Obama ma'muriyati davrida taklif qilingan sog'liqni saqlash sohasidagi islohotlar - Health care reforms proposed during the Obama administration

Ushbu maqola qismidir bir qator kuni
Sog'liqni saqlash tizimini isloh qilish Amerika Qo'shma Shtatlari
Tarix Munozara
Qonunchilik Oldingi 1965 yildagi ijtimoiy ta'minotga o'zgartirishlar EMTALA (1986) HIPAA (1996) Medicare-ni modernizatsiya qilish to'g'risidagi qonun (2003) PSQIA (2005) O'zgartirildi Amerika uchun arzon sog'liqni saqlash (HR 3962) Amerikaning sog'liq uchun maqbul tanlovi (HR 3200) Baucus sog'liqni saqlash to'g'risidagi qonun loyihasi (S. 1796) Taklif qilingan Amerika sog'liqni saqlash to'g'risidagi qonun (2017) Amerika Qo'shma Shtatlarining sog'liqni saqlash bo'yicha milliy qonuni (2009 y., 676 y.) Sog'lom amerikaliklar to'g'risidagi qonun (2007, 2009) Sog'liqni saqlash xavfsizligi to'g'risidagi qonun (HR 3600) Oxirgi kuchga kirgan Arzon parvarishlash to'g'risidagi qonun (HR 3590) Sog'liqni saqlash va ta'limni yarashtirish to'g'risidagi qonun (HR 4872)
Islohotlar Obama ma'muriyatining takliflari Jamoatchilik fikri Targ'ibot guruhlarini isloh qilish Rationing Sug'urta qoplamasi
Tizimlar Erkin bozor Tibbiy sug'urta birjasi Milliylashtirilgan sug'urta Jamiyat tomonidan moliyalashtiriladi Yagona to'lovchi Kanadalik va amerikalik Ikki darajali Umumjahon
Uchinchi tomon to'lovlari modellari To'lovchilar uchun stavkani belgilash Imkoniyat Xizmat uchun to'lov Global to'lov
Amerika Qo'shma Shtatlari portali  Sog'liqni saqlash portali

Turli xil narsalar mavjud edi Obama ma'muriyati davrida taklif qilingan sog'liqni saqlash sohasidagi islohotlar. Asosiy islohotlar xarajatlarni qoplash va qamrab olishga qaratilgan bo'lib, semirish, surunkali kasalliklarning oldini olish va davolash, mudofaa tibbiyoti yoki qiynoqlarni isloh qilish, yaxshi g'amxo'rlik o'rniga ko'proq g'amxo'rlik ko'rsatadigan imtiyozlar, ortiqcha to'lov tizimlari, soliq siyosati, me'yorlar, shifokorlar va hamshiralarning etishmasligi, aralashuvni o'z ichiga oladi. boshqalar bilan bir qatorda xospis, firibgarlik va tasvirlash texnologiyasidan foydalanish.

Tomonidan qabul qilinadigan ushbu islohot takliflaridan birinchisi Amerika Qo'shma Shtatlari Kongressi bo'ladi Bemorlarni himoya qilish va arzon narxlarda parvarish qilish to'g'risidagi qonun Senatda paydo bo'lgan va keyinchalik Vakillar Palatasi tomonidan 2010 yil 21 martda o'zgartirilgan shaklda qabul qilingan (219–212 ovoz bilan).^[1][2] Prezident Obama islohotlarni 2010 yil 23 martda imzoladi.^[3] Reuters va CNN islohotlar va ular kuchga kirgan yilni sarhisob qildi.^[4][5]

Umumiy nuqtai

2015 yilga kelib, OECD mamlakatlari uchun tug'ilish va umr bo'yi sog'liqni saqlash xarajatlarini aholi jon boshiga ko'rsatadigan jadval. AQSh xarajatlari ancha yuqori, ammo o'rtacha umr ko'rish darajasidan pastroq.^[6]

Qo'shma Shtatlarning sog'liqni saqlash tizimini takomillashtirish uchun turli xil aniq islohot turlari taklif qilingan. Bu tibbiy sug'urta kompaniyalarini boshqaradigan ishonchga qarshi qoidalarni o'zgartirish va sog'liqni saqlash tizimlarini parvarishlash tartibini o'zgartirish orqali sog'liqni saqlash texnologiyasidan foydalanishning ko'payishidan. Shuningdek, turli xil umumiy strategiyalar taklif qilingan.^[7]

The Tibbiyot instituti 2012 yil sentyabr oyida AQShda yiliga taxminan 750 milliard AQSh dollarini tashkil etgani haqida xabar bergan. sog'liqni saqlash xarajatlari oldini olish yoki isrof qilish. Bunga quyidagilar kiradi: keraksiz xizmatlar (har yili 210 milliard dollar); yordamni samarasiz etkazib berish (130 milliard dollar); ortiqcha ma'muriy xarajatlar (190 milliard dollar); oshirilgan narxlar (105 milliard dollar); oldini olishdagi muvaffaqiyatsizliklar (55 milliard dollar) va firibgarlik (75 milliard dollar).^[8]

2009 yil iyun oyida Prezident nutqi paytida Barak Obama islohotlar strategiyasini bayon qildi. U elektron yozuvlarni yuritish, qimmat sharoitlarning oldini olish, semirishni kamaytirish, shifokorlarni rag'batlantirishni yordamning sonidan sifatiga qayta yo'naltirish, paketli to'lovlar maxsus xizmatlarga emas, balki sharoitlarni davolash, eng samarali davolash usullarini yaxshiroq aniqlash va etkazish va mudofaa tibbiyotini kamaytirish uchun.^[9]

Prezident Obama o'zining rejasini 2009 yil sentyabr oyida Kongressning qo'shma majlisidagi nutqida aytib o'tdi. Uning rejasida quyidagilar qayd etilgan: defitsit neytrallik; sug'urta kompaniyalarini oldindan mavjud bo'lgan shartlar asosida kamsitishga yo'l qo'ymaslik; cho'ntak xarajatlarini qoplash; yaratish sug'urta birjasi jismoniy shaxslar va kichik biznes uchun; jismoniy shaxslar va kichik kompaniyalar uchun soliq imtiyozlari; firibgarlik, isrofgarchilik va suiiste'molni aniqlash bo'yicha mustaqil komissiyalar; va boshqa mavzular qatorida noto'g'ri ishlashni isloh qilish loyihalari.^[10][11]

2009 yil noyabrda, keyin-OMB Direktor Piter Orszag intervyu davomida Obama ma'muriyati strategiyasining jihatlarini tasvirlab berdi: "[yordam berish uchun [ Medicare va Medicaid ] uzoq muddatli istiqbolda xarajatlarning o'sishi, biz raqamli ma'lumotga ega bo'lgan yangi sog'liqni saqlash tizimiga muhtojmiz ... bu ma'lumot nima ishlayotganini va nimani aqlli emasligini baholash uchun ishlatiladi va biz miqdorni emas, sifatni to'laymiz "Shuningdek, u profilaktika va sog'lom turmushni rag'batlantiradi." Shuningdek, u to'lovlarni birlashtirish va hisobot beradigan g'amxo'rlik tashkilotlari, bu jamoaviy ish va bemorning natijalari uchun shifokorlarni mukofotlaydi.^[12]

Mayo klinikasi Prezident va bosh ijrochi direktor Denis Kortese islohotlarni amalga oshirishga qaratilgan umumiy strategiyani qo'llab-quvvatladi. Uning ta'kidlashicha, AQSh sog'liqni saqlash tizimini qayta tuzish imkoniga ega va islohotlar zarurligi to'g'risida keng kelishuv mavjud. U bunday strategiyaning to'rtta "ustuni" ni bayon qildi:^[13]

• U qiymatga e'tiborni qarating, u u taqdim etgan xizmat sifati narxiga nisbatan nisbati sifatida aniqladi;
• Rag'batlantirishlarni to'lash va qiymatiga moslashtirish;
• Barchasini yoping;
• Tibbiy xizmatni ko'rsatish tizimini takomillashtirish mexanizmlarini yaratish, bu qiymatni yaxshilashning asosiy vositasi hisoblanadi.

