The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You

Illness Trends The bubonic plague is a good example of a disease that can drastically change the healthcare system by quickly shifting all resources to handle an epidemic. In the Middle Ages, the Black Death spread so quickly across Europe that it is responsible for an estimated 75 million deaths. It may be surprising that the bubonic plague still circulates today.

In fact, according to Center for Disease Control data, there were 11 cases and three deaths in the U. Although the bubonic plague is not near the threat it once was, other diseases and conditions of concern are on the rise. The following seven conditions are on the rise and can be expected to have an impact on healthcare in the near future: Chlamydia and gonorrhea rates have increased, and syphilis rates rose by Obesity continues to be an issue in the U. Obesity rates have increased 17 percent in the past five years.

For every , people, 1, are diagnosed with autism. This number continues to rise annually. Recent increases may be due to awareness as doctors become more familiar with the symptoms of autism. Within 10 years, cases of E. Incidences of liver cancer have increased by 47 percent in a recent year timeframe. Healthcare practitioners have treated The year increase for whopping cough is nearly percent. This may be due in part to parents opting out of whopping cough vaccinations. The healthcare industry has identified these previous conditions, preparing to handle further increases with supplies and resources.

However, a new threat is always possible. If something similar to the Ebola virus spread across the country, this would have a drastic impact on patient care and healthcare facilities. Population Shift The current baby boomer generation, which initially consisted of 76 million people born between and , will be coming to retirement age and will increase federal spending on Medicare and Medicaid by an average of 5.

• Deine Arzneien (German Edition);
• Hyperion (Hyperion Cantos Book 1)!
• Technology and the Future of Healthcare?
• Trono de Cristal (Trono de Cristal 1) (Spanish Edition)!
• The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

Advances in Technology Healthcare technology trends focus heavily on patient empowerment. The introduction of wearable biometric devices that provide patients with information about their own health and telemedicine apps allow patients to easily access care no matter where they live. With new technologies focused on monitoring, research and healthcare availability, patients will be able to take a more active role in their care.

From policy to patients and everything in-between, the healthcare industry is constantly evolving. Aging populations, technological advancements and illness trends all have an impact on where healthcare is headed. Since it is crucial to pay attention shifts in society to understand where healthcare is headed, consider dedicating time each day to reading recommended industry literature that you will find in our list of 25 books for every healthcare professional. More Faculty and Graduates Profiles. Pearson Embanet is the online education partner of the George Washington University.

This Privacy Statement discloses how Pearson Embanet collects, uses and safeguards the personal information you provide to us. We reserve the right to append or modify this Privacy Statement at anytime. We ask that you re-visit our Privacy Statement to check for updates or changes. All of this is used to improve the navigation of the site and make it more useful for our visitors.

The information that you voluntarily provide us… In addition to the information automatically collected by your browser, we also collect information that you voluntarily provide to us when you fill out an information request for one of the programs featured on any of our sites. The submission forms require participants to provide the school with contact information. Analyzing website traffic… Google Analytics is used to analyze traffic to this site.

Google Analytics does not create individual profiles for visitors. Google Analytics is software that provides business insight and marketing trends without compromising the privacy of users on the web. We do not sell or rent your personal information… We do not sell or rent any personal data submitted by visitors to any of our websites to any third parties. We abide by all applicable laws concerning the release of your personal information.

Occasionally, we may use the information that we have collected to send you information about other products and services offered by the George Washington University, and updated information that might interest you. We respect your wishes. If you tell us that you do not want to have this information used as a basis for further contact then you will not receive any further information. If you do not want to receive our e-mail marketing, please submit a request to have your e-mail address removed at the following e-mail address: More about The Future of Medicine.

How a failing university hospital in Baltimore became a thriving academic medical center. Health care in the United States is a paradox. We have the most expensive, technologically advanced medicine in the world, Yet, even basic medical care is not uniformly available or it is much too expensive.

