Fund Report uses a combination of national-level administrative data (12 items) and surveys of patients and providers (59 items) to rank countries in each of five domains: care process, access, administrative efficiency, equity and health care outcomes. The domain rankings are then averaged to assign an overall ranking for each country. Careful perusal of the individual items used to create the scores shows some surprising insights.

For example, Canada's poor rankings in the domains of "access" and "equity" are largely driven by the costs of dental care and drugs, with 30% of Canadian respondents reporting difficulties in paying for drugs and 28% skipping routine dental care (compared with 12% and 11%, respectively, in the United Kingdom, the country ranked highest in these domains). This highlights one of the key challenges in international comparisons: health system boundaries differ among countries, and although some (such as the UK) include dental care and drug coverage as universal benefits, Canada does not.

Although Canada also ranked poorly in the "care process" domain, this appears to be driven by lack of electronic health records and clinical decision support in the primary care practices surveyed (28% in Canada v. 81% in the UK). However, 92% of the Canadian physicians who were surveyed reported having necessary test results or medical records when seeing a patient compared with 94% of UK physicians, and patients reported that their physician had their key medical information 83% of the time in Canada versus 84% of the time in the UK. These survey items do not support the idea that relative lack of electronic health records truly compromises care in Canada, in particular, since Canada ranked highest in vaccination rates and mammography screening, and had the lowest rates of admissions to hospital for ambulatory care-sensitive conditions. Taken together with accumulating evidence that electronic health record and decision support technology may not improve (and indeed may sometimes adversely affect) efficiency, communication or the satisfaction of patients or providers, we believe it reasonable to question whether access to such electronic resources should be a metric for measuring quality of health care.

Furthermore, we question whether the health care outcomes that the Commonwealth Fund focuses on are truly comparable across jurisdictions. For example, because the threshold for admission to hospital of patients with stroke varies widely among countries, the Commonwealth Fund's choice to focus on 30-day survival rates after hospital admission for ischemic stroke penalizes countries like Canada, where only the sickest patients are admitted to hospital. In fact, although Canada is ranked last in the Commonwealth Fund Report for stroke care while in hospital, Canada's total stroke mortality (considering all cases, not just the hospitalized cases) and disability-adjusted life-years lost to stroke per 100 000 is among the lowest in the world, and lower than in the UK and United States.,

A similar problem arises with respect to infant mortality rates. Canada includes babies born before 24 weeks gestation and weighing less than 500 g as part of infant mortality data, whereas several European countries do not, resulting in high infant mortality rates for Canada.

The Commonwealth Fund Report also ranks Canada low because it has one of the highest rates of reporting of two or more chronic diseases by adults aged 18-64 years. However, we believe that this item conflates "presence" of disease and "prevalence" of screening/reported diagnosis/patient awareness. Moreover, although Canadians with cardiovascular risk factors are more likely to be aware of their conditions compared with peers in the US or the UK, Canadians are also more likely to be receiving treatment and do exhibit higher control rates.

In contrast to the Commonwealth Fund Report, the WHO ranks Canada among the top 10 of 191 countries and third among the 11 countries included in the Commonwealth Fund Report for HALE at 72.3 health-adjusted life-years (compared with 71.4 life-years in the UK and 69.1 life-years in the US). Although HALE incorporates both mortality and morbidity (by weighting years of life by health status in those years estimated using the Health Utilities Index), the accuracy and comparability of survey data from different countries on disease prevalence, severity and quality of life are uncertain.

A recent analysis from the Global Burden of Disease Study showed that Canada was in the top 10% of the 195 countries that were compared on the Healthcare Access and Quality Index, ranking above several countries that scored higher in the Commonwealth Fund Report. The index uses data from the Global Burden of Disease Study to rank countries by cause-specific death rates in each country that are adjusted for factors that health care cannot directly influence, such as demographics, social determinants of health and environmental risk exposures (but not individual risk factor levels or behaviours). Countries with lower rates of death from 32 conditions defined as amenable to health care interventions are ranked higher in the Healthcare Access and Quality Index. However, it should be recognized that this index does not provide insight into conditions that cause substantial morbidity but not mortality, and for which health care can still improve quality of life (e.g., osteoarthritis, cataracts or mental health conditions). Furthermore, the list of amenable mortality diagnoses needs updating to include infectious conditions such as HIV or hepatitis C that are now treatable. In addition, as with any study relying on data from death certificates, there is a substantial risk of misclassification bias for causes of death.

Oscar Wilde noted that "the truth is rarely pure and never simple," and this is surely the case when one country's health care system is benchmarked against others. It is disconcerting that three international comparisons reach very different conclusions about the quality of health care in Canada, particularly when the public and government may view these data without proper context. It is important to recognize the potential data limitations with all comparisons across national boundaries, and we advise readers to look beyond the headlines when presented with such comparisons in the future.

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Comparing Canadian health care to that in other countries: looking beyond the headlines

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KEY POINTS Health care in Canada is ranked poorly relative to other high-income countries by the 2017 Commonwealth Fund Report. Both the health-adjusted life expectancy tables from the World Health Organization and the Healthcare Access and Quality Index from the Global Burden of Disease Study place Canada in the top 10% of countries, above several comparators that were included in the Commonwealth Fund Report.

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- Lower 30-day mortality rate for heart attacks and strokes
- High admissions rates of chronic diseases which could be prevented with primary care
- Cesarean sections are the most common performed surgery in the U.S.
- High rates of post-operative complications

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The coronavirus pandemic has resulted in millions of cases across the globe. The United States has one of the highest death rates due to COVID-19 across the world, and its mortality rates will likely increase. Due to different approaches to containing the virus across countries - as well as the quality and accessibility of health care - we may see diverging rates of mortality, disease burden, and other measures of health outcomes between the U.S. and comparable countries. This chart collection provides a baseline of how the U.S. already compared to similarly large and wealthy countries prior to the onset of the coronavirus pandemic.

The following charts and a related brief explore a number of different metrics used to look at health outcomes, quality of care, and access to services. While inconsistent and imperfect metrics make it difficult to firmly assess system-wide health quality in the U.S., a review of the available data prior to the onset of the pandemic suggests that in most of these measures, the U.S. continued to lag behind comparably wealthy and sizable countries. As rates of all-cause mortality, maternal mortality, and years of life lost have stagnated or increased over time, the gap has widened between the U.S. health system and those of its peers.

We examine long-term outcomes, treatment outcomes, hospital-related care and patient safety in the U.S. and 11 other countries identified as similarly wealthy based on GDP and GDP per capita. The data from most of the charts come from the Organization for Economic Co-operation and Development (OECD), which has compiled health quality statistics and data from several countries around the world. It is important to note that the healthcare systems, populations, and public health responses in these countries can vary considerably, and that these factors play a role in population health outcomes.