Yozish Nyu-Yorker, jarroh Atul Gavande bemorlarga tibbiy xizmat qanday ko'rsatilishini ko'rsatadigan etkazib berish tizimi va xizmatlar uchun to'lovlar qanday amalga oshirilishini ko'rsatadigan to'lov tizimi o'rtasida yanada ko'proq farqlanadi. Uning ta'kidlashicha, etkazib berish tizimini isloh qilish xarajatlarni nazorat ostiga olish uchun juda muhimdir, ammo to'lov tizimini isloh qilish (masalan, hukumat yoki xususiy sug'urtalovchilar to'lovlarni amalga oshiradimi) unchalik ahamiyatli emas, ammo ularning nomutanosib ulushini to'playdi. Gavandening ta'kidlashicha, etkazib berish tizimidagi keskin yaxshilanishlar va tejash "kamida o'n yil" davom etadi. U sog'liqni saqlashdan haddan tashqari ko'proq foydalanishga qaratilgan o'zgarishlarni tavsiya qildi; imtiyozlarni foyda emas, balki qiymatga yo'naltirish; ilg'or tajribalarni aniqlash uchun turli xil tibbiy xizmat ko'rsatuvchilar bo'yicha davolanish narxlarining qiyosiy tahlili. Uning ta'kidlashicha, bu takrorlanuvchi, empirik jarayon bo'lib, takomillashtirish imkoniyatlarini tahlil qilish va etkazish uchun "sog'liqni saqlashni etkazib berish milliy instituti" tomonidan boshqarilishi kerak.^[14]

Tomonidan chop etilgan hisobot Hamdo'stlik jamg'armasi 2007 yil dekabr oyida 15 ta federal siyosat variantlarini o'rganib chiqib, ular birgalikda kelgusi 10 yil ichida sog'liqni saqlashga sarflanadigan xarajatlarni 1,5 trillion dollarga kamaytirish imkoniyatiga ega degan xulosaga kelishdi. Ushbu variantlar tibbiy qarorlarni qabul qilishni yaxshilash uchun tibbiy axborot texnologiyalari, tadqiqotlarni va rag'batlantirishni ko'payishi, tamaki iste'mol qilish va semirishni kamaytirish, samaradorlikni rag'batlantirish uchun provayderlar to'lovlarini isloh qilish, tibbiy sug'urta mukofotlari uchun soliq federal imtiyozlarini cheklash va bozorning bir qator o'zgarishini isloh qilishni o'z ichiga olgan. Medicare Advantage rejalari uchun etalon stavkalarni qayta tiklash va Sog'liqni saqlash va aholiga xizmat ko'rsatish departamentiga dori narxlari bo'yicha muzokaralar olib borish imkoniyatini berish. Mualliflar o'zlarining modellashtirishlarini ushbu o'zgarishlarni universal qamrovni amalga oshirish bilan birlashtirish ta'siriga asoslangan. Mualliflar sog'liqni saqlash xarajatlarini nazorat qilish uchun sehrli o'qlar yo'qligi va mazmunli taraqqiyotga erishish uchun ko'p qirrali yondashuv zarur degan xulosaga kelishdi.^[15]

2010 yil fevral oyida Prezident Obama islohotlar bo'yicha takliflarini yangilab, shu vaqtgacha qabul qilingan qonun loyihalariga o'zgartirishlar kiritdi.^[16]

Xarajatlarni ko'rib chiqish

AQSh sog'liqni saqlash xarajatlari to'g'risidagi ma'lumotlar, jumladan, o'zgarish darajasi, jon boshiga va YaIMning foizlari.

1999-2014 yillarda ish beruvchilar tomonidan oilani qoplash uchun tibbiy sug'urta mukofotlari. 2014 yildagi 3 foiz o'sish 16 yillik davrda eng past ko'rsatkichga ega bo'ldi.

2010 yilda Qo'shma Shtatlarda sog'liqni saqlash xarajatlari YaIMning 17,6 foizini tashkil etdi, bu 2009 yildagiga nisbatan bir oz pasaygan (17,7 foiz) va OECDdagi eng yuqori ulushga ega va OECD o'rtacha 9,5 foizdan sakkiz foizga yuqori. Qo'shma Shtatlardan keyin Gollandiya (YaIMning 12,0%) va Frantsiya va Germaniya (ikkalasi ham YaIMga nisbatan 11,6%). Qo'shma Shtatlar 2010 yilda aholi jon boshiga sog'liq uchun 8233 dollar sarfladi, bu Iqtisodiy taraqqiyot va rivojlanish tashkilotining o'rtacha 3268 AQSh dollaridan (sotib olish qobiliyati pariteti uchun tuzatilgan) ikki yarim baravar ko'p. Qo'shma Shtatlardan keyin Norvegiya va Shveytsariya bo'lib, ular jon boshiga 5250 dollardan ko'proq mablag 'sarfladilar. Fransiyaliklar, Shvetsiya va Buyuk Britaniya kabi amerikaliklar nisbatan boy Evropa mamlakatlaridan ikki baravar ko'proq mablag 'sarfladilar.^[17][18]

Narxlarning yillik o'sish sur'ati 2010 va 2011 yillar davomida sekinlashdi. Sabablari tortishuvlarga bog'liq bo'lib, vrachlarga tashrif buyurish kechikishidan tortib sug'urta mukofotlari moderatsiyasining uzoq muddatli tendentsiyalari va inshootlar va jihozlarga sarflanadigan xarajatlarni qisqartirishgacha.^[19]

Medicare va Medicaid xizmatlari markazlari 2013 yilda sog'liqni saqlash uchun yillik xarajatlarning o'sish sur'ati 2002 yildan beri pasayganligi haqida xabar berishdi. Ammo aholi jon boshiga xarajatlar o'sishda davom etmoqda. Aholi jon boshiga xarajatlarning o'sishi 2000 yildan beri har yili o'rtacha 5,4% ni tashkil etdi. Yalpi ichki mahsulotga nisbatan xarajatlar 2000 yildagi 13,8% dan 2009 yilga kelib 17,9% gacha ko'tarildi, ammo 2010 va 2011 yillarda shu darajada saqlanib qoldi.^[20]

Bir necha tadqiqotlar yillik o'sish sur'ati pasayishini tushuntirishga harakat qildi. Sabablarga boshqalar qatori kiradi:

• Iste'molchilarning sog'liqni saqlash xizmatlarini sotib olish imkoniyatlarini cheklab qo'ygan 2008-2012 yillardagi tanazzul tufayli yuqori ishsizlik darajasi;
• Cho'ntagidan to'lovlarni oshirish;
• Chegirmalar (shaxs sug'urta da'volarini qoplay boshlagunga qadar to'laydigan miqdor) keskin oshdi. Ishchilar sog'liqni saqlash xarajatlarining katta qismini to'lashlari kerak va odatda ularni kamroq sarflashga majbur qilishadi; va
• Ish beruvchining homiyligidagi tibbiy sug'urtaga ega bo'lgan ishchilarning ulushi, chegirma talab qilinadigan rejaga kiritilgan, bu 2006 yilga nisbatan taxminan yarim yilga nisbatan 2012 yilda to'rtdan uch qismga ko'tarildi.^[21][22]

Sog'liqni saqlash xarajatlarining ko'payishi ish haqining turg'unlashishiga ham yordam beradi, chunki korporatsiyalar ish haqini emas, balki nafaqalarni to'laydilar. Bloomberg 2013 yil yanvarida shunday deb yozgan edi: "Agar sog'liqni saqlash iqtisodchilari o'rtasida biron bir narsa to'g'risida kelishuv mavjud bo'lsa, demak, ish beruvchining sog'lig'i uchun to'lovlar ish haqidan kelib chiqadi. Agar tibbiy sug'urta arzonroq bo'lsa yoki bozor shunday tuzilgan bo'lsa, aksariyat odamlar sog'liqni saqlashni o'zlari uchun sotib olishlari kerak edi buni o'z ishi bilan olishdan ko'ra, odamlarga ko'proq maosh va ish haqining ko'tarilishi yuqori bo'lar edi. "^[23]

Eng yaxshi amaliyotlar

Mustaqil maslahat panellari

Prezident Obama Medicare-ni qoplash siyosati va boshqa islohotlar bo'yicha tavsiyalar berish uchun "Mustaqil Medicare Maslahatch Panel" (IMAC) ni taklif qildi. Qiyosiy samaradorlikni tadqiq qilish IMAC tomonidan qo'llaniladigan ko'plab vositalardan biri bo'ladi. IMAC kontseptsiyasi OMB direktori Piter Orszag tomonidan xulosa qilingan sog'liqni saqlash siyosatining bir necha taniqli mutaxassislarining maktubida tasdiqlangan:^[24]

IMAC taklifini qo'llab-quvvatlashi sog'liqni saqlash bo'yicha eng jiddiy tahlilchilar bir muncha vaqtdan beri nimani tan olishganini ta'kidlaydilar: sog'liqni saqlash tizimiga songa emas, sifatga urg'u berish doimiy tirishqoqlikni talab qiladi va qonunchilikning asosiy maqsadi tuzilmalarni o'rnatish (masalan, masalan) vaqt o'tishi bilan bunday o'zgarishni osonlashtiradigan IMAC). Va nihoyat, sog'liqni saqlash bozori rivojlanib borishi bilan sog'liqni saqlash xarajatlarini uzoq muddat ichida ushlab turishga yordam beradigan tuzilmasdan, soliq siyosatida biz qiladigan boshqa hech narsa katta ahamiyatga ega emas, chunki oxir-oqibat sog'liqni saqlash xarajatlarining ko'tarilishi federal byudjetni zabt etadi.