How We Can Expect the Healthcare Industry to Change in the Future

Furthermore, the quality of care is all too often less than satisfactory and not nearly safe enough. There are many disruptive, often transformational changes coming, which will further complicate matters for the average patient. One of the most important changes is a shift from a focus on the treatment and prevention of acute illness e. There are also many misconceptions about what medical care delivery is and what it could and should be. For example, few people understand that true comprehensive healthcare delivery requires both an intensive focus on both diagnosing and treating diseases and injuries when they occur as well as an equally intense focus on health promotion and disease prevention.

Furthermore, few in the general public understand that those with chronic illnesses require well coordinated care by a multi-disciplinary team. Healthcare reform legislation has been touted as offering us better care opportunities when, in fact, healthcare reform is not about healthcare ; it is mostly about paying for medical care for the uninsured, eliminating some of the health insurance restrictions consumers face, and only somewhat about the rising costs of medical care or improved quality.

The Future of the Public's Health in the 21st Century. National Academies Press US ; 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.

The Future of the Public's Health in the 21st Century.

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 b: This chapter addresses the issues of access, managing chronic disease, neglected health care services i. 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. 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, b and other literature, this health care system is faced with serious quality and cost challenges. In the aggregate, these per capita expenditures account for 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 s, 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.

See a Problem?

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.

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. It is also associated with having a regular source of care and with greater and more appropriate use of health services.

Private insurance is predominantly purchased through employment-based groups and to a lesser extent through individual policies Mills, Publicly funded insurance is provided primarily through seven government programs see Table 5—1. Medicare provides coverage to 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.

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. 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. 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: Safety-net providers are also more likely to offer outreach and enabling services e. 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. The persistently large proportion of the American population that is uninsured—about one in five working-age adults and one in seven children— is the most visible and troubling sign of the nation's failure to assure access to health care. Yet the public and many elected officials seem almost willfully ignorant of the magnitude, persistence, and implications of this problem.

Surveys conducted over the past two decades show a consistent underestimation of the number of uninsured and of trends in insurance coverage over time Blendon et al. The facts about uninsurance in America are sobering see Box 5—1. By almost any metric, uninsured adults suffer worse health status and live shorter lives than insured adults IOM, a. Findings from Coverage Matters. Forty-two million people in the United States lacked health insurance coverage in Mills, Because insurance status affects access to secure and continuous care, it also affects health, leading to an estimated 18, premature deaths annually IOM, a.

Having a regular source of care improves chances of receiving personal preventive care and screening services and improves the management of chronic disease. When risk factors, such as high blood pressure, can be identified and treated, the chances of developing conditions such as heart disease can be reduced. Similarly, if diseases can be detected and treated when they are still in their early stages, subsequent rates of morbidity and mortality can often be reduced.

Without insurance, the chances of early detection and treatment of risk factors or disease are low. However, even when the uninsured receive care, they fare less well than the insured.

For example, Hadley and colleagues found that uninsured adult hospital inpatients had a significantly higher risk of dying in the hospital than their privately insured counterparts. Emergency and trauma care were also found to vary for insured and uninsured patients. Uninsured persons with traumatic injuries were less likely to be admitted to the hospital, received fewer services when admitted, and were more likely to die than insured trauma victims Hadley et al.

For children, too, being uninsured tends to reduce access to health care and is associated with poorer health. That report emphasized that untreated health problems can affect children's physical and emotional growth, development, and overall health and well-being. Untreated ear infections, for example, can have permanent consequences of hearing loss or deafness. Even when insured, limitations on coverage may still impede people's access to care.

Many people who are counted as insured have very limited benefits and are exposed to high out-of-pocket expenses or service restrictions. Three areas in which benefits are frequently circumscribed under both public and private insurance plans are preventive services, behavioral health care treatment of mental illness and addictive disorders , and oral health care. When offered, coverage for these services often carries limits that are unrelated to treatment needs and are stricter than those for other types of care King, Cost-sharing requirements for these services may also be higher than those for other commonly covered services.

The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You

Access to care for the insured can also be affected by requirements for cost sharing and copayments. Cost sharing is an effective means to reduce the use of health care for trivial or self-limited conditions. Numerous studies, starting with the RAND Health Insurance Experiment, show that copayments also reduce the use of preventive and primary care services by the poor, although not by higher-income groups Solanki et al. The same effects have been shown for the use of behavioral health care services Wells et al. As a result of the nation's increased awareness of bioterrorist threats, there are concerns about the implications of copayments and other financial barriers to health care.