Life expectancy dropped sharply in 2020 within the U.S. and most comparable countries

As discussed in more detail in a separate brief, life expectancy at birth was similar in the U.S. and comparable countries in 1980 (74.5 and 73.7 years, respectively), but the gap has grown substantially in the following decades. Driven by the COVID-19 pandemic, life expectancy dropped in 2020 to 77.3 years in the U.S. and 82.1 in comparable countries on average. Prior to the pandemic, life expectancy was increasing in comparable countries, while the U.S. had experienced slower growth with declines in recent years.

Of note, the above life expectancy data are period life expectancy estimates based on excess mortality observed in 2020. The period life expectancy at birth represents the mortality experience of a hypothetical cohort if current conditions persisted into the future and not the mortality experience of a birth cohort. Though the U.S. continues to have one of the highest excess mortality rates due to COVID-19 in 2021, excess mortality rates are lower in 2021 than in 2020. CDC has noted that 2021 life expectancy may increase slightly from 2020 but will likely stay below pre-pandemic rates.

Since the pandemic, the gap between the U.S. and comparable countries in mortality rates has widened

One method for measuring quality is to look at all-cause mortality rates (number of deaths per 100,000 people, adjusted for age differences across countries). The mortality rate had been falling in the U.S. and in comparable countries, but had plateaued prior to the pandemic. Meanwhile, the mortality rate in comparable countries continued to trend downward, on average. From 1980 to 2020 (the latest year with internationally comparable data), the overall mortality rate for all causes of death in the U.S. fell about 19%, compared to a 43% decline in comparable countries.

The COVID-19 pandemic has widened the gap in mortality rates between the U.S and peer countries.

Premature death rates in the U.S. continue to be higher than in comparable countries

An alternative to overall mortality rates is "years of life lost", a marker of premature deaths. Years of life lost is measured by adding the collective years lost by those in a population who died before the longest possible life expectancy (e.g. 70). For example, a person who dies at age 45 would have 25 years of life lost. As a measure, it provides more weights to deaths at younger ages. The U.S. and comparable OECD countries have made progress in reducing years of life lost over the last 27 years (down 24% and 42%, respectively), although the gap between the U.S. and comparable countries increased over time, standing at 12,724 vs. 8,258 years of life lost in 2019.

In a separate brief, we reviewed excess death rates by age groups to examine how the pandemic has affected premature death in the U.S. and peer countries. With a much higher rate of death among people under age 75, the U.S. had the highest increase in premature deaths due the pandemic in 2020. The per capita premature excess death rate in the U.S. was over twice as high as the next closest peer country, the U.K. The higher rate of new premature deaths in the U.S. compared to peer countries was driven in part by racial disparities within the U.S. The premature excess death rates for American Indian and Alaska Native, Black, Hispanic, and Native Hawaiian and Other Pacific Islander people in the U.S. were 3 times higher than the rates among White or other Asian people.

Disease burden is higher in the U.S. than in comparable countries

Disease burden, which accounts for both premature death and years living with disability, is often measured using disability adjusted life years (DALYs). Though DALYs have declined in the U.S. and comparable countries since 2000, the U.S. continues to have higher age-adjusted rates than those of peer countries. In 2017, the DALYs rate was 37% higher in the U.S. than for comparable countries, on average.

The U.S. ranks last in a measure of health care access and quality, indicating higher rates of amenable mortality than peer countries

Mortality amenable to healthcare is a measure of the rates of death considered preventable by timely and effective care. While the healthcare system might not be expected to prevent death in all instances, differences in amendable mortality indicate how effectively healthcare is delivered. The Healthcare Access and Quality (HAQ) Index is scaled from 0 (worst) to 100 (best) and is based on amenable mortality. The HAQ index uses age-standardized, risk-standardized mortality rates for 32 causes of death that timely and effective health care could potentially prevent. Lower scores indicate high mortality rates for causes amenable to health care, while higher scores indicate lower mortality rates, possibly reflecting better quality and access to care. The U.S. ranks last among comparable countries on the HAQ index with a score of 88.7, compared to an average of 93.7 for comparable countries in 2016.

Related Content:

Maternal mortality rates in the U.S. have risen over time and are much higher than in peer countries

While wealth and economic prosperity are highly correlated with lower maternal mortality rates, the U.S. is an outlier with the highest rate of pregnancy-related deaths (23.8 deaths per 100,000 live births in 2020) when compared to similar countries (4.5 deaths per 100,000 live births).

Within the U.S., there are significant racial disparities in maternal mortality rates. Black women are more than three times as likely to die from pregnancy-related causes as White women - a disparity that persists across socioeconomic class.

30-day mortality for heart attacks and strokes is lower in the U.S. than in comparable countries

Mortality within 30 days of being admitted to a hospital is not entirely preventable, but high quality of care can reduce the mortality rate for certain diagnoses. The 30-day mortality rates after hospital admissions for heart attacks (acute myocardial infarction) and hemorrhagic stroke (caused by bleeding) are similar in the U.S. and comparable countries. The 30-day mortality rates for ischemic strokes (caused by blood clots) was 4.1 deaths per 100 patients in the U.S. in 2018, compared to an average of 6.4 deaths per 100 patients in similar countries.

Hospital admissions for diabetes and congestive heart failure were more frequent in the U.S. than in comparable countries

Hospital admissions for certain chronic diseases like circulatory conditions, chronic obstructive pulmonary diseases (COPD), asthma, and diabetes, can arise for a variety of reasons, but preventative services - or lack thereof - play a large role. Hospital admission rates in the U.S. are higher than in comparable countries for congestive heart failure and complications due to diabetes. Hospital admissions for these chronic conditions could be minimized with adequate primary care.

More cesarean sections are performed in the U.S. than in comparable countries

Cesarean sections are the most commonly performed surgical procedures in the U.S. and have become a key indicator of quality of care in maternal health. Cesarean sections can be lifesaving; however, when they are not medically indicated, they can pose unnecessary risks for both the mother and newborn, including an increased chance of blood clots, infections, and other complications that require further surgery.

The U.S. has consistently had higher cesarean section rates than its peers, on average, though rates have decreased slightly in recent years. In 2019, the rate of cesarean sections per 1,000 live births with inpatient admissions was 317 in the U.S. and 256 in comparable countries.

Obstetric trauma during vaginal delivery is more common in the U.S. than in most comparable countries, especially when instruments are involved

Obstetric trauma is more likely to occur in deliveries where instruments are utilized (i.e. forceps). The rate of obstetric trauma during deliveries with an instrument in the U.S. was 11.4 per 100 vaginal deliveries in 2018, higher than most comparable countries with available data. The rate of obstetric trauma during deliveries without an instrument in the U.S. was 1.8 per 100 vaginal deliveries in 2018, slightly lower than most other comparable countries with available data.