Mayo Clinic-ning bosh direktori doktor Denis Kortese va jarroh / muallif Atul Gavandening ta'kidlashicha, ushbu panel (lar) etkazib berish tizimini isloh qilish va qiymatni yaxshilash uchun juda muhimdir. Washington Post sharhlovchisi Devid Ignatius Prezident Obamaga Kortese singari odamni islohotlarni amalga oshirishda faolroq rol o'ynashi uchun jalb qilishni tavsiya qildi.^[25]

Qiyosiy samaradorlikni tadqiq qilish

Tibbiy yordamning bir kishiga sarflanadigan xarajatlari 2006 yilda shtatlar bo'yicha sezilarli darajada farq qilgan

Haddan tashqari foydalanish Bemor shifokorni haddan tashqari ishlatganda yoki muayyan holatni samarali hal qilish uchun talab qilinadiganidan ko'proq testlar yoki xizmatlarni buyuradigan shifokorga murojaat qiladi. Muayyan tibbiy holat uchun bir nechta davolanish alternativalari mavjud bo'lishi mumkin, ammo xarajatlar sezilarli darajada farq qiladi, ammo natijada statistik farq yo'q. Bunday stsenariylar parvarishlash sifatini saqlab qolish yoki yaxshilash hamda xarajatlarni sezilarli darajada kamaytirish imkoniyatini taqqoslash samaradorligini tadqiq qilish orqali taqdim etadi. Iqtisodchining fikriga ko'ra Piter A. Diamond va tomonidan keltirilgan tadqiqotlar Kongressning byudjet idorasi (CBO), AQShda bir kishiga to'g'ri keladigan sog'liqni saqlash xarajatlari geografiya va tibbiy markazga qarab sezilarli darajada farq qiladi, natijada statistik farq juda kam yoki umuman yo'q.^[26] Qiyosiy samaradorlikni tadqiq qilish shuni ko'rsatdiki, xarajatlarni sezilarli darajada kamaytirish mumkin. Avvalgi OMB Direktor Piter Orszag "Medicare xarajatlarining qariyb o'ttiz foizini sog'liqni saqlash natijalariga salbiy ta'sir ko'rsatmasdan tejash mumkin edi, agar yuqori va o'rtacha narxlardagi xarajatlarni arzon joylar darajasiga tushirish mumkin bo'lsa".^[14]

Uchuvchi dasturlar

Gawande, Obamacare-da uzoq muddatli istiqbolda narx va sifatga sezilarli ta'sir ko'rsatishi mumkin bo'lgan turli xil sinov dasturlarini o'z ichiga olgan, ammo ular CBO xarajatlar smetasida hisobga olinmagan bo'lsa-da, deb yozgan. Uning so'zlariga ko'ra, ushbu uchuvchi dasturlar sog'liqni saqlash sohasidagi mutaxassislarning har qanday g'oyasini o'z ichiga oladi, noto'g'ri ishlash / qiynoq islohotidan tashqari. U AQSh qishloq xo'jaligi bilan bog'liq xarajatlar muammosiga qanday duch kelganligini, 1900 yilda uy xo'jaliklarining bir martalik daromadining 40 foizini oziq-ovqat xarajatlari o'zlashtirganligini aytib o'tdi. Markaziy nazorat paneli (USDA) va ko'plab tajriba dasturlari yordamida AQSh hosildorlikni sezilarli darajada yaxshilay oldi. uning oziq-ovqat mahsulotlarini ishlab chiqarish va vaqt o'tishi bilan ushbu xarajatlarni kamaytirish. U yozgan:

Hozirda Medicare va Medicaid klinisyenlarga natijalaridan qat'i nazar bir xil miqdorda haq to'laydi. Ammo yuqori sifatli tibbiy yordamni kam xarajat bilan ko'rsatadigan shifokorlar uchun to'lovlarni ko'paytirish bo'yicha tajriba dasturi mavjud, ammo past sifatli tibbiy xizmatni yuqori narxlarda etkazib beradiganlar uchun to'lovlarni kamaytirish. Yurak etishmovchiligi, pnevmoniya va jarrohlikdan so'ng bemorlarning natijalarini yaxshilaydigan shifoxonalarga bonuslarni to'laydigan dastur mavjud. Sog'liqni saqlash xodimlari yuqtirgan yuqumli kasalliklar darajasi yuqori bo'lgan muassasalarga moliyaviy jazo tayinlaydigan dastur mavjud. Boshqasi esa uy sharoitida sog'liqni saqlash va reabilitatsiya yordami sifatidagi jazo va mukofotlar tizimini sinovdan o'tkazadi. Boshqa tajribalar tibbiyotni pullik xizmatdan butunlay voz kechishga harakat qilmoqda. To'plamga to'lanadigan to'lov tibbiy guruhlarga, masalan, operatsiya bilan bog'liq bo'lgan barcha ambulatoriya va statsionar xizmatlari uchun atigi o'ttiz kunlik to'lovni to'laydi. Bu klinisyenlarga parvarish qilish va asoratlarni kamaytirish uchun birgalikda ishlashga turtki beradi. Bitta uchuvchi bundan ham uzoqroq yurib, klinisyenlarni o'zlarining barcha bemorlarining ehtiyojlari uchun, shu jumladan profilaktika uchun javobgarlikni o'z zimmalariga oladigan "Hisobga olinadigan parvarishlash tashkilotlari" tarkibiga qo'shilishga da'vat etar edi, shunda birinchi navbatda bemorlar soni kamroq bo'ladi. Ushbu guruhlarga ular ishlab chiqaradigan jamg'armalarning bir qismini saqlashga ruxsat beriladi, agar ular sifat va xizmat ko'rsatish chegaralariga to'g'ri kelsa. Qonun loyihasida tizimning boshqa qismlarida ham o'zgarishlarga oid g'oyalar mavjud. Ba'zi qoidalar ma'muriy islohotlar orqali samaradorlikni oshirishga harakat qiladi, masalan, sug'urta kompaniyalaridan klinisyenlarning xizmat yukini engillashtirish uchun sug'urta qoplamasini qoplash uchun yagona standartlashtirilgan shaklini yaratishni talab qiladi. Har xil turdagi sog'lomlashtirish dasturlarining sinovlari mavjud. Qonunchilik, shuningdek, qiyosiy samaradorlik tadqiqotlarini moliyalashtiradigan rag'batlantiruvchi dastur dasturini davom ettiradi - mavjud muolajalarni bir-biriga qarshi holatini sinab ko'rish, chunki davolanishning kamligi past xarajatlarni anglatishi kerak.^[27]

Profilaktik strategiyalar

Profilaktik yordamni ko'paytirish (masalan, shifokorlarning doimiy tashrifi) sog'liqni saqlash xarajatlarini kamaytirishning usullaridan biridir. Ning rasmiy byudjet ballari universal sog'liqni saqlash takliflarida aytilishicha, uning tejashning katta qismi sug'urtalanmaganlarga profilaktika yordamini ko'rsatishdan iborat bo'ladi.^[28] Umumjahon sog'liqni saqlashni, shu jumladan profilaktika yordamini ko'rsatadigan kanadalik shifokorlar, tegishli profilaktika choralarini oshirish va kamaytirish orqali umumiy sog'liqni saqlash xarajatlarini 40 foizga kamaytirishi mumkinligini aniqladilar.^[29] Sug'urtasiz saraton kasalligida tashxis qo'yilgan to'rtinchi bosqich bir necha oy ichida kasalxonadagi to'lovlar yarim million dollardan oshishi mumkin, bu boshqa barcha sog'liqni saqlash iste'molchilari tomonidan qoplanishi kerak. profilaktik skrining ancha arzonga tushadi.^[30] Biroq, profilaktika yordami odatda hech qachon kasal bo'lib qolmaydigan ko'plab odamlarga ko'rsatiladi va kasal bo'lib qolganlar uchun bu qo'shimcha hayot davomida sog'liqni saqlash xarajatlari bilan qisman qoplanadi.^[31]

Semirib ketish va ortiqcha vazn holatlarining oldini olish xarajatlarni kamaytirish uchun katta imkoniyat yaratadi. The Kasalliklarni nazorat qilish markazlari 1998 yilda sog'liqni saqlash xarajatlarining taxminan 9% ortiqcha vazn va semirishga yoki 2002 dollardagi 92,6 mlrd. Ushbu xarajatlarning deyarli yarmi hukumat tomonidan Medicare yoki Medicaid orqali to'langan.^[32] Ammo, 2008 yilga kelib, CDC ushbu xarajatlar qariyb ikki baravarga oshib, 147 milliard dollarni tashkil etdi.^[33] CDC semirish tufayli yuzaga kelishi mumkin bo'lgan bir qator qimmat sharoitlarni aniqladi.^[34] CDC semirish va ortiqcha vaznning oldini olish bo'yicha bir qator strategiyalarni e'lon qildi, shu jumladan: sog'lom oziq-ovqat va ichimliklar mavjud bo'lishini ta'minlash; sog'lom oziq-ovqat tanlovini qo'llab-quvvatlash; bolalarni faolroq bo'lishga undash; va jismoniy faoliyatni qo'llab-quvvatlash uchun xavfsiz jamoalarni yaratish.^[35][36] 2007 yilda AQSh kattalarining taxminiy 25,6% semirib ketgan bo'lsa, 2005 yildagi 23,9% ga teng. Shtatlarning semirish darajasi 18,7% dan 30% gacha bo'lgan. Semirib ketish darajasi erkaklar va ayollar o'rtasida teng edi.^[37] Ba'zilar "yog 'solig'i "semirib ketishiga hissa qo'shadi deb hisoblangan mahsulotlarga (alkogolsiz ichimliklar kabi) soliq solinib, sog'lom turmush tarzi uchun imtiyozlar berish"^[38] yoki jismoniy shaxslarga, xuddi Yaponiyada bo'lgani kabi, tana o'lchovlari asosida.^[39] 2010 yil oktyabr oyida chop etilgan bir tadqiqot shunga o'xshash xarajatlarni taxmin qildi, ya'ni 168 milliard AQSh dollarini, AQSh tibbiy xarajatlarining deyarli 17 foizini tashkil etdi. Bu semirib ketgan odamga taxminan 2400 dollarni tashkil etadi. Tadqiqotni Kornell va Emori universitetlari tadqiqotchilari olib borishdi.^[40]

