Health Systems: State Control And Hospital Management

The healthcare system in the United States has evolved since the Colonial Era, when community-oriented care was the norm. Today, the US healthcare system is primarily owned by private entities, but federal, state, county, and city governments also own and operate certain facilities. As of 2018, there were 5,534 registered hospitals in the US, with about 70% being non-profit. The federal government is involved in financing and providing healthcare services, particularly for military personnel and veterans, while states play a crucial role in regulating and delivering healthcare services to their citizens. States like Massachusetts have led the way in universal healthcare coverage, inspiring national policies like the Affordable Care Act. State hospitals cater to various populations, including those with mental health issues, and are reimbursed through various sources, including Medicaid and Medicare.

Federal and state-owned hospitals

In the United States, the federal government is responsible for financing personal and public health services through the Health Care Financing Administration's Medicare and Medicaid offices. The federal government also directly delivers personal health services under the Health Resources and Services Administration, the Veteran's Administration, and the Department of Defense, which operates hospitals and clinics for military personnel and their dependents.

The federal government's activities in the healthcare sector fall into two primary categories. The first category includes activities conducted directly by the federal government, such as assessment, policymaking, resource development, knowledge transfer, financing, and the delivery of personal healthcare. The second category involves activities contracted by the federal government to states, localities, and private organizations, encompassing most direct service programs.

Regarding hospital ownership, data released by the Centers for Medicare and Medicaid Services (CMS) in December 2022 revealed that of the 4,644 Medicare-enrolled hospitals, 49.2% are non-profit, 36.1% are for-profit, and 14.7% are government-owned. Individuals own 8.0% of hospital shares, with a higher proportion of specialty hospitals owned by individuals compared to short-term acute care hospitals.

At the state level, Massachusetts has been a leader in universal healthcare coverage. In 2006, the state enacted a plan that inspired former President Barack Obama's Affordable Care Act. This demonstrates the role of individual states in pioneering healthcare policies that can have a broader impact on the national level.

Healthcare accessibility

The US Department of Health and Human Services (HHS) plays a pivotal role in enhancing the health and well-being of Americans. Various agencies, including the Administrations on Aging, Native Americans, Children, Youth and Families, Refugees, and the Developmentally Disabled, work towards this mission. The HHS also addresses critical issues like chronic diseases in children, with initiatives such as the Presidential Commission to Make America Healthy Again (MAHA).

At the state level, Texas provides an example of state-run hospitals with nine facilities and one residential youth center dedicated to mental health services. These institutions serve diverse populations, including individuals involved with the justice system. The state ensures that patients are screened and admitted based on their needs, with emergency screenings mandated by the Emergency Medical Treatment and Active Labor Act (EMTALA).

To improve healthcare accessibility, strategies to increase insurance coverage are vital. Additionally, interventions that enhance access to healthcare professionals and improve communication can make a significant difference. The utilization of electronic health information and online medical records can also play a role in making healthcare more accessible and efficient.

Mental health services

The Substance Abuse and Mental Health Services Administration (SAMHSA) offers a free, confidential, and multilingual crisis support service that is accessible 24/7 to all US residents and those in its territories. This service provides assistance to individuals experiencing emotional distress related to natural or human-caused disasters. Additionally, SAMHSA provides a treatment referral service for those struggling with mental health or substance use disorders.

At the state level, initiatives like the New York State Office of Mental Health aim to address the unique mental health challenges faced by different populations. Similarly, Orange County, California, has the Behavioral Health Services, which strive to prevent substance abuse and mental health crises, intervening early and providing appropriate treatment when needed.

The federal government also directly finances mental health care through Medicare and Medicaid programs and operates a mental health hospital. In 1983, the federal government spent more than $3 billion on mental health programs, care, and financing for individuals.