Post-operative complications - such as pulmonary embolism or deep vein thrombosis - are more common in the U.S. than most peer countries

Rates of post-operative complications are an important measure of hospital-based safety. Pulmonary embolisms and deep vein thrombosis are common complications after major surgeries, such as hip or knee replacement. The prevalence of post-operative clots for these procedures is higher in the U.S. than in the U.K., Sweden, Belgium, and the Netherlands, but lower than in Australia (among comparable countries with available data for the latest available year).

Post-operative sepsis is less common in the U.S. than in some peer countries

Sepsis is a spectrum of disease afflicting patients with infections, that can range from organ failure and shock to death in severe cases. Rates of post-operative infections and sepsis is an important marker of quality in patients undergoing surgery because this is a major source of morbidity and mortality and can sometimes be prevented. Prevention is multifactorial and can be affected by operative techniques and training, hygiene and safety protocols and antibiotic utilization amongst other things. The rate of post-operative sepsis following abdominal surgery is just above 1% in the U.S., lower than in most other countries that report data.

The U.S. has higher rates of reported medication and treatment errors than most comparable countries

Patients in the U.S. are more likely than those in comparable countries to report experiencing a medication or medical error at some point during their care, according to a survey by the Commonwealth Fund. In this case, medication errors include being given the wrong medication or dose, and treatment errors indicate that people thought a medical mistake had been made in their treatment or care. In 2020, 12.6% of patients in the U.S. experienced a medical error compared to 11.4% of patients in similar countries.

The Peterson Center on Healthcare and KFF are partnering to monitor how well the U.S. healthcare system is performing in terms of quality and cost.

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How does the quality of the U.S. health system compare to other countries? - Peterson-KFF Health System Tracker

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The coronavirus pandemic has resulted in millions of cases across the globe. The United States has one of the highest death rates due to COVID-19 across the world, and its mortality rates will likely increase. Due to different approaches to containing the virus across countries - as well as the quality and accessibility of health [...]

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- Universal health coverage funded through Medicare
- Publicly administered with comprehensive coverage
- Funded by general tax revenue
- Hospitals are publicly funded and have a fixed-budget

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Columbia University Mailman School of Public Health

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Skip to site alert. Skip to content

OVERVIEW

Population: 37.74 million

Housing: 81.2% Urban, 18.8% Rural

HISTORY

The Government of Canada tells the story of the history of its health care system. Under the Constitution Act of 1867, health care was the responsibility of provinces, and was privately funded and delivered through World War II. ⁴ In 1947, led by leader Tommy Douglas, the province of Saskatchewan provided the first provincial hospital care program. ⁴ Then, in 1957, major health legislation was passed called the Hospital Insurance and Diagnostic Services Act (HIDS). It financed approximately 50% of health care expenses in the provinces and territories. ⁴ During this time, doctors, insurance companies, and big businesses were fighting against the expansion of public health coverage. In 1960, according to the Canadian Health Coalition, the Canadian Medical Association joined in the protest by opposing all publicly funded health care. ⁵ In 1962, Saskatchewan's government introduced the first medical insurance plan for physicians' services. ⁴ Doctors refused to comply with the government-controlled scheme, and many went on strike and closed their offices or took a temporary leave from providing health services. The strike collapsed in just three weeks. ⁴

The Medical Care Act, also known as Medicare, passed in 1966. ⁴ This act, "offered to reimburse, or cost share, one-half of provincial and territorial costs for medical services provided by a doctor outside hospitals. Within six years, all the provinces and territories had universal physician services insurance plans. ⁴" The last major health legislation was the Canada Health Act in 1984. ⁴ The act addressed the issue of "extra-billing," which doctors were using to raise their income, by banning it. ⁴ It also set requirements for all provincial and territorial health plans to abide by by setting "conditions and criteria on portability, accessibility, universality, comprehensiveness, public administration." ⁴

HEALTH & HEALTH SYSTEM

Canada has universal health coverage funded through a health system called Medicare. It was created from the Canada Health Act and must comply with the five pillars of that act. ⁶ The system must be universal, publicly administered, have comprehensive coverage, portable across provinces, and accessible to the population. ⁶ Medicare covers 100% of the population and each province or territory manages all of its own residents with their specific residency requirements. The health system is funded mainly by provincial or territorial general tax revenue with some federal transfers and is free at the point of delivery for citizens. There is no cost-sharing for inpatient or outpatient care and prescription drug prices vary but are still inexpensive. There are some safety-net, public programs that assist low-income individuals, children with disabilities, and the elderly with prescription drug costs. Non-citizens such as temporary legal visitors and undocumented immigrants are not entitled to Medicare but provinces and territories may provide limited emergency services to these populations since medical care can't be refused in an emergency. ⁶

According to The Commonwealth Fund, about 67% of Canadians have some sort of private, supplementary coverage for prescription drugs, dental and eye care, rehabilitation services, and private hospital rooms which Medicare does not cover. Overall, Canadians are allowed to choose where they receive health care services and even have flexibility in other provinces and territories. If a Canadian citizen receives care outside of their province or territory, they pay upfront and receive reimbursements from their home province or territory. It is important to note an individual is reimbursed at their home province's fee schedule, therefore, if rates are different they may end up covering the rest. ¹⁰

Most hospitals are publicly funded and are required to function under a fixed budget. Most family physicians are private and operate on a fee-for-service payment system. The Canadian government also heavily regulates the health system and may limit services as a strategy to contain costs which may lead to longer wait times. Another challenge for the Canadian health system is a lack of cohesiveness and coordination within the system. Although they have universal health coverage and favorable health outcomes, Canada doesn't reach better results like the Netherlands or other Nordic countries due to the lack of efficiency in the health system. ¹¹

HEALTH INDICATORS & DEMOGRAPHICS

The country provides excellent access to health care and has low rates of health disparities leading to overall favorable health outcomes throughout the whole country.

Fertility Rate: 1.5 live births per woman

Life Expectancy (Female, Male): 85, 81

Infant Mortality Rate: 3.9 deaths per 1,000 live births

Child Mortality Rate: 4.8 per 1,000 live births

Maternal Mortality Rate: 8.3 deaths per 100,000 live births

Prevalence of Obesity: 26.3%

0-14 years: 15.4%

15-24 years: 11.6%

25-54 years: 39.6%

55-64 years: 14.2%

65 years and over: 19.1%

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OVERVIEW | HISTORY | HEALTH & HEALTH SYSTEM | HEALTH INDICATORS & DEMOGRAPHICSOVERVIEW GDP: 1.736 Trillion USD1 Health Expenditure (% of GDP): 10.57%2 Populace3 Population: 37.74 million Housing: 81.2% Urban, 18.8% Rural HISTORYThe Government of Canada tells the story of the history of its health care system.