Cost sharing may discourage early care seeking, impeding infectious disease surveillance, delaying timely diagnosis and treatment, and posing a threat to the health of the public. The committee encourages health care policy makers in the public and private sectors to reexamine these issues in light of the concerns about bioterrorism. This committee was not constituted to make specific recommendations about health insurance. The issues are complex, and the failures of health care reform efforts over the past 30 years testify to the difficulty of crafting a solution.

However, the committee finds that both the scale of the problem and the strong evidence of adverse health effects from being uninsured or underinsured make a compelling case that the health of the American people as a whole is compromised by the absence of insurance coverage for so many. Assuring the health of the population in the twenty-first century requires finding a means to guarantee insurance coverage for every person living in this country.

Adequate population health cannot be achieved without making comprehensive and affordable health care available to every person residing in the United States. It is the responsibility of the federal government to lead a national effort to examine the options available to achieve stable health care coverage of individuals and families and to assure the implementation of plans to achieve that result.

Absent the availability of health insurance, the role of the safety-net provider is critically important.

Technology and the Future of Healthcare

Increasing their numbers and assuring their viability can, to some degree, improve the availability of care. That committee further identified core safety-net providers as having two distinguishing characteristics: The organization and delivery of safety-net services vary widely from state to state and community to community Baxter and Mechanic, The safety net consists of public hospital systems; academic health centers; community health centers or clinics funded by federal, state, and local governmental public health agencies see Chapter 3 ; and local health departments themselves although systematic data on the extent of health department services are lacking IOM, a.

A recent study of changes in the capacities and roles of local health departments as safety-net providers found, however, that more than a quarter of the health departments surveyed were the sole safety-net providers in their jurisdictions and that this was more likely to be the case in smaller jurisdictions Keane et al. Safety-net service providers, which include local and state governmental agencies, contribute to the public health system in multiple ways.

Services provided by state and local governments often include mental health hospitals and outpatient clinics, substance abuse treatment programs, maternal and child health services, and clinics for the homeless. In addition, an estimated 1, public hospitals nationwide Legnini et al. A survey of 69 hospitals belonging to the National Association of Public Hospitals indicated that in , public hospitals provided more than 23 percent of the nation's uncompensated hospital care measured as the sum of bad debt and charity care IOM, a.

These demands can overwhelm the traditional population-oriented mission of the governmental public health agencies. Furthermore, changes in the funding streams or reimbursement policies for any of these programs or increases in demand for free or subsidized care that inevitably occur in periods of economic downturn create crises for safety-net providers, including those operated by state and local governments see the section Collaboration with Governmental Public Health Agencies later in this chapter for additional discussion.

Intact but Endangered IOM, a: Despite today's robust economy, safety net providers—especially core safety net providers—are being buffeted by the cumulative and concurrent effects of major health policy and market changes. The convergence and potentially adverse consequences of these new and powerful dynamics lead the committee to be highly concerned about the future viability of the safety net. Although safety net providers have proven to be both resilient and resourceful, the committee believes that many providers may be unable to survive the current environment.

Taken alone, the growth in Medicaid managed care enrollment; the retrenchment or elimination of key direct and indirect subsidies that providers have relied upon to help finance uncompensated care; and the continued growth in the number of uninsured people would make it difficult for many safety net providers to survive. Taken together, these trends are beginning to place unparalleled strain on the health care safety net in many parts of the country. The committee believes that the effects of these combined forces and dynamics demand the immediate attention of public policy officials.

Intact but Endangered IOM, a , aimed at ensuring the continued viability of the health care safety net see Box 5—2. Recommendations Concerning Safety-Net Services. Federal and state policy makers should explicitly take into account and address the full impact both intended and unintended of changes in Medicaid policies on the viability of safety-net providers and more 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. The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care IOM, b. Such services include immunizations and screening tests, as well as counseling aimed at changing the personal health behaviors of patients long before clinical disease develops. The importance of counseling and behavioral interventions is evident, given the influence on health of factors such as tobacco, alcohol, and illicit drug use; unsafe sexual behavior; and lack of exercise and poor diets.