Biroq, yillik xarajatlardan farqli o'laroq, umr bo'yi xarajatlar uzoq umr ko'radigan sog'lom odamlar orasida eng yuqori bo'lishi mumkin. Niderlandiyada o'tkazilgan bir tadqiqot shuni ko'rsatadiki: "56 yoshga qadar sog'liq uchun yillik xarajatlar semiz odamlar uchun eng yuqori va sog'lom turmush tarzi uchun eng past bo'lgan. Keksayganlarida eng yuqori yillik xarajatlar chekish guruhi tomonidan qilingan. Ammo, chunki umr ko'rish davomiyligidagi farqlar (20 yoshdagi umr ko'rish semiz guruh uchun 5 yilga kam, chekish guruhi uchun 8 yoshga nisbatan kam bo'lgan), sog'lom turmush tarzi bilan solishtirganda, umr bo'yi sog'liq uchun sarflangan xarajatlar, chekuvchilar uchun eng past, semiz odamlar uchun esa oraliqdir. "^[41]

Keraksiz testlarni yo'q qiling

2012 yil aprel oyi davomida to'qqizta shifokorlar guruhlari odatda qo'llaniladigan, ammo bemorlarga tasdiqlangan foyda keltirmaydigan yoki aslida zararli bo'lishi mumkin bo'lgan 45 ta testni aniqladilar. Bu 2010 yilgi maqolasida ushbu tavsiyanomani nashr etgan doktor Xovard Brodining taklifi bilan amalga oshirildi. To'qqiz guruh (tibbiyot jamiyatlari) ekspertlar qo'mitalari tomonidan tibbiy adabiyotlarni bir necha oylik tahlillari va sharhlaridan so'ng ro'yxatlarni ishlab chiqdilar. The Nyu-York Tayms tahririyat shunday deb yozgan edi: "Ehtiyojsiz g'amxo'rlikni yo'q qilish me'yor emas. Bu sog'lom tibbiyot va sog'lom iqtisoddir".^[42]

2012 yil iyul oyining bir taklifida sog'liqni saqlash iste'molchilari har doim "o'yin terisiga" ega bo'lishlari kerak edi, shuning uchun ko'proq xizmatlar ko'rsatilishi bilan ularning narxi ko'tariladi.^[43]

Surunkali qimmat holatlarga murojaat qiling

CBO 2005 yil may oyida xabar bergan edi: "Tibbiyot xarajatlari juda konsentratsiyalangan, unchalik katta bo'lmagan miqdordagi benefitsiarlar Medicare dasturining yillik xarajatlarining katta qismini tashkil qiladi. 2001 yilda Medicare-ning pullik xizmatiga ro'yxatdan o'tgan eng qimmat 5 foiz nafaqaxo'rlar (2001 yilda) FFS) sektori umumiy xarajatlarning 43 foizini, eng qimmat 25 foizi ... xarajatlarning to'liq 85 foizini tashkil etdi ... Ushbu yuqori narxlardagi foyda oluvchilar, sarf-xarajatlari jihatidan eng past 75 foizdagi benefitsiarlarga nisbatan biroz kattaroq, surunkali kasalliklardan, masalan, koronar arteriya kasalligi va diabetdan aziyat chekishi va ma'lum bir yilda o'lishi ehtimoli ko'proq. " ^[44] Bunday konsentratsiya asosiy kasalliklarga va davolanish usullariga e'tibor qaratish imkoniyatini beradi. Piter Orszag 2011 yil may oyida yozgan edi: "Haqiqat shundaki, sog'liqni saqlashni kelgusi xarajatlarini cheklash turli xil yondashuvlarni talab qiladi, ammo xususan, bu provayderlar o'zlarining bemorlari va eng yaxshi amaliyotlari to'g'risida ma'lumotni yaxshilash va provayderlarga beriladigan imtiyozlarni anglatadi. ayniqsa, qimmat holatlarda yaxshiroq parvarish qilish. "^[45]

Bozorga asoslangan echimlar

Medicare-ni vaucher tizimi bilan xususiylashtiring

Rep. Pol Rayan (R) taklif qildi Amerika kelajagi uchun yo'l xaritasi, bu bir qator byudjet islohotlari. Uning rejasining 2010 yil yanvaridagi versiyasi Medicare-ni vaucher tizimiga o'tishni o'z ichiga oladi, ya'ni jismoniy shaxslar xususiy bozorda tibbiy sug'urtani sotib olish uchun ishlatilishi mumkin bo'lgan vaucherni oladi. Bu pensiyaga yaqin yoki hozirda Medicare-da o'qiyotganlarga ta'sir qilmaydi.^[46] Reja ta'sirini sarhisob qiladigan bir qator grafikalar va jadvallar kiritilgan.^[47] Iqtisodchilar rejaning alohida xususiyatlarini maqtadilar va tanqid qildilar.^[48][49] Markaziy bank ham hisobni qisman yig'di.^[50]

Medicaid oluvchilarga o'zlarining shaxsiy sug'urtalarini sotib olish uchun soliq imtiyozlari yoki subsidiyalar ham berilishi mumkin, bu esa dasturda qolishlari uchun imtiyozlarni kamaytiradi.^[43]

Sug'urta kompaniyasining monopoliyaga qarshi islohotlari

Ba'zi konservatorlar sug'urta va litsenziyalash bo'yicha davlat monopoliyalarini tarqatib yuborish va iste'molchilarga boshqa davlatlar tomonidan litsenziyalangan tibbiy sug'urtani sotib olishga ruxsat berish kabi erkin bozor islohotlarini qo'llab-quvvatlamoqda.^[51][52]

The GAO 2002 yilda (2000 ta ma'lumotdan foydalangan holda) davlat bozorlaridagi sug'urta raqobatiga oid quyidagi statistik ma'lumotlarni e'lon qildi: "The o'rtacha har bir shtat uchun kichik guruhlar bozorida litsenziyali tashuvchilar soni 28 tani tashkil etdi, ularning soni Gavayida 4 tadan Indiana shtatida 77 taga etdi. Eng yirik aviakompaniyaning o'rtacha bozor ulushi taxminan 33 foizni tashkil etdi, Texasdagi 14 foizdan Shimoliy Dakotada 89 foizgacha. Beshta eng yirik tashuvchilar birlashganda, ma'lumot etkazib beradigan 34 ta davlatning 19tasida bozorning to'rtdan uchi va undan ko'prog'ini tashkil etgan va ular ushbu shtatlarning 7tasida 90 foizdan ko'prog'ini namoyish etgan. Ma'lumot etkazib beradigan 37 shtatdan 25 nafari Blue Cross and Blue Shield (BCBS) tashuvchisini kichik guruh bozorida tibbiy sug'urtani taklif qiluvchi eng yirik tashuvchi deb topdi va qolgan 12 ta shtatdan bittasidan tashqari, BCBS tashuvchisi beshta mamlakat qatoriga kirdi. eng katta. Axborot etkazib beradigan 34 shtatdagi barcha BCBS tashuvchilarining o'rtacha bozor ulushi taxminan 34 foizni tashkil etdi, Vermontda taxminan 3 foizdan Shimoliy Dakotada 89 foizgacha; ushbu davlatlarning 9tasida BCBS tashuvchilar bozorning yarmi yoki undan ko'prog'ini birlashtirgan. "^[53]

The GAO 2008 yilda (2007 yildagi ma'lumotlardan foydalangan holda) quyidagi statistik ma'lumotlar keltirilgan: "Har bir shtat uchun kichik guruhlar bozorida litsenziyaga ega bo'lgan tashuvchilarning o'rtacha soni 27 tani tashkil etdi. Kichik guruhlar bozoridagi eng yirik transport vositalarining o'rtacha bozor ulushi 47 foizni tashkil etdi, Arizonadagi Alabama shtatidagi taxminan 21 foizdan 96 foizgacha bo'lgan oraliqda. Bozor ulushini etkazib beruvchi 39 shtatdan 31tasida eng yuqori kompaniyaning bozordagi ulushi uchdan bir qismiga yoki undan ko'piga ega edi. Kichik guruhlar bozoridagi beshta eng yirik tashuvchilar, birlashganda, ushbu ma'lumotni etkazib beradigan 39 shtatdan 34tasida bozorning to'rtdan uch qismi yoki undan ko'prog'ini namoyish etgan va ular ushbu shtatlarning 23tasida 90 foizini yoki undan ko'pini namoyish qilgan. Eng yuqori tashuvchida ma'lumot etkazib beradigan 44 davlatning 36tasining oltitasi Moviy Xochni aniqlagan va Blue Shield (BCBS) tashuvchisi eng yirik tashuvchi sifatida, qolgan 8 ta shtatdan 1 tasidan boshqasida, BCBS tashuvchisi beshta eng yirik tashuvchilar qatoriga kirgan.T etkazib beradigan 38 ta shtatdagi barcha BCBS tashuvchilarining o'rtacha bozor ulushi. uning ma'lumotlari taxminan 51 foizni tashkil etdi, Vermont va Viskonsin shtatlarida 5 foizdan kam, Alabama va Shimoliy Dakotada 90 foizdan ko'proq ... 38 ta shtatdagi barcha BCBS aviatashuvchilarining o'rtacha bozor ulushi 2008 yilda ushbu ma'lumotni taqdim etgan 51 foizni tashkil etdi, bu 2005 yilda e'lon qilingan 44 foizga va 2002 yilda 34 foizga teng bo'lgan, bu yillarning har birida ma'lumot etkazib beradigan 34 ta davlat. "^[54]

Iqtisodchi Pol Krugman davlatlararo raqobatga yo'l qo'yib, "pastga qarab poyga" hosil bo'lishini ta'kidladi, unda u eng zaif qoidalarni - masalan, sug'urta kompaniyalariga oiladagi zo'ravonlik qurbonlarini qamrab olishdan bosh tortishga imkon beradiganlarni - ta'kidlaydi. Umuman olganda millat. Natijada, azob chekayotganlarni qiynash, avvalgi sharoitlari bo'lgan amerikaliklarning hayotini yanada qiyinlashtirish edi. "^[55]

Shifokorlarni rag'batlantirish tizimini isloh qilish

Tanqidchilarning ta'kidlashicha, sog'liqni saqlash tizimida qimmatbaho xatti-harakatlarni keltirib chiqaradigan bir nechta imtiyozlar mavjud. Ulardan ikkitasiga quyidagilar kiradi:^[56]

1. Shifokorlar, odatda, maosh bilan emas, balki ko'rsatilgan xizmatlar uchun haq olishadi. Bu taqdim etilayotgan davolanish xarajatlarini oshirishga moddiy rag'bat beradi.
2. To'liq sug'urtalangan bemorlar alternativa vositalarini tanlashda xarajatlarni minimallashtirish uchun moddiy rag'batga ega emaslar. Umumiy ta'sir - bu hamma uchun sug'urta mukofotlarini oshirishdir.