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- High in cost
- unequal access to healthcare
- Technology-driven system
- Practice behaviors are influenced by legal risks
- No central governing agency

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For Americans to enjoy optimal health-as individuals and as a population-they must have the benefit of high-quality health care services that are effectively coordinated within a strong public health system. In considering the role of the health care sector in assuring the nation's health, the committee took as its starting point one of the recommendations of the Institute of Medicine (IOM) report Crossing the Quality Chasm (2001b: 6): "All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States."

This chapter addresses the issues of access, managing chronic disease, neglected health care services (i.e., clinical preventive services, oral, and mental health care and substance abuse services), and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, the workforce, financing, information technology, and emergency preparedness. In addition, the chapter discusses the responsibility of the health care system to recognize and play its appropriate role within the intersectoral public health system, particularly as it collaborates with the governmental public health agencies.

The health care sector in the United States consists of an array of clinicians, hospitals and other health care facilities, insurance plans, and purchasers of health care services, all operating in various configurations of groups, networks, and independent practices. Some are based in the public sector; others operate in the private sector as either for-profit or not-for-profit entities. The health care sector also includes regulators, some voluntary and others governmental. Although these various individuals and organizations are generally referred to collectively as "the health care delivery system," the phrase suggests an order, integration, and accountability that do not exist. Communication, collaboration, or systems planning among these various entities is limited and is almost incidental to their operations. For convenience, however, the committee uses the common terminology of health care delivery system.

As described in Crossing the Quality Chasm (IOM, 2001b) and other literature, this health care system is faced with serious quality and cost challenges. To support the system, the United States spends more per capita on health care than any other country ($4,637 in 2000) (Reinhardt et al., 2002). In the aggregate, these per capita expenditures account for 13.2 percent of the U.S. gross domestic product, about $1.3 trillion (Levit et al., 2002). As the committee observed in Chapter 1, American medicine and the basic and clinical research that inform its practice are generally acknowledged as the best in the world. Yet the nation's substantial health-related spending has not produced superlative health outcomes for its people. Fundamental flaws in the systems that finance, organize, and deliver health care work to undermine the organizational structure necessary to ensure the effective translation of scientific discoveries into routine patient care, and many parts of the health care delivery system are economically vulnerable. Insurance plans and providers scramble to adapt and survive in a rapidly evolving and highly competitive market; and the variations among health insurance plans-whether public or private-in eligibility, benefits, cost sharing, plan restrictions, reimbursement policies, and other attributes create confusion, inequity, and excessive administrative burdens for both providers of care and consumers.

Because of its history, structure, and particularly the highly competitive market in health services that has evolved since the collapse of health care reform efforts in the early 1990s, the health care delivery system often does not interact effectively with other components of the public health system described in this report, in particular, the governmental public health agencies. Health care's structure and incentives are technology and procedure driven and do not support time for the inquiry and reflection, communication, and external relationship building typically needed for effective disease prevention and health promotion. State health departments often have legal authority to regulate the entry of providers and purchasers of health care into the market and to set insurance reimbursement rates for public and, less often, private providers and purchasers. They may control the ability of providers to acquire desired technology and perform complex, costly procedures that are important to the hospital but increase demands on state revenues. Finally, virtually all states have the legal responsibility to monitor the quality of health services provided in the public and private sectors. Many health care providers argue that such regulation adds to their costs, and high-profile problems can create additional tensions that impede collaboration between the state public health agency and the health care delivery system.

Furthermore, when the delivery of health care through the private sector falters, the responsibility for providing some level of basic health care services to the poor and other special populations falls to governmental public health agencies as one of their essential public health services, as discussed in Chapter 1. In many jurisdictions, this default is already occurring, consuming resources and impairing the ability of governmental public health agencies to perform other essential tasks.

Although this committee was not constituted to investigate or make recommendations regarding the serious economic and structural problems confronting the health care system in the United States, it concluded that it must examine certain issues having serious implications for the public health system's effectiveness in promoting the nation's health. Drawing heavily on the work of other IOM committees, this chapter examines the influence that health insurance exerts on access to health care and on the range of care available, as well as the shortcomings in the quality of services provided, some of the constraints on the capacity of the health care system to provide high-quality care, and the need for better collaboration within the public health system, especially among governmental public health agencies and the organizations in the personal health care delivery system.

ACCESS TO HEALTH CARE

Health care is not the only, or even the strongest, determinant of health, but it is very important. For most Americans, having health insurance- under a private plan or through a publicly financed program-is a threshold requirement for routine access to health care. "Health insurance coverage is associated with better health outcomes for adults. It is also associated with having a regular source of care and with greater and more appropriate use of health services. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and the effective treatment of acute conditions," IOM notes in a recent report (IOM, 2002a: 6).

Private insurance is predominantly purchased through employment-based groups and to a lesser extent through individual policies (Mills, 2002). Publicly funded insurance is provided primarily through seven government programs (see Table 5-1). Medicare provides coverage to 13.5 percent of the population, whereas Medicaid covers 11.2 percent of the population (Mills, 2002). Additionally, public funding supports directly delivered health care (through community health centers and other health centers qualified for Medicaid reimbursement) accessed by 11 percent of the nation's uninsured, who constitute 41 percent of patients at such health centers (Markus et al., 2002). Because the largest public programs are directed to the aged, disabled, and low-income populations, they cover a disproportionate share of the chronically ill and disabled. However, they are also enormously important for children. In early 2001, Medicaid and the State Children's Health Insurance Program (SCHIP) provided health care coverage to 23.1 percent of the children in the United States, and this figure had risen to 27.7 percent according to data from the first-quarter estimates in the National Health Interview Survey (NCHS, 2002).

Being uninsured, although not the only barrier to obtaining health care, is by all indications the most significant one. The fact that more than 41 million people-more than 80 percent of whom are members of working families-are uninsured is the strongest possible indictment of the nation's health care delivery system. Those without health insurance or without insurance for particular types of services face serious, sometimes insurmountable barriers to necessary and appropriate care.

Adults without health insurance are far more likely to go without health care that they believe they need than are adults with health insurance of any kind (Lurie et al., 1984, 1986; Berk and Schur, 1998; Burstin et al., 1998; Baker et al., 2000; Kasper et al., 2000; Schoen and DesRoches, 2000). Children without health insurance may be compromised in ways that will diminish their health and productivity throughout their lives.

When individuals cannot access mainstream health care services, they often seek care from the so-called safety-net providers. These providers include institutions and professionals that by mandate or mission deliver a large amount of care to uninsured and other vulnerable populations. People turn to safety-net providers for a variety of reasons: some because they lack health insurance and others because there are no other providers in the area where they live or because language and cultural differences make them uncomfortable with mainstream care. Safety-net providers are also more likely to offer outreach and enabling services (e.g., transportation and child care) to help overcome barriers that may not be directly related to the health care system itself.

