Although the U.S. remains a world leader in many areas of health care,broad discrepancies persist in who can afford that care and how well it is delivered,according to a recent report.
Overall,the report gave the health care system a grade of 66 out of 100 possible points.
Ten states have the highest percentages of people without health insurance,at least 23 percent of adults ages 18 to 64,according to the Commonwealth Fund's National Scorecard on the U.S. Health System. The states are Alaska,Arizona,Arkansas,California,Florida,Louisiana,Montana,New Mexico,Texas and West Virginia.
Nationally,the number of people without health insurance continues to grow. In 2005,46.6 million people – or 15.9 percent of the population – reported having no coverage,an increase of 1.1 million since 2004,according to the U.S. Census Bureau.
The reasons for these regional inequalities can be traced to the types of jobs that predominate those states,Cathy Schoen,the fund's senior vice president,said.
“If you look at these states that have more migrant farm workers,more farm industry,more low-wage service sector jobs – those jobs have traditionally come without insurance,” Schoen said.
The number of states considered to have the worst record of coverage,predominantly Southwestern states,has increased by six since 2000.
Similarly,there has been a parallel decrease in the number of states with the best records. Fifteen states that once insured more than 86 percent of their populations have more uninsured people than they did six years ago.
“This is definitely a shared concern across the country,” Schoen said. “There's just a handful of states that have done quite well to hold a line.”
Only Iowa,Maine,Minnesota,and Wisconsin have kept the number of insured people as low as it was six years ago,covering all but 14 percent of their adult populations.
“These are unionized states,” Schoen said. “They came off of a manufacturing base where the definition of a good job is a job that came with benefits.”
Patients were more likely to be readmitted to the hospital in the poorest performing regional groups of states than they were in the best performing regional groups. This suggests low-performing hospitals fall short of effectively treating the patients the first time.
Poor-performing hospitals have little incentive to improve because the system fails to reward them for doing so,said Elliott Fisher,a Dartmouth College professor of medicine.
For example,high-performing hospitals usually have computerized records of a patient's treatment history and have fewer physicians involved in patient care,two measures that improve patient health,Schoen said.
“When you're in the middle of complicated care and you're seeing multiple doctors,mistakes are more likely to happen,” she said.
However,insurance companies fail to reimburse physicians who establish these measures,Fisher said. Insurance policies should provide incentives for doctors to change their ways.
“It's very hard in a busy practice to establish the sort of systems that would help a doctor to do this,” he said.
There have been some recent moves toward policy change. In September,Rep. Patrick Kennedy,D-R.I.,introduced a bill that would offer physicians an additional $2 for each electronic patient record they create,said Michael Zamore,a Kennedy policy adviser.
But this and other similar bills “dip their toes in the water but don't go far enough” to improve this area in lower-end hospitals,Zamore said.
“What my boss says – and what every other politician I've ever heard likes to say – is,‘We have the best health care system in the world,'” Zamore said. “But what we actually have is a terrible system that delivers some of the best health care in the world.”
Fisher said lawmakers must encourage hospitals to reduce physician visits per patient,adopt technology such as electronic patient records and emphasize quality treatment over quantity of patients treated.
“We need to reward better care,not just more care,” he said.
That some hospitals do achieve high scores implies that the hospitals are capable of providing much better care,said Stephen Schoenbaum,CF's executive vice president for programs.
“So ask yourself,why not the best for all Americans?” Schoenbaum said.
The Commonwealth Fund will release a new scorecard with more details on state-by-state health care variations in the spring.