Gavandning ta'kidlashicha: "Bizning pullik tizimimiz, har bir narsa va bemorni parvarish qilishda ishtirok etadigan har bir kishi uchun alohida to'lovlarni bekor qilish, barcha noto'g'ri rag'batlantiruvchi omillarga ega: bu ko'proq ish qilishdan ko'proq foyda keltiradi, bu hujjatlar va harakatlarning takrorlanishini ko'paytiradi va bu klinisyenlarni eng yaxshi natijalarga erishish uchun birgalikda ishlashga to'sqinlik qiladi. "^[57]

Gawande bir jarrohning so'zlarini keltiradi: "Shifokorlar shifokor bo'lishni to'xtatib, ishbilarmon bo'lib qolishganda biz noto'g'ri yo'l tutdik". Gawande sog'liqni saqlashning haddan tashqari sarflanishiga olib kelishi mumkin bo'lgan shifokorlar tomonidan yuqori xarajatlarga ega bo'lgan sohalarda daromadlarni ko'paytirishga qaratilgan turli xil yondashuvlar va foyda keltiradigan imtiyozlarni aniqladilar. U buni maoshli shifokorlar va qiymatni mukofotlash uchun boshqa usullardan foydalanadigan arzonroq joylar bilan taqqosladi va buni "Amerika tibbiyotining ruhi uchun kurash" deb atadi.^[14]

Variantlardan biri, har bir alohida xizmat uchun to'lovni emas, balki tarmoqdagi ishtiroki uchun bemorlardan premium yoki doimiy to'lovni oladigan sog'liqni saqlash xizmatlarining birlashtirilgan qatorini o'z ichiga oladi. Bu shifokorni ko'proq xizmatlarni buyurtma qilishdan muammoni samarali hal etishga qadar rag'batlantiruvchi omilni o'zgartiradi (ya'ni ko'proq g'amxo'rlik iqtisodiy jihatdan tejamli davolanishga qadar). Provayderlar tarmog'i, shuningdek, halokatli (o'ta qimmat) holatlar uchun sug'urta sotib oladi.^[58]

Tibbiy xatolar uchun javobgarlik xarajatlari va huquqbuzarliklarni isloh qilish

Ushbu bo'lim balki juda uzoq qulay o'qish va navigatsiya qilish. Iltimos, ko'rib chiqing bo'linish tarkibni kichik maqolalarga, kondensatsiya uni qo'shish yoki qo'shish pastki sarlavhalar. (2009 yil noyabr)

Tanqidchilar buni ta'kidladilar tibbiy noto'g'ri ishlash xarajatlar (masalan, sug'urta va sud ishlari) juda muhim va ular orqali hal qilinishi kerak sud islohoti.^[59]

Ushbu xarajatlar qancha ekanligi munozarali masaladir. Biroz^{[JSSV? ]} buni ta'kidladilar noto'g'ri ishlash sud ishlari tibbiy xarajatlarning asosiy omilidir.^[60] 2005 yildagi tadqiqot natijalariga ko'ra xarajatlar taxminan 0,2 foizni tashkil etgan va 2009 yilda sug'urta qildiruvchi WellPoint Inc. "majburiyatlar sug'urta mukofotlari emas edi".^[61] 2006 yilda o'tkazilgan tadqiqot natijalariga ko'ra Qo'shma Shtatlardagi nevrologlar nazariy klinik vaziyatlarda nemis hamkasblariga qaraganda ko'proq testlarni o'tkazishni buyurdilar; AQSh klinisyenlari sud jarayonlaridan qo'rqish ehtimoli ko'proq, bu mudofaa strategiyasini o'rgatish bilan bog'liq bo'lib, ular AQSh o'quv dasturlarida tez-tez uchraydi.^[62] To'g'ridan-to'g'ri va bilvosita xarajatlarni hisobga olgan holda, boshqa tadqiqotlar shuni ko'rsatadiki, noto'g'ri ishlashning umumiy qiymati "umumiy tibbiy xarajatlarning 5% dan 10% gacha".^[61]

Tomonidan 2004 yilgi hisobot Kongressning byudjet idorasi tibbiy noto'g'ri ishlash xarajatlarini AQSh sog'liqni saqlash xarajatlarining 2 foiziga tenglashtirishi va "hatto sezilarli darajada kamaytirilishi" sog'liqni saqlash xarajatlarining o'sishini kamaytirish uchun juda kam yordam beradi.^[61] 2009 yilgi CBO hisobotida tibbiy xatolar bo'yicha sud ishlarini cheklash orqali o'n yil davomida taxminan 54 milliard dollar tejash mumkinligi taxmin qilingan. Jazoni etkazish uchun 500 ming dollar va "azob va azob" uchun etkazilgan zarar uchun 250 ming dollar miqdoridagi hakamlar hay'ati mukofotlari miqdorini o'z ichiga olgan tortishish islohotlari to'plami javobgarlik sug'urta badallarini taxminan 10 foizga kamaytiradi.^[63]

2009 yil avgustda shifokor va sobiq Demokratik Milliy Qo'mita raisi Xovard Din Kongressning sog'liqni saqlash tizimini isloh qilish to'g'risidagi qonun loyihalarida tortishish islohoti nima uchun olib tashlanganligini tushuntirib berdi: "Agar siz haqiqatan ham ulkan qonun loyihasini qabul qilmoqchi bo'lsangiz, unda qancha ko'p narsalar qo'shsangiz, shunchalik ko'p dushmanlar qilasiz, to'g'rimi? ... Va sud islohotining qonun loyihasida yo'qligi sababi, uni yozgan odamlar o'zlari qabul qilayotgan boshqa barcha shaxslardan tashqari sud advokatlarini ham jalb qilishni istamaganliklari. Bu aniq va sodda haqiqat. "^[64][65]

Boshqalar ta'kidlashlaricha, hatto muvaffaqiyatli amalga oshirilgan qiynoq islohoti ham umumiy javobgarlikni pasayishiga olib kelmaydi. Masalan, amaldagi shartli to'lovlar tizimi sud ishlarini katta ahamiyatga ega bo'lgan ishlarni chetlab o'tib, katta ahamiyatga ega kichik ishlarni e'tiborsiz qoldiradi; Sud ishlarini yutuqlar bilan yanada yaqinroq tartibga solish, shu bilan kichik mukofotlarning sonini ko'paytirishi va katta mukofotlarning kamayishini qoplashi mumkin.^[66] Nyu-Yorkdagi tadqiqotlar shuni ko'rsatdiki, shifoxonadagi beparvolikning atigi 1,5% da'volarni keltirib chiqardi; bundan tashqari, CBO "sog'liqni saqlash xodimlari o'zlarining noto'g'ri ishlash xavfining moliyaviy xarajatlariga duch kelmaydilar, chunki ular javobgarlikni sug'urtalashadi va ushbu sug'urta uchun to'lovlar individual provayderlarning yozuvlari yoki amaliyot uslublarini aks ettirmaydi, lekin umuman olganda joylashuvi va tibbiyot ixtisosi kabi omillar. "^[67] Umumiy majburiyat shifokorlarning noto'g'ri sug'urta mukofotlari to'laydigan miqdoriga nisbatan kichikligini hisobga olib, noto'g'ri sug'urtalashni isloh qilishning muqobil mexanizmlari taklif qilindi.^[68]

2004 yilda CBO tomonidan tavsiya etilgan noto'g'ri ishlash mukofotlari bo'yicha cheklovlar o'rganildi Jorj V.Bush Kongress ma'muriyati va a'zolari; CBO "bugungi kungacha mavjud bo'lgan dalillar, noto'g'ri ishlash uchun javobgarlikni cheklash iqtisodiy samaradorlikka ijobiy yoki salbiy ta'sir ko'rsatishi mumkinligi to'g'risida jiddiy dalillarni keltirib chiqarmaydi" degan xulosaga keldi.^[67] O'shandan beri o'tkazilgan empirik ma'lumotlar va hisobotlar shuni ko'rsatdiki, tibbiy xarajatlarning eng katta qismi hozirgi kunda qiynoq islohoti allaqachon noto'g'ri ish haqi va sud da'volarining pasayishiga olib kelgan shtatlarda; keraksiz va zararli protseduralar, aksincha, "ko'pincha bemorlarning ehtiyojlari bo'yicha daromadlarni ko'paytirishga yo'naltirilgan" tizim tufayli yuzaga keladi.^[69][70][71]