In this section, the committee reviews concerns about the barriers to health care that are raised by the lack of health insurance and by threats to the nation's safety-net providers.

NEGLECTED CARE

The committee is concerned that the specific types of care that are important for population health-clinical preventive services, mental health care, treatment for substance abuse, and oral health care-are less available because of the current organization and financing of health care services. Many forms of publicly or privately purchased health insurance provide limited coverage, and sometimes no coverage, for these services.

PROBLEMS IN QUALITY OF CARE

Crossing the Quality Chasm (IOM, 2001b) examined health system failures that compromise the quality of care provided to all Americans. As noted, it is often the responsibility of state departments of health to monitor providers and levy sanctions when quality problems are identified. This adds to potential tensions with the public health system. Two particular quality problems have special significance in terms of assuring the health of the population: disparities in the quality of care provided to racial and ethnic minorities and inadequate management of chronic diseases. As the American population grows both older and more racially and ethnically diverse and as rates of chronic disease increase, important vulnerabilities in the health care delivery system are compromising individual and population health (Murray and Lopez, 1996; Hetzel and Smith, 2001).

CAPACITY OF THE HEALTH CARE SYSTEM TO SERVE THE POPULATION

The resources of the health care delivery system are not balanced well enough to provide patient-centered care, to address the complex health care demands of an aging population, to absorb normal spikes in demand for urgent care, and to manage a large-scale emergency such as that posed by a terrorist attack. The relentless focus on controlling costs over the past decade has squeezed a great deal of excess capacity out of the health care system, particularly the hospital system. It has also reduced the time that physicians spend with patients and the quality of the clinical encounter. At the same time, the design of insurance plans (in both the public and the private sectors) does not support the integrated disease management protocols needed to treat chronic disease or the data gathering and analysis needed for both disease management and population-level health. Underlying all of these problems is the absence of a national health information infrastructure to support research, clinical medicine, and population-level health.

COLLABORATION WITH GOVERNMENTAL PUBLIC HEALTH AGENCIES

The activities and interests of the health care delivery system and the governmental public health agencies clearly overlap in certain areas, but there is relatively little collaboration between them. In addition, the authority of state health departments in quality monitoring, licensure, and rate setting can cause serious tensions between them and health care organizations. The committee discusses the extent of this separation and the particular need for better collaboration, especially in regard to assuring access to health care services, disease surveillance activities, and partnerships toward broader health promotion efforts.

COLLABORATION WITH OTHER PUBLIC HEALTH SYSTEM ACTORS

In addition to the linkages between the health care delivery system and governmental public health agencies, health care providers also interface with other actors in the public health system, such as communities, the media, and businesses and employers.

Relationships between the health care sector-hospitals, community health centers, and other health care providers-and the community are not new and have gained increased recognition for the value they bring to health care operations, their potential for enhancing provider accountability (VHA and HRET, 2000), the knowledge and empowerment they help to create in communities, and their potential for promoting health.

The recent trend among universities to assess their level of involvement in their communities and to develop programs focused on "service learning," and such public service oriented academic work includes AHCs. Calleson and colleagues (2002) surveyed the executives and staff of eight AHCs around the country and found that community-campus partnerships can strengthen the traditional mission of AHCs. The involvement of AHCs in the communities is also likely to increase in the coming years. The AHCs surveyed listed several factors that facilitated the development of relationships with communities and community organizations, including the request of the communities themselves and the growing population health orientation of the health care sector. Furthermore, non-academic community health centers also frequently have close ties to their communities, collaborating to assess local health needs, providing needed services, and supporting community efforts with research expertise and technical assistance in planning and evaluation. Many hospitals participate in broad community-based efforts to achieve some of the conditions necessary for health, for instance, collaborating with community development corporations to contribute financial, human, and technical resources (U.S. Department of Housing and Urban Development, 2002). Montefiore Medical Center in the Bronx, New York, for example, has partnered with a local nonprofit organization to develop low- and moderate-income housing and to establish a neighborhood kindergarten (Seedco and N-PAC, 2002). Additionally, Montefiore Medical Center partners with local high schools to develop health care professions education programs intended to create new career options and improve the likelihood inner-city youth will stay in school (Montefiore Medical Center, 2001). Hospitals are also employers, and in the case of two Lawndale, Illinois, hospitals, collaboration with the local development corporation and other neighborhood organizations in 1999 made affordable local housing available to employees, helping to facilitate community development (University of Illinois, 1999). In Providence, Rhode Island, a community partnership of nonprofit and independent hospitals and colleges works to improve children's quality of life by providing school-based health services, innovative and enhanced education through teacher and staff training, and support to improve home environments through housing advocacy (Health & Education Leadership for Providence, 2001; Providence Public School District, 2002).

Many hospitals and health care systems have seen the value of going beyond the needs of the individuals who enter the health care system to engage in broader community health action, even within the constraints of the current environment. The National Community Care Network Demonstration Program, sponsored by the Hospital Research and Education Trust (HRET), reports on hospitals across the country that are supporting activities beyond the delivery of medical care to improve health status and quality of life in local communities. Some of the motivation comes from the increasing pressure on nonprofit hospitals to justify their tax-exempt status through the provision of services that benefit the community, largely the provision of charity care; yet, many are seeing that investments in community health improvement are greater in value than the provision of medical care for preventable diseases (Barnett and Torres, 2001).

Vignettes drawn from the experience of American Hospital Association NOVA Award recipients illustrate the importance of investing in overall community health (AHA, 2002). For example, in 1994, Parkland Health and Hospital System in Dallas noted that injury rates in the community were three times the national average and that trauma admissions had jumped 38 percent in one year (53 percent of that care is uncompensated). As a result, the organization decided to convene the county's leading trauma care providers, police, and civic groups to investigate and solve the problem. With start-up funding from a local foundation, its own fundraising, and annual corporate sponsorships ranging from $35,000 to $150,000 from local hospitals and businesses, the coalition launched a Safe Communities initiative with a 52-member community advisory panel. Coalition members decided to tackle, in order, injuries caused by car accidents, violence, falls, and burns, through 11 initiatives involving more than 80 community organizations and agencies. Over a 2-week period, there was a 13 percent reduction in trauma admissions from car crashes due to a public awareness campaign and police initiative (AHA, 2002).