These risk behaviors are estimated to account for more than half of all premature deaths; smoking alone contributes to one out of five deaths McGinnis and Foege, Coverage of clinical preventive services has increased steadily over the past decade. In , about three-quarters of adults with employment-based health insurance had a benefit package that included adult physical examinations.

Two years later, the proportion had risen to 90 percent Rice et al. The type of health plan is the most important predictor of coverage RWJF, The use of financial incentives and data-driven performance measurement strategies to improve physicians' delivery of services such as immunizations IOM, c may account for the fact that managed care plans tend to offer the most comprehensive coverage of clinical preventive services and traditional indemnity plans tend to offer the least comprehensive coverage.

Although the trend toward inclusion of clinical preventive services is positive, such benefits are still limited in scope and are not well correlated with evidence regarding the effectiveness of individual services. Public Health Service, has endorsed a core set of clinical preventive services for asymptomatic individuals with no known risk factors. In the committee's view, this guidance to clinicians on the services that should be offered to specific patients should also inform the design of insurance plans for coverage of age-appropriate services.

However, the USPSTF recommendations have had relatively little influence on the design of insurance benefits, and recommended counseling and screening services are often not covered and, consequently, not used Partnership for Prevention, see Box 5—3. As might be expected, though, adults without health insurance are the least likely to receive recommended preventive and screening services or to receive them at the recommended frequencies Ayanian et al.

Counseling to address serious health risks—tobacco use, physical inactivity, risky drinking, poor nutrition—is least likely to be covered by an employer-sponsored more Having any health insurance, even without coverage for any preventive services, increases the probability that an individual will receive appropriate preventive care Hayward et al. Studies of the use of preventive services by Hispanics and African Americans find that health insurance is strongly associated with the increased receipt of preventive services Solis et al.

However, the higher rates of uninsurance among racial and ethnic minorities contribute significantly to their reduced overall likelihood of receiving clinical preventive services and to their poorer clinical outcomes Haas and Adler, For example, African Americans and members of other minority groups who are diagnosed with cancer are more likely to be diagnosed at advanced stages of disease than are whites Farley and Flannery, ; Mandelblatt et al. Preventive services are important for older adults, for whom they can reduce premature morbidity and mortality, help preserve function, and enhance quality of life.

• Project MUSE - The Future of Health-Care Delivery.
• How We Can Expect the Healthcare Industry to Change in the Future - Healthcare MBA GWU?
• Mystery at the Great Wall (Nick and Siam Mysteries Book 1).
• Seven visions of the future of healthcare!
• The Complexity of Healthcare;
• Such a Simple Little Tale: Critical Responses to L.M. Montgomerys Anne of Green Gables.
• The Future of Medicine: Megatrends in Medicine - by Dr. Stephen C. Schimpff, MD.

Unfortunately, the Medicare program was not designed with a focus on prevention, and the process for adding preventive services to the Medicare benefit package is complex and difficult. Unlike forms of treatment that are incorporated into the payment system on a relatively routine basis as they come into general use, preventive services are subject to a greater degree of scrutiny and a demand for a higher level of effectiveness, and there is no routine process for making such assessments.

Box 5—4 lists the preventive services currently covered by Medicare. Preventive Services Covered by Medicare. For individuals with Medicare, the following services are covered by Medicare Part B: Bone mass measurements for people at risk of losing bone mass. The level of use of preventive services among older adults has been relatively low CDC, This may reflect the limited range of benefits covered by Medicare, as well as other barriers such as copayments, participants' unfamiliarity with the services, or the failure of physicians to recommend them.

Cardiovascular disease and diabetes exemplify the problem. Although cardiovascular disease is the leading cause of death and diabetes is one of the most significant chronic diseases affecting Medicare beneficiaries, physicians cannot screen for lipids disorders or diabetes unless the patient agrees to pay out-of-pocket for the tests.

Medicaid benefits vary by state in terms of both the individuals who are eligible for coverage and the actual services for which coverage is provided. The exception is preventive services for children. In , the U. This entitled poor children to a comprehensive package of preventive health care and medically necessary diagnostic and treatment services. Given its potential to reach such a high proportion of the nation's neediest children, the program could have a very positive, widespread impact on children's health.

