The United States government provides healthcare services through an unstructured and locally organized delivery system. Hospitals can open or close depending on community resources, preferences, and the dictates of an open market for hospital services. Doctors are free to set up their office wherever they choose, and there is no health planning at the federal level. State planning efforts range from none to a strict review of hospital and nursing home construction projects.
Most hospitals are owned by private non-profit institutions, while the rest are owned by governments or private for-profit companies. Doctors, the vast majority of whom work in private offices and are paid in the form of fee-for-service (FFS), care for their patients in their offices and place them in hospitals where they can continue to care for them. About two-fifths of doctors practice alone, although there is a long-term trend toward the formation of more and more group practices. A relatively small number of doctors do not belong to the FFS sector, but rather work in government, companies, managed care networks, or hospitals.
In recent years, health reform in the United States has focused on controlling rapidly rising health care costs and increasing financial access to health care. Various cost control strategies have been tried at the federal, state, and local government levels and by private payers. Despite these efforts, health care costs continue to rise. The resulting pressure on public, private, and individual budgets keeps the issue of controlling health care costs high on the public agenda. The vast majority of the population, about 74 percent, is covered by private health insurance.
Children under 65 and their dependents obtain private health insurance through their employers (61% of the population) or through the direct purchase of non-group health insurance (13% of the population). A small proportion of the population, 13%, has multiple health insurance coverage. Not all companies offer health insurance; most uninsured people (75 percent) are employees or their dependents. There are more than 1,000 private health insurance companies that offer health insurance policies with different benefit structures, premiums, and rules for paying policyholders or health care providers. To be eligible for Medicaid, a person must be poor, elderly, blind, disabled, pregnant, or the mother of a dependent child.
Dependent mothers and children account for about 68 percent of Medicaid recipients, the elderly 13 percent, the blind and disabled 15 percent, and others 4 percent. States define eligibility levels in more detail; consequently, about 60 percent of the poor below the federal poverty line are excluded from Medicaid. Adults under 65 without children and without disabilities are not eligible for Medicaid; nor are people with assets above levels defined by the State. On the other hand, since Medicaid is the only public program that funds long-term nursing home care, a significant number of middle-class older people have become eligible for care in nursing homes covered by Medicaid by intentionally transferring assets to their children and exhausting their income for nursing home expenses. Services for the uninsured are provided through a variety of sources; federal, state, and local governments support public health clinics and hospitals with the primary mission of providing care for the indigent. In some cases they also pay private providers to care for the indigent.
Public health spending supports preventive health measures such as vaccines, cancer screening programs, and healthy child care. The services are usually available to everyone although a fee may be charged that varies depending on income. Public budgets represented 42% of health spending in 1990 while private sector spending was 58%. The proportion of total health care expenditures covered by public sources is lower in the United States than in all but one of the member countries of the OECD. The federal budget funded 29 percent of all health expenditures mainly through Medicare and Medicaid programs but also through the health expenditures of the Departments of Defense and Veterans Affairs for current and retired military personnel and their dependents. Of the 13 percent of state and local health expenditures approximately 5 percent went to Medicaid and 8 percent to other state and local health programs. Health expenditures represent an increasing proportion of public budgets; in 1990 they represented 15% of the federal budget and 11% of state and local budgets while Medicare alone now represents 9 percent of the federal budget. So what rights do individuals have when it comes to receiving healthcare services consistent with their beliefs and values in public hospitals and clinics in Hawaii? The answer depends on several factors including eligibility requirements for Medicaid as well as state regulations regarding insurance premiums and other aspects of healthcare delivery. In general individuals have a right to receive healthcare services that meet their needs regardless of whether they receive those services from a public or private provider.
However individuals may need to take into account any restrictions imposed by state regulations when selecting a provider or type of service. In addition individuals should be aware that some services may not be covered by public programs such as Medicaid or Medicare so they may need to seek out alternative sources such as private insurance or out-of-pocket payments. Finally individuals should be aware that some services may not be available at all public hospitals or clinics so they may need to seek out alternative providers if they wish to receive services consistent with their beliefs and values.