A 1998 finalist for the Foster G. McGaw Prize for Excellence in Community Service co-sponsored by AHA, the Franklin Community Health Network (FCHN) in Farmington, Maine, took the lead in developing a coalition and providing seed money to start a Rural Schools Equity Campaign (AHA, 2002). With high levels of youth involvement, and media cooperation, the campaign led to the legislative reformulation of property taxes to increase funding for rural schools in FCHN's service area by $1.3 million. In a further example, the Crozer-Keystone Health System that serves Chester, Pennsylvania, was declared a distressed municipality by the state in 1994. Although at the time the health system had been increasing its health care outreach programs, it realized it had to look at "root causes." As the largest employer in Chester, the system organized Community Connections, a mosaic of health, economic, and social programs and services developed in partnership with 20 other organizations, a local university, and governmental agencies. Programs included attracting other businesses to Chester, setting up a business incubator building, and colocating multiple health and social programs to facilitate "one-stop shopping." The effort has had a major stabilizing effect on Chester, and although overall health indicators are still behind state averages for chronic diseases, they are improving. Immunization rates have improved from 36 to 99 percent, and teen pregnancy is down to 31 per 1,000 from 44 per 1,000.

Under the guidance of an external review panel, HRET and the Voluntary Hospital Association of America (VHA) Health Foundation reviewed the experiences of recipients of the Foster G. McGaw Prize from 1986 to 1998 and VHA Community Health Improvement Leadership Awards from 1996 to 1998. Fifteen of 20 winners participated in a study, which included a self-assessment of changes since the time of the award and in-depth interviews with chief executive officers, trustees, and those leading the initiative. Although this survey serves only as an illustration of what may be possible, several elements appeared supportive of a sustained commitment to efforts at community health improvement. These included

Committing leadership at multiple levels through the top leadership to sustain changes;

Developing community partnerships to develop champions outside the organization;

Protecting funding and leadership of community health initiatives while integrating community health values into the culture of the parent organization;

Linking community work with clinical work (mission alignment);

Building an evidence base through evaluation and ongoing measurement of community health indicators; and

Exploring external revenue streams and advocating for changes in current health care financing and funding for such efforts (VHA Health Foundation and HRET, 2000).

Boufford (1999) has suggested a Community Health Improvement Strategy that identifies a number of steps that provider organizations can take in such community-based efforts (see Box 5-9). However, payment systems are critical to encourage and sustain these network initiatives, and current reimbursement policies in public and private insurance are not designed to support population-focused care in a noncapitated system.

The health care sector can also develop linkages with the media to help ensure the accuracy of health information, communicate risk, and facilitate the public understanding of health care. For example, health care organizations may use the media to disseminate health care information to their market areas, as demonstrated by the Minneapolis Allina Health System in its collaboration with a local television station and a health care news provider (Rees, 1999). Additionally, the media may be a powerful tool for familiarizing the public with health and health care issues and a conduit for raising important questions, stimulating public interest, or even influencing the public's health behaviors. For example, the popular prime time television show ER frequently serves as a platform for health information, with episodes exploring topics such as childhood immunizations, contraception, and violence (Brodie et al., 2001; also see Chapter 7).

Businesses and employers most commonly interface with the health care sector in purchasing and designing employee health benefits, with goals such as the inclusion of comprehensive preventive health care services. However, there are examples of wide-reaching business-health care linkages, such as the efforts to ensure quality of care and enhanced consumer choice undertaken by the Pacific Business Group on Health (see Chapter 6). Chapter 4 provides additional examples of fruitful community partnerships involving the health care sector.

IMPLICATIONS OF GROWING HEALTH CARE COSTS

As the committee has noted, health-related (mostly health care-related) spending in the United States amounted to $1.3 trillion in 2000, about 13.2 percent of the gross domestic product (Levit et al., 2002). After a period of stability in the mid-1990s, health care costs are again rising because of several factors (Heffler et al., 2002). Prescription drug spending, in particular, has increased sharply, and increased by 17.3 percent from 1999 to 2000 (HCFA, 2002). This increase comes from the growth of the older population and the proportion of the overall population with chronic conditions, along with the introduction of new and more expensive drugs, many of which are used to treat chronic conditions. In addition, spending for hospital services increased by 5.1 percent between 1999 and 2000, reaching $412 billion, and the cost of nursing home and home health care increased by 3.3 percent (Levit et al., 2002). However, the increase in health spending also reflects the success of federal and state efforts to enroll more low-income children in Medicaid and the State Children's Health Insurance Program, increased enrollment in Medicare as the population ages, and some erosion of unpopular cost-control features imposed by managed care plans.

With the economic downturn in 2001, the growth in health care spending creates added financial burdens for everyone, including individuals seeking care or insurance coverage, employers offering health insurance benefits, and governments at the federal, state, and local levels managing publicly funded insurance programs (Fronstin, 2002; Trude et al., 2002). Substantial increases in health insurance premiums are a clear indication of these economic stresses. For example, the California Public Employees' Retirement System, which is the nation's second largest public purchaser of employee health benefits, recently announced that health insurance premiums would increase by 25 percent (Connoly, 2002). States are experiencing serious pressures from growth in Medicaid spending, which increased by about 13 percent from 2001 to 2002, following a 10.6 percent increase in 2001 (NASBO, 2002a). With revenues increasing by only about 5 percent in the same period, Medicaid now accounts for more than 20 percent of total state spending (NASBO, 2002b).

The growing cost of health care has obvious implications for the nation's readiness to address the problems discussed in this chapter. Providing coverage to the uninsured, improving coverage for certain types of care, strengthening the emergency response and surge capacity in the hospital sector, and investing in information systems that can improve the quality of individual care and population-based disease surveillance will all require significant new resources from the public and private sectors. Although these steps can be expected to improve the nation's health and may even reduce costs over time, the initial investment will be substantial. The committee is concerned that with the escalation of expenditures, going in large measure toward maintaining current services, it will be difficult to identify the necessary public- and private-sector resources that will be needed for new activities.
The committee recommends that bold, large-scale demonstrations be funded by the federal government and other major investors in health care to test radical new approaches to increase the efficiency and effectiveness of health care financing and delivery systems. The experiments should effectively link delivery systems with other components of the public health system and focus on improving population health while eliminating disparities. The demonstrations should be supported by adequate resources to enable innovative ideas to be fairly tested.
CONCLUDING OBSERVATIONS

This chapter has outlined the main areas in which the health care delivery system and the governmental public health agencies interface. These areas include the regulatory and quality monitoring functions performed by governmental agencies, disease surveillance and reporting by health care providers, and the provision of safety-net services. Although assurance is a core function of public health, governmental public health agencies often do more than assure that people can access health care services; public health departments may become providers of last resort in areas where no other services are available for low-income, uninsured populations and when managed care services to Medicaid and uninsured populations are discontinued. These circumstances force public health departments to provide personal health care services instead of using their resources and population-level approaches to guide and support community efforts to change the conditions for health. Closer collaboration and integration between governmental public health agencies and the health care delivery system may enhance the capacities of both to improve population health and may support the efforts of other public health system actors.

REFERENCES

AAMC (Association of American Medical Colleges). 2000. Minority Graduates of US Medical Schools: Trends, 1950-1998. Washington, DC: Association of American Medical Colleges.