Taklif qilingan variantlardan biri sudyalar tizimidan ko'ra ixtisoslashgan sog'liqni saqlash sudlarini o'z ichiga oladi. Bunday sudlar boshqa fanlarda ham mavjud. Ma'muriy sog'liqni saqlash sudlarida ekspert sudya apellyatsiya sudiga shikoyat qilinishi mumkin bo'lgan xulosasini yozib, ilg'or tibbiyot amaliyotiga asoslanib ishlarni hal qiladi. Shuningdek, shifoxonalar tomonidan to'liq ma'lumot berilishi kerak va barcha faktlar sog'liqni saqlash tizimiga qaytarilishi kerak, shuning uchun provayderlar o'zlarining xatolaridan saboq olishadi. Bunday yondashuv sud advokatlari lobbistlari tomonidan qarshilik ko'rsatmoqda.^[72]

Shifokorlar va hamshiralar etishmovchiligini hal qilish

AQSh shifokorlar va hamshiralarning etishmovchiligiga duch kelmoqda, ular Amerika yoshi o'tgan sayin kuchayib borishi taxmin qilinmoqda, bu esa ushbu xizmatlarning narxini ko'tarishi mumkin. Yozish Vashington Post, kardiolog Artur Feldman AQShning "tanqidiy" shifokorlar etishmovchiligiga duch kelayotganini ko'rsatadigan turli xil tadqiqotlarni, shu jumladan 2010 yilga kelib 1300 nafar umumiy jarrohlarni keltirib o'tdi.^[73]

Amerika Oila Shifokorlari Akademiyasi 2020 yilga qadar 40 mingta boshlang'ich tibbiy yordam shifokorlari etishmasligini (shu jumladan oilaviy amaliyot, ichki kasalliklar, pediatriya va akusherlik / ginekologiya) bashorat qilmoqda. 1997 yildan beri tibbiy yordamni tanlagan talabalar soni 52 foizga kamaydi. , tibbiyot fakulteti bitiruvchilarining atigi 2 foizi kasbiy faoliyat sifatida birlamchi tibbiy yordamni tanlaydilar. Senat sog'liqni saqlash to'g'risidagi qonun loyihasiga kiritilgan o'zgartish, birlamchi tibbiyot va umumiy jarrohlik yo'naltirilgan 2 ming yangi yashash joylarini yaratish uchun 10 yil ichida 2 milliard dollar mablag 'o'z ichiga oladi. Writing in Forbes, a physician argued that this is a "tiny band-aid at best," advocating full loan repayments and guaranteed positions upon graduation.^[74]

Physicians wrote a NYT Op Ed in May 2011 stating that doctors typically graduate with an average of $155,000 in debt from Medical school, with over 80% owing debt of some type. This drives some doctors into higher paying specialties as opposed to primary care. As specialists, they prescribe more expensive treatments. About $2.5 billion/year would be required to make Medical school free, which the writers estimated at one-thousandth the total annual healthcare costs. Making medical school free would help address the shortage in their view.^[75]

The U.S. had 2.3 doctors per 1,000 people in 2002, ranking 52nd. Germany and France had approximately 3.4 and ranked in the top 25.^[76] The OECD average in 2008 was 3.1 doctors per 1,000 people, while the U.S. had 2.4.^[77]

The American Association of Colleges of Nurses cited studies estimating that a shortage of registered nurses would reach 230,000 by 2025 as America ages, with over 135,000 open positions during 2007. An additional 30% more nurses would have to graduate annually to keep up with demand. A study by Price Waterhouse advanced several strategies for addressing the nursing shortage, including developing more public-private partnerships, federal and state-level grants for nursing students and educators, creating healthy work environments, using technology as a training tool, and designing more flexible roles for advanced practice nurses given their increased use as primary care providers.^[78]

Newsweek wrote: "Lately, some policymakers have argued that instead of having a primary-care doctor, more people—especially young, healthy patients with simple medical needs—should see a nurse or physician assistant who administers routine care and kicks more complex problems up to a doctor when they arise. 'If you're just coming in to have your blood pressure checked and your pulse taken, you really don't need to see a doctor, and you might not need to see a nurse, either,' says David Barrett, president and CEO of the Lahey Clinic in Burlington, Mass. "There are three-stripe military sergeants with two-year degrees who can provide excellent primary care. There's absolutely no reason to force all primary-care providers to have an M.D."^[79]

Tax reform

Health insurance premiums paid on behalf of workers are increasingly offsetting compensation

The Kongressning byudjet idorasi has described how the tax treatment of insurance premiums may affect behavior:^[80]

One factor perpetuating inefficiencies in health care is a lack of clarity regarding the cost of health insurance and who bears that cost, especially employment-based health insurance. Employers’ payments for employment-based health insurance and nearly all payments by employees for that insurance are excluded from individual income and payroll taxes. Although both theory and evidence suggest that workers ultimately finance their employment-based insurance through lower take-home pay, the cost is not evident to many workers...If transparency increases and workers see how much their income is being reduced for employers’contributions and what those contributions are paying for, there might be a broader change in cost-consciousness that shifts demand.

Piter qo'shiqchisi da yozgan Nyu-York Tayms that the current exclusion of insurance premiums from compensation represents a $200 billion subsidy for the private insurance industry and that it would likely not exist without it.^[81] In November 2009, Iqtisodchi estimated that taxing employer-provided health insurance (which is presently exempt from tax) would add $215 billion per year to federal tax revenue.^[82]

Employer-provided health insurance receives uncapped tax benefits. According to the OECD, it "encourages the purchase of more generous insurance plans, notably plans with little cost sharing, thus exacerbating moral hazard".^[83] Consumers want unfettered access to medical services; they also prefer to pay through insurance or tax rather than out of pocket. These two needs create cost-efficiency challenges for health care.^[84] Some studies have found no consistent and systematic relationship between the type of financing of health care and cost containment.^[85]

Some have proposed an "excise tax" for high cost 'Kadillak ' insurance plans.^[86][87] Yilda nashr etilgan tadqiqot Sog'liqni saqlash in December 2009 found that high-cost health plans do not provide unusually rich benefits to enrollees. The researchers found that only 3.7% of the variation in the cost of family coverage in employer-sponsored health plans is attributable to differences in the actuarial value of benefits. Only 6.1% of the variation is attributable to the combination of benefit design and plan type (e.g., PPO, HMO, etc.). The employer's industry and regional variations in health care cost explain part of the variation, but most is unexplained. The researchers conclude ". . . that analysts should not equate high-cost plans with Cadillac plans, . . . [w]ithout appropriate adjustments, a simple cap may exacerbate rather than ameliorate current inequities"^[88]

Premium tax subsidies to help individuals purchase their own health insurance have also been suggested as a way to increase coverage rates. Research confirms that consumers in the individual health insurance market are sensitive to price. It appears that price sensitivity varies among population subgroups and is generally higher for younger individuals and lower income individuals. However, research also suggests that subsidies alone are unlikely to solve the uninsured problem in the U.S.^[89][90]

Government action

Address Medicare fraud

The Davlatning hisobdorligi idorasi lists Medicare as a "high-risk" government program due to its vulnerability to improper payments.^[91][92][93] Estimates of Medicare fraud or "improper payments" vary. The Boshqarish va byudjet idorasi reported that $54 billion in "improper payments" were made to Medicare ($24B), Medicaid ($18B) and Medicaid Advantage ($12B) during FY2009. This was 9.4% of the $573 billion spent in these categories.^[94] GAO reported in 2000: "The Department of Health and Human Services’ Office of Inspector General has reported that $13.5 billion of processed Medicare fee-for-service claim payments for fiscal year 1999 may have been improperly paid for reasons that ranged from inadvertent error to outright fraud and abuse."^[95] Fewer than 5% of Medicare claims are audited.^[96] CBO reported in October 2014 that it is difficult to quantify healthcare fraud related to government programs. CBO reported that: "According to HHS, since 2009 the HEAT Medicare taskforce has filed criminal and civil charges against more than 1,700 defendants who falsely billed the Medicare program for more than $5.5 billion." However, false billing is a partial measure of fraud, as much of it is undetected.^[97]

According to CBS News, Medicare fraud accounts for an estimated $60 billion in Medicare payments each year, and "has become one of, if not the most profitable, crimes in America."^[98] Criminals set up phony companies, then invoice Medicare for fraudulent services provided to valid Medicare patients who never receive the services. These costs appear on the Medicare statements provided to Medicare card holders. The program pays out over $430 billion per year via over 1 billion claims, making enforcement challenging.^[98] Its enforcement budget is "extremely limited" according to one Medicare official. AQSh Bosh prokurori Erik Xolder said in an interview: "Clearly more auditing needs to be done and it needs to be done in real time."^[98] The Obama administration is providing Medicare with an additional $200 million to fight fraud as part of its stimulus package, and billions of dollars to computerize medical records and upgrade networks, which should assist Medicare in identifying fraudulent claims.^[98]

During July 2010, President Obama signed into law the Improper Payments Elimination and Recovery Act of 2010, citing approximately $110 billion in unauthorized payments of all types, including Medicare and Medicaid. President Obama has directed his administration to reduce these payments by $50 million annually by 2012, less than 1%.^[99]

Coverage mandates

Reforming or restructuring the private health insurance market is often suggested as a means for achieving health care reform in the U.S. Insurance market reform has the potential to increase the number of Americans with insurance, but is unlikely to significantly reduce the rate of growth in health care spending.^[100] Careful consideration of basic insurance principles is important when considering insurance market reform, in order to avoid unanticipated consequences and ensure the long-term viability of the reformed system.^[101] According to one study conducted by the Urban Institute, if not implemented on a systematic basis with appropriate safeguards, market reform has the potential to cause more problems than it solves.^[100]