Unfortunately, data on the program's progress are incomplete and inconsistent across the country, despite federal requirements for state reports GAO, a. However, some studies have demonstrated that EPSDT has never been fully implemented, and the percentage of children receiving preventive care through it remains low for reasons ranging from systemic state or local deficiencies e. Additionally, data show that as many as 50 percent of children who have an EPSDT visit are identified as requiring medical attention, but if they are referred for follow-up care, only one-third to two-thirds go for their referral visit Rosenbach and Gavin, Children's Preventive Health Care under Medicaid.

Number of eligible children. The Surgeon General's report on mental illness DHHS, estimates that more than one in five adults are affected by mental disorders in any given year see Box 5—6 and 5. Data for children are less reliable, but the overall prevalence of mental disorders is also estimated to be about 20 percent DHHS, Mental disorders are a major public health issue because they affect such a large proportion of the population, have implications for other health problems, and impose high costs, both financial and emotional, on affected individuals and their families.

Facts About Mental Illness. About 40 million people more than one in five ages 18 to 64 are estimated to have a single mental disorder of any severity or both a mental and an addictive disorder in a given year Regier et al. For the most prevalent mental health disorders such as depression and anxiety, receipt of appropriate care is associated with improved functional outcomes at 2 years Sturm et al. Access to care is constrained by limitations on insurance coverage that are greater than those imposed for other diseases.

Annual and lifetime coverage limits are frequently less, and mental health coverage often has more hidden costs in the forms of copayments and higher deductibles Zuvekas et al. Table 5—2 shows the distribution of sources of payment for treatment for mental health and addictive disorders in Additionally, those with no insurance all year paid nearly 60 percent of costs out-of-pocket, whereas those with some private insurance paid 40 percent of costs out-of-pocket in Zuvekas, Adults' use of mental health services in both the general and the specialty mental health sectors correlates highly with health insurance coverage Cooper-Patrick et al.

Recent studies have shown impressive results for treatment of depression in primary care settings Sturm and Wells, ; Schoenbaum et al. The provision of such services is cost-effective and comparable to the cost-effectiveness of other common procedures. However, reimbursement policies for primary care do not support the services necessary to provide evidence-based care for depression Wells et al. Adults with either no insurance coverage or coverage that excludes or limits extended treatment of mental illness receive less appropriate care and may experience delays in receiving services until they gain public insurance Rabinowitz et al.

Adults with mental disorders are also more likely to lose health insurance coverage within a year following their diagnosis than those without a mental disorder Sturm and Wells, The limited and unstable nature of insurance for treatment of mental illness has several implications for governmental public health agencies because the severely mentally ill are likely to end up receiving care in publicly funded safety-net programs Rabinowitz et al.

Funding to support the public mental health system comes from reimbursements for services provided to Medicare and Medicaid participants, from federal block grants to states, and from state and local funds that support community-based programs and hospital care. Taken in the aggregate, these funding streams are neither adequate nor reliable enough to meet the needs of individuals with serious mental disorders IOM, a.

As with other forms of safety-net care, the urgency of providing treatment to the severely mentally ill erodes funds available for prevention purposes. In the United States, more than 18 million people who use alcohol and nearly 5 million who use illicit drugs need substance abuse treatment SAMHSA, Substance abuse, like mental illness, exacts enormous social costs across all segments of society.

Most recipients 87 percent of specialty treatment for alcohol or drug abuse receive it in outpatient settings RWJF, , but overall, less than one-fourth of those who need treatment get it. Barriers to treatment include stigma, lack of available treatment facilities, unwillingness to admit that treatment is needed, and inability to pay for care.

Public sources provide more than two-thirds of the funding for alcohol and drug treatment facilities. Half of such funds come from dedicated funding at the federal, state, and local levels in the form of various block grants to state safety-net programs. Medicaid and Medicare cover 21 percent of treatment, private insurance covers 14 percent, and 10 percent is paid directly by patients as out-of-pocket costs.