AHCPR (Agency for Health Care Policy and Research). 1993. Depression in Primary Care: Treatment of Major Depression. Rockville, MD: Department of Health and Human Services.

American Medical Association. 1998. Socioeconomic characteristics of medical practice 1997/ 98. Chicago: American Medical Association.

CMS (Centers for Medicare and Medicaid Services). 2002. a. CMS program operations. Section II. In Program Information on Medicare Medicaid, SCHIP & Other Programs of the Centers for Medicare & Medicaid Services. Available online at http://cms.hhs.gov/charts/ series/. Accessed October 4, 2002.

Coffey RM, Mark T, King E, Harwood H, McKusick D, Genuardi J, Dilonardo J, Chalk M. 2001. National Estimates of Expenditures for Substance Abuse Treatment, 1997. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services.

Department of Veterans Affairs. 1993. Clinical Guidelines for Major Depressive Disorder. Washington, DC: Veterans Health Administration.

DHHS (Department of Health and Human Services). 1999. Mental Health: A Report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Administration, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services.

DHHS. 2000. b. Oral Health in America: A Report of the Surgeon General. Rockville, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health, Department of Health and Human Services.

GAO (General Accounting Office). 2000. Oral health: dental disease is a chronic problem among low-income populations. Letter Report GAO/HEHS-00-72, April 12. Washington, DC: General Accounting Office.

GAO. 2001. a. Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health Screening Services. Report to Congressional Requesters, GAO-01-749. Washington, DC: General Accounting Office.

Haas JS, Adler NE. 2001. The causes of vulnerability: disentangling the effects of race, socioeconomic status and insurance coverage on health. Background paper prepared for the Institute of Medicine Committee on the Consequences of Uninsurance.

HCFA (Health Care Financing Administration). 2001. Your Medicare Benefits: Your Health Care Coverage in the Original Medicare Plan for Part A (Hospital Insurance), Part B (Medical Insurance), including Preventive Services. Publication No. HCFA - 10116. Baltimore, MD: Federal Medicare Agency, Health Care Financing Administration, Department of Health and Human Services.

Henry J. Kaiser Family Foundation and Health Research and Educational Trust (HRET). 2000. Employer Health Benefits: 2000 Annual Survey. Primary authors: Levitt L, Holve E, Wang J, Gabel JR, Whitmore HH, Pickreign JD, Miller N, Hawkins S. Menlo Park, CA: and Chicago: Henry J. Kaiser Family Foundation; and HRET.

HRSA (Health Resources and Services Administration). 2001. The Registered Nurse Population, March 2000. Rockville, MD: Health Resources and Services Administration, Department of Health and Human Services.

IOM. 2002. c. Setting the Course: A Strategic Vision for Immunization Part 1: Summary of the Chicago Workshop. Committee on the Immunization Finance Dissemination Workshops, Division of Health Care Services, Institute of Medicine. Washington, DC: The National Academies Press.

Johnson R, editor; , Morris TF, editor. (Ed.). 1998. Stabilizing the Rural Health Infrastructure. National Advisory Committee on Rural Health. Health Resources and Services Administration and the North Carolina Rural Health Research and Policy Analysis Program, the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.

Kaiser Family Foundation and Health Research and Educational Trust. 2000. 2000 Employer Health Benefits Survey. Menlo Park, CA: The Henry J. Kaiser Family Foundation.

Keane C, Marx J, Ricci E. 2001. Local health departments' changing role in provision and assurance of safety-net services. A project funded by the Center for Health Services Financing and Managed Care of the Health Resources and Service Administrative through a cooperative agreement with the Association of Schools of Public Health.

Lasker RD, Committee on Medicine and Public Health. 1997. Medicine and Public Health: The Power of Collaboration. New York: The New York Academy of Medicine.

Macinko JA, Starfield B, Shi L. [in press]. The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970-1998. Health Services Research. [ PMC free article: PMC1360919 ] [ PubMed: 12822915 ]

Mays GP, Miller CA, Halverson PK. 2000. Local Public Health Practice: Trends & Models. Washington, DC: American Public Health Association.

Murray CJL, Lopez AD. 1996. The Global Burden of Disease. A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard University Press.

NACCHO (National Association of County and City Health Officials). 2001. Local Public Health Agency Infrastructure: A Chartbook. Washington, DC: NACCHO.

NCVHS (National Committee on Vital and Health Statistics). 2002. Information for Health: A Strategy for Building the National Health Information Infrastructure. Report and Recommendations from the National Committee on Vital and Health Statistics. Atlanta, GA: NCVHS, CDC.

Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. 2001. Nurse Staffing and Patient Outcomes in Hospitals. Final Report. Contract No. 230-99-0021. Washington, DC: Health Resources and Services Administration, Department of Health and Human Services.

Olson K, Perkins J, Pate T. 1998. Children's Health under Medicaid: A National Review of Early Periodic Screening, Diagnosis and Treatment. Washington, DC: National Health Law Program.

Partnership for Prevention. 1999. Why Invest in Disease Prevention? Results from the William M. Mercer/Partnership for Prevention Survey of Employer Sponsored Plans. Washington, DC: Partnership for Prevention.

Partnership for Prevention. 2001. Prevention Priorities: Employers' Guide to the Highest Value Preventive Health Services. Washington, DC: Partnership for Prevention.

Pew Environmental Health Commission. 2001. Transition Report to the New Administration: Strengthening Our Public Health Defense Against Environmental Threats January 17. Baltimore: Pew Environmental Health Commission.

Rice T, Pourat N, Levan R, Silbert LJ, Brown ER, Gabel J, Kim J, Hunt KA, Hurst KM. 1998. Trends in job-based health insurance coverage. Los Angeles, CA: UCLA Center for Health Policy Research and KPMG Peat Marwick.

Robert Wood Johnson Foundation (RWJF). 2001. Substance Abuse: The Nation's Number One Health Problem. Key Indicators for Policy. February 2001 update. Waltham, MA: The Schneider Institute for Health Policy, Brandeis University.

Spratley E, Johnson A, Sochalski J, Fritz M, Spencer W. 2000. The Registered Nurse Population. Findings from the National Sample Survey of Registered Nurses. Rockville, MD: Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration.

Starfield B. 1998. Primary Care: Balancing Health Needs, Services and Technology. New York: Oxford University Press.

Starfield B. 2002. The role of primary care in improving population health and equity in the distribution of health: an unappreciated phenomenon. Presented at the Macy-Morehouse Conference on Primary Care, Atlanta, GA, September 17-19, 2002.

Teutsch SM, editor; , Churchill RE, editor. (Eds.). 1994. Principles and Practices of Public Health Surveillance. New York: Oxford University Press.

U.S. Department of Housing and Urban Development. 2002. Building Higher Education- Community Development Corporation Partnerships. Washington, DC: Department of Housing and Urban Development.