Since most Americans with private coverage receive it through employer-sponsored plans, many have suggested employer "pay or play" requirements as a way to increase coverage levels (i.e., employers that do not provide insurance would have to pay a tax instead). However, research suggests that current pay or play proposals are limited in their ability to increase coverage among the working poor. These proposals generally exclude small firms, do not distinguish between individuals who have access to other forms of coverage and those who do not, and increase the overall compensation costs to employers.^[102]

2009 yil oktyabr oyida Wall Street Journal reported that while requirements to purchase health insurance were central to proposals in both the House and Senate, these coverage mandates were "under fire from both ends of the political spectrum, with some liberals saying the penalties are too harsh for those who refuse and conservatives denouncing the whole concept."^[103] According to the article, however, "[h]ealth-policy experts . . .say there is a good reason for the mandate."^[103] Proposed reforms would prohibit health insurers from denying coverage to individuals with pre-existing medical conditions.^[103] Insurers said that, to keep premiums from rising for everyone, it is necessary for healthier people to pay into the insurance pools to balance out the cost of these higher cost individuals.^[103]

Arguing against requiring individuals to buy coverage, the Kato instituti has asserted that the Massachusetts law forcing everyone to buy insurance has increased costs: "Premiums are growing 21 to 46 percent faster than the national average, in part because Massachusetts' individual mandate has effectively outlawed affordable health plans."^[104] They say that "the mandate gives politicians enormous power to dictate the content of every American's health plan – a power that health care providers inevitably capture and use to increase the required level of insurance" and state that providers were successful in persuading legislators to include an additional 16 benefit mandates in the required benefit package during the first three years after the coverage mandate was enacted.^[104] They also say that by prohibiting the use of health status in pricing, the Massachusetts law "further increase[s] premiums for the young and healthy" and, as the result of adverse selection, drives more comprehensive health plans out of the market.^[104] The conclusion they draw is that "[T]he most sweeping provision . . . is an 'individual mandate' that makes health insurance compulsory. Massachusetts shows that such a mandate would oust millions from their low-cost health plans and force them to pay higher premiums."^[104]

Writing in the Nyu-York Tayms opinion blog "Room for Debate" the single-payer health care advokat Marcia Angell, former editor-in-chief of the Nyu-England tibbiyot jurnali, said that a coverage mandate would not be necessary within a single-payer system and that even within the context of current system she was "troubled by the notion of an individual mandate."^[105] She described the Massachusetts mandates as "a windfall for the insurance industry" and wrote, "Premiums are rising much faster than income, benefit packages are getting skimpier, and deductibles and co-payments are going up."^[105]

2009 yil aprelda the Boston Globe reported that the number of people seeking emergency room care and the cost of emergency room visits increased after the 2006 mandates went into effect (comparing 2005 to 2007).^[106] The number of visits increased by 7% during that period, while costs rose by 17%.^[106] State officials cautioned that it was too early to determine if the state's new coverage mandate had failed to reduce the emergency room use, but several physicians and policymakers said that it was unlikely that a coverage mandate alone could solve the problems of emergency room crowding and overuse.^[106] In August 2009 the Boston Globe reported that Massachusetts had "the most expensive family health insurance premiums in the country."^[107] Premiums in Massachusetts increased by 40 percent from 2003 to 2008, compared to a national average increase of 33%.^[107] The report did not break out the amount of the increase since 2006, but as the Massachusetts reforms are often taken as a model for national reform, "advocates on various sides of the issue said the report underscores the urgency of including cost controls in any large-scale federal or state overhaul."^[107] Karen Davenport, director of health policy at the Center for American Progress, has argued that "before making coverage mandatory, we need to reform the health insurance market, strengthen public health insurance programs, and finance premium subsidies for people who can’t afford coverage on their own."^[105]

Addressing the issue when it was proposed in 1994, CBO wrote: "A mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action. The government has never required people to buy any good or service as a condition of lawful residence in the United States."^[108] There is also disagreement as to whether federal mandates would be constitutional,^[103][109] and state initiatives opposing federal mandates may lead to litigation and delay.^[110]

On June 28, 2012, the AQSh Oliy sudi upheld the individual mandate provision as Constitutional.^[111]

Rationing of care

Prezident Barak Obama argues that U.S. healthcare is rationed, based on income, type of employment, and pre-existing medical conditions, with nearly 46 million uninsured. He argues that millions of Americans are denied coverage or face higher premiums as a result of pre-existing medical conditions.^[112]

Piter qo'shiqchisi va David Leonhardt have each separately noted that health care rationing is not a choice, but an economic necessity. All health care resources are finite and have to be allocated in some way or other. The issue is which way is the most sensible way to do it.^[81][113]

Former Republican Secretary of Commerce Piter G. Peterson has also argued that some form of rationing is inevitable and desirable considering the state of U.S. finances and the trillions of dollars of unfunded Medicare liabilities. He estimated that 25–33% of healthcare services are provided to those in the last months or year of life and advocated restrictions in cases where quality of life cannot be improved. He also recommended that a budget be established for government healthcare expenses, through establishing spending caps and pay-as-you-go rules that require tax increases for any incremental spending. He has indicated that a combination of tax increases and spending cuts will be required. All of these issues would be addressed under the aegis of a fiscal reform commission.^[114]

Rationing by price means accepting that there is no triage according to need. Thus in the private sector it is accepted that some people get expensive surgeries such as liver transplants or non life-threatening ones such as cosmetic surgery, when others fail to get cheaper and much more cost effective care such as prenatal care, which could save the lives of many fetuses and newborn children. Some places, like Oregon for example, do explicitly ration Medicaid resources using medical priorities.^[115]

Politicians on the right tend to be fearful of democratically elected governments becoming involved in rationing decision. Former House Speaker Nyut Gingrich (R-GA) argued that the reform plans supported by President Obama expand the control of government over healthcare decisions, which he referred to as a type of healthcare rationing.^[116] Senator Charles Grassley (R-IA) makes similar arguments claiming for example that people like the late Senator Edward Kennedy received health care in the U.S. that would have been denied in countries which have government controlled health care,^[117] a claim that Iqtisodchi magazine said was "dangerous" and went on to say that "The reality is that America, like Britain, already makes extensive use of rationing.^[118]

Better usage of healthcare technology

Automation of patient records

The Kongressning byudjet idorasi has concluded that increased use of health information technology has great potential to significantly reduce overall health care spending and realize large improvements in health care quality providing that the system is integrated. The use of health IT in an unintegrated setting will not realize all the projected savings.^[119]

Treatment registries

One application of healthcare technology is the creation of registries or databases to relate treatments to outcomes. Useful treatments could be identified and those less useful could be avoided to reduce costs.^[120]

Payment system reform

The payment system refers to the billing and payment for medical services, which is distinct from the delivery system through which the services are provided. The over 1,300 U.S. health insurance companies have different forms and processes for billing and reimbursement, requiring enormous costs on the part of service providers (mainly doctors and hospitals) to process payments. For example, the Cleveland Clinic, considered a low-cost, best-practices hospital system, has 1,400 billing clerks to support 2,000 doctors.^[121] Further, the insurance companies have their own overhead functions and profit margins, much of which could be eliminated with a single payer system. Economist Paul Krugman estimated in 2005 that converting from the current private insurance system to a single-payer system would enable $200 billion per year in cost savings, primarily via insurance company overhead.^[122] One advocacy group estimated savings as high as $400 billion annually for 2009 and beyond.^[123]

Proponents of health care reform argue that moving to a single-payer system would reallocate the money currently spent on the administrative overhead required to run the hundreds^[124] of insurance companies in the U.S. to provide universal care.^[125] An often-cited study by Garvard tibbiyot maktabi va Canadian Institute for Health Information determined that some 31 percent of U.S. health care dollars, or more than $1,000 per person per year, went to health care administrative costs.^[126] Other estimates are lower. One study of the billing and insurance-related (BIR) costs borne not only by insurers but also by physicians and hospitals found that BIR among insurers, physicians, and hospitals in California represented 20–22% of privately insured spending in California acute care settings.^[127]

Advocates of "single-payer" argue that shifting the U.S. to a single-payer health care system would provide universal coverage, give patients free choice of providers and hospitals, and guarantee comprehensive coverage and equal access for all medically necessary procedures, without increasing overall spending. Shifting to a single-payer system, by this view, would also eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship.^[128] Among the organizations in support of single-payer health care in the U.S. is Physicians for a National Health Program (PNHP), an organization of some 17,000 American physicians, medical students, and health professionals.^[129]

Reduce costs of imaging technology

During 2009, Medicare spent $11.7 billion for medical imaging, such as CT scans and MRI's. From 2005 to 2009, usage of scans grew at an annual rate of 14%, but may have slowed since due to a combination of changing incentives and saturation of usage. Initially, demanding patients insisted on scans; doctors feared malpractice suits if they refused; and doctors and hospitals wanted to maximize revenues. One study indicated that changing incentives may have reduced cost growth. From 2006 to 2010, the share of workers with deductibles exceeding $1,000 grew from 10 percent to 27 percent. Increased out-of-pocket expenses have made patients and physicians more cost conscious. Further, a combination of prior notification, higher patient co-payments and restrained reimbursements may have contributed to slowing cost growth.^[130]

Motivatsiya

Medicare and Medicaid Spending as % GDP (data from the CBO )

International comparisons of healthcare have found that the United States spends more per-capita than other similarly developed nations but falls below similar countries in various health metrics, suggesting inefficiency and waste. In addition, the United States has significant underinsurance and significant impending unfunded liabilities from its aging demographic and its social insurance dasturlar Medicare va Medicaid (Medicaid provides free long-term care to the elderly poor). The fiscal and human impact of these issues have motivated reform proposals.