Another 5 percent is covered through various charitable sources. Insurance policies held by many individuals constrain the use of substance abuse services by the exclusion of benefits for such services and by the use of annual and lifetime limits on benefits and other controls on service utilization.

Between and , private insurance for substance abuse services fell 0. Over the same period, out-of-pocket payments for specific types of substance abuse treatment increased Coffey et al. However, the high out-of-pocket costs faced by individuals who pay for their own treatment discourage many who need care from seeking it. Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system. The consequences in terms of individual and population health are significant—oral health is a matter of public health concern because it affects a large proportion of the population and is linked with overall health status see Box 5—7.

Oral diseases are causally related to a range of significant health problems and chronic diseases, as well as individuals' ability to succeed in school, work, and the community DHHS, b. The effects of oral diseases are cumulative and influence aspects of life as fundamental as the foods people can eat, their ability to communicate effectively, and their social acceptability. The problems in the way the health care delivery system relates to oral health include lack of dental coverage and low coverage payments, the separation of medicine and dentistry in training and practice, and the high proportion of the population that lacks any dental insurance.

The committee focused on the problem of insurance and access to care. Oral Health as a Component of Total Health. When people think about the components of good health, they often forget about the importance of good oral health. This oversight is often reflected by health insurance coverage restrictions that exclude oral more According to the Department of Health and Human Services DHHS Office of Health Promotion and Disease Prevention, more than million Americans have limited or no dental insurance, nearly four times the number who lack insurance for medical care cited by Allukian, As with other types of health services, insurance is a strong predictor of access to and use of dental services, and minorities and low-income populations are much less likely to have dental insurance or to receive dental care.

Individuals and families living below the poverty level experience more dental decay than higher-income groups, and their cavities are less likely to be treated GAO, More than a third of poor children ages 2 to 9 have one or more primary teeth with untreated decay, compared with Mexican-American adults and children are more likely to have untreated decayed teeth than any other population group. Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth The pattern for adults is similar DHHS, b: Medicare excludes coverage of routine dental care, and many state Medicaid programs do not provide dental coverage for eligible children or adults.

According to a report of the Surgeon General, fewer than one in five Medicaid-covered children received a single dental visit in a recent year-long study period DHHS, b. Low-income Hispanic children and adults are less likely to be eligible for Medicaid than other groups, so even the limited Medicaid benefits are unlikely to be available to them. The forecast for major oral health problems among the nation's fastest-growing population group, Hispanics, is especially alarming.

The committee found that preventive, oral health, mental health, and substance abuse treatment services must be considered part of the comprehensive spectrum of care necessary to help assure maximum health. Therefore, the committee recommends that all public and privately funded insurance plans include age-appropriate preventive services as recommended by the U. Preventive Services Task Force and provide evidence-based coverage of oral health, mental health, and substance abuse treatment services. Crossing the Quality Chasm IOM, b 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: 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, ; Hetzel and Smith, Evidence shows that racial and ethnic minorities do not receive the same quality of care afforded white Americans.

These findings are consistent across a range of illnesses and health care services and remain even after adjustment for socioeconomic differences and other factors that are related to access to health care IOM, b. Furthermore, poor-quality health care is an important independent variable contributing to lower health status for minorities IOM, b. For example, racial differences in cervical cancer deaths have increased over time, despite the greater use of screening tests by minority women Mitchell and McCormack, The lower quality of care also compounds the adverse health effects of other disadvantages faced by minorities, including lower incomes and education, less healthy living environments, and a greater likelihood of being uninsured.

As discussed in Unequal Treatment IOM, b , the factors that may produce disparities in health care include the role of bias, discrimination, and stereotyping at the individual provider and patient , institution, and health system levels. The report found that aspects of the health care system—its organization, financing, and availability of services—may have adverse effects specifically for racial and ethnic minorities.

For example, time pressures on physicians hamper their ability to accurately assess presenting symptoms, especially when cultural or language barriers are present. Nearly 14 million people in the United States are not proficient in English. Changes in the financing and delivery of health care services, such as the emphasis on cost controls and the almost complete conversion to managed care for the delivery of services under Medicaid, may be especially problematic for racial and ethnic minorities.