The relationship between health care and health. “In developed countries, the marginal contribution of medical care to life expectancy is very small.” (Fuchs1998) Many critical factors associated with poor health may be outside the health care system. Universally, the poor are sicker, and inequalities in health persist in industrialized countries with universal financing systems designed to provide equal access. Great Britain, Sweden, Finland, Holland, and the World Health Organization extensively documented large and often increasing gaps in health status and social and economic parity. There is growing recognition that these health disparities cannot be explained by differential access. Gunning-Schepers and Stronks (1999) note “differences in health between social groups, defined by class, educational level, income or professional status have been recorded in every country that has carried out research and have not visibly diminished despite social policies such as universal access to health care, greater access to educational opportunities, occupational health efforts, or reductions in income inequality.” In the United States, differential access for the poor through Medicare, Medicaid, and private health.
The problem extends beyond the usual boundaries of health services. In fact, access may not be corrected under universal coverage due to time costs experienced by workers without sick leave, language barriers, isolation and physical difficulty in availing oneself of services, distance, transportation, consumer information, culture, time preferences (the rate at which people discount the future relative to the present), self-efficacy, poor lifestyle, and genetics. Unemployment appears to have a significant, widespread association with poor health although the direction of the association is not clear. Educational level is a strong covariate with health as well as poverty and employment. (Fuchs 1998, La Viest et al 2000) Systemic factors identified with poor access under universal coverage are distribution of health care professionals and differences in medical custom by small geographic area.
Strategies to improve. McGlynn and Brook (2001) recommend creating “quality champions,” developing a functional information system, routine monitoring and reporting on performance, and ensuring adequate funding for quality measurement. In exploring strategies for improving quality of care for coronary heart disease in the US and England, Ayanian and Quinn (2001) reported on clinical guidelines; national standards; performance reports; benchmarking, feedback and professional leadership; and marker-oriented approaches. Clinical guidelines have not demonstrated effectiveness in changing physicians’ behavior and “inappropriate care remains common.” Without a national health care system, the US hasn’t the mandate or means to implement national standards; public release of performance reports have had limited impact. They regarded benchmarking, feedback, and professional leadership as potentially useful tools to promote quality improvement at the local level. They recommend developing systems of care that promote quality, standardized information gathering and dissemination, greater financial and non-financial incentives by public and private purchaser, and the culture of the health care organization itself is critical. Strategies continually highlight the importance of accountability, information systems, organizational culture, reduction of bureaucratic complexity, and incentives to improve the quality of care. Incentives of payers, providers, patients and the public should be aligned to address quality and reduce error.
We have not clarified our obligation to include genetics testing and treatment in an equitable system. Would universal health care include an obligation to correct for the genetics conditions that alter functioning? If we are no longer subject to “bad luck” through a social or natural lottery over which we had no control or choice, do we have a duty to change if we can? Does can mean ought? As an example, Buchanan et al (2000) ask, given an opportunity to prevent Alzheimer’s disease through genetic manipulation, is the person with the disease now seen as a victim of injustice rather than misfortune? Are we then obligated to include these services in a universal system? If we can change personal characteristics such as IQ and body height, where does the system’s obligation to pay for genetic alteration end? What is our obligation to the poor and to the uneducated for access to these data, to educate them about the potential and the impact of genetic information and for informed choice?
Competition among groups for limited resources. Given demand for limited resources within the health care system and other sectors of the economy, some observers believe current services might not provide benefits commensurate with costs. However, between 80 -85% health care is still driven by the physician who may be biased toward his or her particular intervention and consented to by the patient. The high cost of care affects the relative spending for health care as compared with the environment, other personal.
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