U.S. House of Representatives. 2001. National Preparedness: Ambulance Diversions Impede Access to Emergency Rooms. Washington, DC: Special Investigative Division, Minority Staff for Representative Henry A. Waxman, Committee on Government Reform, U.S. House of Representatives.

VHA Health Foundation and the AHA Health Research and Educational Trust (HRET). 2000. Sustaining community health: the experience of health care system leaders. White paper. Irving, TX: VHA Health Foundation;

1

Group Health of Puget Sound and the Health Insurance Plan of New York were also pioneers in group model health maintenance organizations.

2

Defined-contribution health care benefits are a new way for employers to provide health care coverage to their employees, while no longer acting as brokers between employees and insurance companies contracted to provide benefits. An employer may choose from several different ways to put money into a health benefits account for each employee and offer the employee a menu of coverage options, with different funding levels and employee financial responsibility for each.

3

The Foster G. McGaw Prize for Excellence in Community Service is awarded by the American Hospital Association to recognize hospitals that have distinguished themselves through efforts to improve the health and well-being of everyone in their communities.

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This chapter addresses the issues of access, managing chronic disease, neglected health care services (i.e., clinical preventive services, oral, and mental health care and substance abuse services), and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, the workforce, financing, information technology, and emergency preparedness.

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The Federal Government is made up of three branches:

Legislative: this branch is given power by the constitution and gives Congress the sole authority to enact legislation and declare war

Judicial: members of the Judicial Branch are appointed by the President and confirmed by the Senate.

Executive: The power of executive branch is in the hands of the president, and the president is voted in by the people.

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Capitalist economy

World's largest national economy

Leading global trader

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Parliament democracy: meaning it is split into chambers the Commons (The House) and The Senate.

Canada recognizes the King as their majesty.

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The U.S's values are:
* Independence
* Individualism
* Democracy
* Innovation
* Capitalism
* Diversity.

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Trading nation

Three main types of industries:

* Service industry: 75% of working Canadians work in the service industry
* Manufacturing industry
* Natural Resource industry

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Canada's values are:
* Democracy
* Peace
* Order and good government
* The rule of law
* Diversity

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339.59 million people

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1.   “Government Procurement.” United States Trade Representative, ustr.gov/issue-areas/government-procurement. Accessed 11 Apr. 2023.
2.   Immigration, Refugees and Citizenship Canada. “Discover Canada - Canada’s Economy - Canada.ca.” Canada.ca, 12 Apr. 2012, www.canada.ca/en/immigration-refugees-citizenship/corporate/publications-manuals/discover-canada/read-online/canadas-economy.html.
3.   Americans Value Independence and Self-Determination.
4.   The White House. “The Executive Branch.” The White House, 2021, www.whitehouse.gov/about-the-white-house/our-government/the-executive-branch/.
5.   Diaconu, Viorela, et al. “Modal Lifespan and Disparity at Older Ages by Leading Causes of Death: A Canada-U.S. Comparison.” Journal of Population Research (Canberra, A.C.T.), U.S. National Library of Medicine, 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686011/#CR20.

6.   “Diabetes Statistics.” DRIF, 31 Mar. 2023, https://diabetesresearch.org/diabetes-statistics/.
7.   “Diabetes in Canada.” DiabetesCanadaWebsite, https://www.diabetes.ca/advocacy---policies/advocacy-reports/national-and-provincial-backgrounders/diabetes-in-canada.

8.   “Burden of Cigarette Use in the U.S.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 Aug. 2022, https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html.

9.   “Current Smoking Prevalence.” Tobacco Use in Canada, 8 Feb. 2023, https://uwaterloo.ca/tobacco-use-canada/adult-tobacco-use/smoking-canada/current-smoking-prevalence.

10.  “FastStats - Life Expectancy.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 7 Feb. 2023, https://www.cdc.gov/nchs/fastats/life-expectancy.htm.

11.  “FASTSTATS - Deaths and Mortality.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 17 Jan. 2023, https://www.cdc.gov/nchs/fastats/deaths.htm.
12.  L;, Bushnik T;Tjepkema M;Martel. “Health-Adjusted Life Expectancy in Canada.” Health Reports, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/29668029/.
13.  “Mortality Rate, Infant (per 1,000 Live Births) - Canada.” World Bank Open Data, https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=CA.
14.  Ridic, Goran, et al. “Comparisons of Health Care Systems in the United States, Germany and Canada.” Materia Socio-Medica, U.S. National Library of Medicine, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3633404/.
15.   Roosa Tikkanen, et al. “Canada.” Home, 5 June 2020. https://www.commonwealthfund.org/international-health-policy-center/countries/canada#universal-coverage
16.   Roosa Tikkanen, et al. “United States.” Home, 5 June 2020. https://www.commonwealthfund.org/international-health-policy-center/countries/united-states
17.   “National Health Expenditure Trends, 2022 - Snapshot.” CIHI. https://www.cihi.ca/en/national-health-expenditure-trends-2022-snapshot
18.   “Nhe Fact Sheet.” CMS.https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet
19.  “Canada: Summary.” Columbia University Mailman School of Public Health, 31 Jan. 2023, https://www.publichealth.columbia.edu/research/others/comparative-health-policy-library/canada-summary#:~:text=Canada%20has%20universal%20health%20coverage,five%20pillars%20of%20that%20act.&text=The%20system%20must%20be%20universal,and%20accessible%20to%20the%20population.
20.  5 The Health Care Delivery System - National Center for Biotechnology...https://www.ncbi.nlm.nih.gov/books/NBK221227/.
21.   McAlister, Finlay A, et al. “Comparing Canadian Health Care to That in Other Countries: Looking beyond the Headlines.” CMAJ : Canadian Medical Association Journal = Journal De L'Association Medicale Canadienne, U.S. National Library of Medicine, 26 Feb. 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826705/#:~:text=A%20recent%20analysis%20from%20the,in%20the%20Commonwealth%20Fund%20Report.
22.  Nisha Kurani and Emma Wager Twitter   KFF, et al. “How Does the Quality of the U.S. Health System Compare to Other Countries?” Peterson-KFF Health System Tracker, 23 Sept. 2022, https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#:~:text=The%20U.S.%20ranks%20last%20in,by%20timely%20and%20effective%20care.
23.  Canada, Health. “Government of Canada.” Canada.ca, / Gouvernement Du Canada, 4 Apr. 2023, https://www.canada.ca/en/health-canada/services/canada-health-care-system.html.
24.   Lubin, Gus. “10 Reasons Why the US Health Care System Is the Envy of the World.” Business Insider, Business Insider, https://www.businessinsider.com/10-reasons-why-the-us-health-care-system-is-the-envy-of-the-world-2010-3.

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38.7 million people