Healthcare standards and regulations

In the United States, national legal standards for healthcare are set by the federal legislature, the federal courts, the President, and the President's executive branch appointees. The Department of Health and Human Services (HHS) is the executive branch department responsible for the portion of American healthcare that is federally controlled. The HHS consists of appointed officers such as the surgeon general and 11 operating divisions, including the Food and Drug Administration, the Centers for Disease Control, the Centers for Medicare & Medicaid Services (CMS), and the Agency for Healthcare Research and Quality (AHRQ).

The HHS's mission is to enhance the health and well-being of all Americans, and its programs and services are administered by the Office of the Secretary Staff Divisions, Operating Divisions, and Regional Offices. The HHS creates regulations (or "rules") under the authority of Congress to help the government carry out public policy. These regulations can be found on Regulations.gov and cover areas such as civil rights, privacy rights, research, fraud prevention and detection, freedom of information, tribal matters, and employment.

Healthcare quality management aims to improve quality by analyzing data and identifying the root causes of events. Healthcare organizations must undergo periodic reviews and submit data to demonstrate that healthcare providers meet quality standards to bill federal and state health insurance programs for services. The National Quality Forum (NQF) is an organization that comprises over 400 for-profit and nonprofit organizations that collect data and endorse healthcare standards. The NQF typically adopts the guidelines set by national medical societies, such as the American Association of Family Medicine or the National Comprehensive Cancer Network.

The majority of federal mental health programs are sponsored by the Public Health Service in the Alcohol, Drug Abuse, and Mental Health Administration. This administration primarily conducts its programs through grants and contracts to states, localities, and private organizations. The federal government also directly finances mental health care through the Medicare and Medicaid programs and operates a mental health hospital.

Healthcare insurance coverage

In the US, healthcare insurance coverage has evolved since the Colonial Era, when community-oriented care was the norm, with families and neighbours assisting the sick. The 19th century saw the professionalisation of medicine, with the emergence of the "Anglo-American model", where medical professionals were empowered by the state to self-regulate. The establishment of medical schools and organisations led to standardised training and certification for doctors. Post–World War II marked a significant expansion of healthcare, with increased accessibility and federal funding for hospital construction through the Hill–Burton Act of 1946. Medicare and Medicaid were established in 1965 to provide healthcare coverage for the elderly and low-income populations, respectively.

Today, healthcare ownership in the US is primarily private, but federal, state, county, and city governments also own facilities. As of 2018, there were 5,534 registered hospitals, with 4,840 being community hospitals. Nonprofit hospitals account for about 70% of total hospital capacity, with the remainder comprising privately owned, for-profit hospitals and government hospitals, mainly owned by county and city governments. The Veteran's Administration runs hospitals and nursing homes, while the Bureau of Mines in the Department of the Interior conducts health and safety programmes for mining industry employees.

The American Medical Association (AMA) played a pivotal role in standardising medical education, and employer-sponsored insurance plans marked the advent of the modern health insurance system. However, despite these advancements, healthcare disparities persist, particularly between urban and rural areas. Approximately 10% of Americans lack health insurance, impacting their access to primary care providers and essential medications. Strategies to enhance insurance coverage are crucial to ensuring that more people receive necessary healthcare services, including preventive care and chronic illness treatment.

Federal mental health programs are predominantly sponsored by the Public Health Service within the Alcohol, Drug Abuse, and Mental Health Administration. These programs are typically conducted through grants and contracts with states, localities, and private organisations. The federal government also directly finances mental health care through Medicare and Medicaid and operates a mental health hospital. State hospital facilities are Medicare-certified and Medicaid-approved, and Texas, for instance, operates nine state hospitals and one residential youth centre for individuals with mental health issues.

Massachusetts has been a pioneer in universal health care coverage, enacting a plan in 2006 that inspired the Affordable Care Act. It is important to note that financing personal and public health services is primarily the responsibility of the Health Care Financing Administration's Medicare and Medicaid offices, with grants administered by the Department of Health and Human Services.

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