Health spending per capita, in US$ PPP-adjusted, compared amongst various first world nations.

According to 2009 World Bank statistics, the U.S. had the highest healthcare costs relative to the size of the economy (GDP) in the world, even though estimated 50.2 million citizens (approximately 15.6% of the September 2011 estimated population of 312 million) lacked insurance.^[131] In March 2010, billionaire Uorren Baffet commented that the high costs paid by U.S. companies for their employees' health care put them at a competitive disadvantage.^[132]

Life expectancy compared to healthcare spending from 1970 to 2008, in the US and the next 19 most wealthy countries by total GDP.^[133]

Further, an estimated 77 million Baby Boomers are reaching retirement age, which combined with significant annual increases in healthcare costs per person will place enormous budgetary strain on U.S. state and federal governments, particularly through Medicare va Medicaid spending (Medicaid provides long-term care for the elderly poor).^[134] Maintaining the long-term fiscal health of the U.S. federal government is significantly dependent on healthcare costs being controlled.^[135]

Insurance cost and availability

In addition, the number of employers who offer health insurance has declined and costs for employer-paid health insurance are rising: from 2001 to 2007, premiums for family coverage increased 78%, while wages rose 19% and prices rose 17%, according to the Kayzer oilaviy fondi.^[136] Even for those who are employed, the private insurance in the US varies greatly in its coverage; one study by the Hamdo'stlik jamg'armasi yilda nashr etilgan Sog'liqni saqlash estimated that 16 million U.S. adults were underinsured in 2003. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes — 73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level.^[137] However, a study published by the Kayzer oilaviy fondi in 2008 found that the typical large employer preferred provider organization (PPO) plan in 2007 was more generous than either Medicare yoki Federal Employees Health Benefits Program Standard Option.^[138] One indicator of the consequences of Americans' inconsistent health care coverage is a study in Sog'liqni saqlash that concluded that half of personal bankruptcys involved medical bills,^[139] although other sources dispute this.^[140]

There are health losses from insufficient health insurance. A 2009 study found more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance.^[141] More broadly, estimates of the total number of people in the United States, whether insured or uninsured, who die because of lack of medical care were estimated in a 1997 analysis to be nearly 100,000 per year.^[142] A study of the effects of the Massachusetts universal health care law (which took effect in 2006) found a 3% drop in mortality among people 20–64 years old - 1 death per 830 people with insurance. Other studies, just as those examining the randomized distribution of Medicaid insurance to low-income people in Oregon in 2008, found no change in death rate.^[143]

The cost of insurance has been a primary motivation in the reform of the US healthcare system, and many different explanations have been proposed in the reasons for high insurance costs and how to remedy them. One critique and motivation for healthcare reform has been the development of the medical–industrial complex. This relates to moral arguments for health care reform, framing healthcare as a social good, one that is fundamentally immoral to deny to people based on economic status.^[144] The motivation behind healthcare reform in response to the medical-industrial complex also stems from issues of social inequity, promotion of medicine over preventative care.^[145] The medical-industrial complex, defined as a network of health insurance companies, pharmaceutical companies, and the like, plays a role in the complexity of the US insurance market and a fine line between government and industry within it.^[146] Likewise, critiques of insurance markets being conducted under a capitalistic, free-market model also include that medical solutions, as opposed to preventative healthcare measures, are promoted to maintain this medical-industrial complex.^[146] Arguments for a market-based approach to health insurance include the Grossman model, which is based on an ideal competitive model, but others have critiqued this, arguing that fundamentally, this means that people in higher socioeconomic levels will receive a better quality of healthcare.^[145]

Uninsured rate

Another concern is the rate of uninsured people in the US. 2014 yil iyun oyida, Gallup –Healthways Well–Being conducted a survey and found that the uninsured rate is going down. 13.4 percent of U.S. adults are uninsured in 2014. This is a decrease from the percentage at 17.1 percent in January 2014 and translates to roughly 10 million to 11 million individuals who gained coverage. The survey also looked at the major demographic groups and found each is making progress towards getting health insurance. However, Hispanics, who have the highest uninsured rate of any racial or ethnic group, are lagging in their progress. Under the new health care reform, Latinos were expected to be major beneficiaries of the new health care law. Gallup found that the biggest drop in the uninsured rate (2.8 percentage points) was among households making less than $36,000 a year.^{[147][148][149]}

Waste and fraud

In December 2011 the outgoing Administrator of the Centers for Medicare & Medicaid Services, Donald Berwick, asserted that 20% to 30% of health care spending is waste. He listed five causes for the waste: (1) overtreatment of patients, (2) the failure to coordinate care, (3) the administrative complexity of the health care system, (4) burdensome rules and (5) fraud.^[150]

An estimated 3%–10% of all health care expenditures in the U.S. are fraudulent. In 2011, Medicare and Medicaid made $65 billion in improper payments (including both error and fraud). Government efforts to reduce fraud include $4.2 billion in fraudulent payments recovered by the Department of Justice and the FBI in 2012, longer jail sentences specified by the Affordable Care Act, and Senior Medicare Patrols —volunteers trained to identify and report fraud.^[151]

International comparisons

The International Federation of Health Plans provides a comparative annual survey of costs for drugs, devices and medical services across countries. According to their 2013 report, the U.S. pays considerably more than other countries in 22 of 23 categories. For example, the average cost of a hip replacement in the U.S. was $40,364, with other countries ranging from $3,365 (Argentina) to $27,810 (Australia). An MRI averaged $1,121 in the U.S. versus $280 in France.^[152] The reasons for these differences are driven by higher prices per unit of service, rather than a higher volume of usage. In other countries, governments intervene more forcefully in setting prices. In countries such as Canada and Britain, prices are set by the government. In others, such as Germany and Japan, they’re set by providers and insurers sitting in a room and coming to an agreement, with the government stepping in to set prices if they fail.^[153]

Boshqa mavzular

Importation of prescription drugs

Congressional proponents argue that drugs manufactured overseas by U.S. companies could be imported and purchased more cheaply in the U.S. Drug manufacturers argue that certain foreign countries have price controls, which they recoup by charging higher prices in the U.S. Whitehouse spokesman Robert Gibbs said President Obama is supportive of importing drugs, provided safety concerns related to the drugs can be addressed. This is because drugs manufactured outside the country may be held to different standards. According to Bloomberg News, drugmakers agreed in June 2009 to contribute $80 billion over 10 years, largely to help the elderly afford medicines, in return for staving off other profit-endangering proposals such as drug importation.^[154]

Adabiyotlar

Tashqi havolalar

• Time jurnali-Stiven Bril-Nega tibbiy to'lovlar bizni o'ldirmoqda-2013 yil fevral
• Qo'shma Shtatlarda sog'liqni saqlash tizimini isloh qilish da Curlie
• Medicare va Medicaid xizmatlari markazlari - Milliy sog'liqni saqlash xarajatlari ma'lumotlari-2012
• Slate-ning sog'liqni saqlashni isloh qilish to'g'risidagi qonun loyihasi bo'yicha onlayn qo'llanmasi. - Timo'tiy Nuh tomonidan
• Vashington Post gazetasi sog'liqni saqlashni isloh qilish bo'yicha Ezra Klayn
• Mark Merlis, "Individual mandat: endi Kongress jismoniy shaxslarning tibbiy sug'urtasini olishlarini talab qilishning turli xil versiyalarini ko'rib chiqmoqda" Sog'liqni saqlash Siyosat qisqacha bayoni, 2010 yil 13 yanvar.
• Syuzan Jaffe, "Sog'liqni saqlashni sug'urtalash rejasi: millat tibbiy sug'urta qoplamasini kengaytirish ustida ish olib borayotganda ba'zi bir sug'urtalanmagan amerikaliklar yangi tuzilgan, jamoat tomonidan boshqariladigan sog'liqni saqlash rejasiga yozilishlari mumkinmi?" Sog'liqni saqlash Siyosiy xulosa, 2009 yil 10-noyabr.
• Syuzan Jaffe, "Tibbiy sug'urtani isloh qilish: qamrovni kengaytirish va bozorni jismoniy va kichik biznes uchun yaxshiroq ishlashini ta'minlash uchun yangi federal qonun va qoidalar bo'lishi kerakmi?" Sog'liqni saqlash Siyosat qisqacha bayoni, 2009 yil 21 oktyabr.
• Syuzan Jaffe, "Sog'liqni saqlash tizimini isloh qilishning asosiy masalalari: Federal hukumatning sog'liqni saqlashni moliyalashtirish va ta'minlashdagi o'rni; Medicare sarf-xarajatlarining o'sish sur'atlarini pasaytirish; Og'ir kasalliklarni oldindan rejalashtirish" Sog'liqni saqlash Siyosat qisqacha bayoni, 2009 yil 20 avgust.
• Prezident Barak Obama, Prezident takliflarining qisqacha mazmuni - 2010 yil fevral
• Tibbiy sug'urtalash bo'yicha asosiy takliflarni tahlil qilishda CBO-asosiy masalalari - 2008 yil dekabr