U.S. Medical Care

U.S. Medical Care: An Uncertain Future

The PaTienT ProTecTion and affordable care acT of 2010

If you are like many who follow the health care reform debate, you grow weary of the rhetoric and find yourself disillusioned by the acrimony it produces. Passed without a single Republican vote, President Barack Obama signed the Patient Protection and Afford- able Care Act (ACA) into law by the United States on March 23, 2010. Despite predictions that support for the plan would increase as Americans became familiar with its details, the number favoring the bill steadily declined throughout the year. By the November 2010 midterm elections, tracking polls indicated that nearly 60 percent of voters opposed the measure and actually favored its repeal (Rasmussen, 2010). Since the 2010 elections, the ACA’s popularity has not improved substantially—30 percent would like to see the legis- lation repealed entirely, 56 percent prefer marginal improvements be made, and only 12 percent say to leave it alone (Rasmussen, 2017).

The negative public perception is really quite puzzling because the act actually addresses many of the concerns of Americans—covering the uninsured, subsidizing the purchase of insurance to make it more affordable, and allowing those with preexisting conditions to purchase insurance at standard premiums. Nevertheless, the plan also has its unintended consequences. The new insurance pooling requirements resulted in sig- nificantly higher premiums for the young and healthy in an effort to subsidize the elderly and those with preexisting conditions. With the addition of 20 million newly insured, access to care, especially primary care, is more difficult for many.

American voters not only elected a Republican president in 2016 but also left the Grand Old Party (GOP) in control of both houses of Congress. Instead of talking about expanding the ACA, we are in the middle of a discussion on how to change it: repeal, replace, delay, and repair. What is it going to be? The Republicans have a clear path to repeal much of the ACA but must rally around a single plan for replacing it. With all the uncertainty, one thing is certain: The debate is just now heating up. There is still plenty of work to do.

uncertainty A state where multiple outcomes are possible but the likelihood of any one outcome is not known.

policy issue How can we best deal with the trade-off between quality and access on the one hand and affordability on the other?

policy issue Most privately insured Americans receive health insurance coverage through their employer, while those without insur- ance rely on public assis- tance and charity care.

06757_ch01_ptg01_001-024.indd 1 8/4/17 4:44 PM

2 Chapter 1: U.S. Medical Care: An Uncertain Future

Public concern over the future of health care has not changed with the passage of health care reform legislation. Americans still worry about three broad issues: quality, access, and affordability (what some call the “triple aim”). Limited access for the uninsured1 and the uncertainty of continued access for those with insurance are key considerations as policy- makers deliberate reform options. High and rising spending (with the associated increases in premiums) continues to challenge employers’ ability to offer group insurance to their employees and focuses attention on the growing burden of the two major government health care programs—Medicare and Medicaid. An additional concern is whether the spending increases associated with expanded access will have a negative effect on the quality of care.

This chapter will first examine the historical development of the medical care deliv- ery system in the United States: the reasons for high and rising spending and the major changes in medical care delivery since the end of the Second World War. We will then develop a framework for the study of health economics. Finally, we will introduce 10 key economic concepts that will serve as unifying themes for our study of health care.

Historical Developments in the Delivery of Medical Care No matter where a health care discussion begins, the topic of conversation soon turns to the issue of affordability. Employees and employers complain about high premiums, patients and providers note high treatment costs, and policymakers lament high and rising spending. Each perspective presents a different aspect of the same problem. In 2016, the average cost of a health insurance policy was $18,142 for a family and $6,435 for an indi- vidual (Kaiser Family Foundation, 2016). The average cost per hospital stay was almost $10,000, and Americans spent over $3.2 trillion on health care—17.8 percent of the gross domestic product (GDP).

The major concern over health care spending is not that it is high; the concern is that the steady upward spiral does not seem to have an end to it. Government projections esti- mate that medical care spending will continue its rise, topping $5.5 trillion by 2025—over 19.9 percent of GDP (Keehan et al., 2017). Although economic theory has yet to determine what the optimal percentage ought to be, the United States spends more on medical care by virtually every measure than any other country in the world. What does it mean then to spend 8, 10, or 16 percent of a country’s GDP on medical care? More importantly, should the amount spent on medical care be a concern to policymakers?

Postwar Experience Table 1.1 summarizes medical care spending in the United States over the post-World War II period. The four summary measures provide evidence that medical care spending is high and growing. During the decade of the 1950s, total spending increased at a rate of 8 percent per year. Total spending at the beginning of the decade was $12.7 billion, doubling by its end. Medical care spending as a percent of GDP increased from 4.5 to 5.0 percent, and per capita medical care spending increased from $82 in 1950 to $146 ten years later.

The 1960s was the first of three decades characterized by rapid growth in medical care spending. The annual compound rate of growth was 11.5 percent between 1960 and 1990. At the beginning of that 30-year period, medical care spending was $27.2 billion, 5.0 per- cent of GDP, and $146 per capita. By 1990, it stood at $721.4 billion, 12.1 percent of GDP, and $2,854 per capita. The primary factors contributing to growth in spending during

1The Emergency Medical Treatment and Active Labor Act (EMTALA) passed in 1985 made it illegal for hospital emergency depart- ments to deny care to anyone requesting care. Turning away patients because of lack of health insurance is not an option.

Medicare Health insurance for the elderly provided under an amendment to the Social Security Act.

Medicaid Health insurance for the poor financed jointly by the federal government and the states.

premium A periodic payment required to purchase an insurance policy.

gross domestic prod- uct (GDp) The mone- tary value of the goods and services produced in a country during a given time period, usu- ally a year.

policy issue What is the optimal percentage of GDP that a country should spend on health care? Is a continu- ously growing percentage affordable?

policy issue How many years does it take to constitute a trend?

http:// The National Institutes of Health provides an overview of its programs and activities at http:// www.nih.gov.

06757_ch01_ptg01_001-024.indd 2 8/4/17 4:44 PM

Chapter 1: U.S. Medical Care: An Uncertain Future 3

this period include the expansion of federal government involvement in the payment for medical care services for specific groups—Medicare for the elderly and Medicaid for the indigent—and cost shifting by providers to subsidize care for those without insurance.

Rapid advancement in medical technology and the subsequent cost-containment strate- gies that emphasized regulation and planning characterized the 1970s. The federal govern- ment became a major force in biomedical research and development with the expansion of the National Institutes of Health. Technological advances that included open-heart sur- gery, organ transplantation, various types of imaging, and the ability to preserve and pro- long life in the intensive care unit increased public awareness of medicine and served as a major cost driver. While it all seemed justifiable, this emphasis on advanced technologies precipitated a growing concern over cost issues.

Federal legislation, specifically the National Health Planning Act of 1974, created a network of government planning agencies to control medical care costs. In addition, states passed certificate-of-need (CON) laws to limit the growth in hospital investment in cap- ital improvements and technology. Even a brief national experiment with wage and price controls during the Nixon presidency did little to curb the growth in medical care costs and spending.

Possibly the most significant piece of legislation affecting health care was not viewed as particularly significant at the time. Passed to regulate the corporate use of pension funds, the Employee Retirement Income Security Act (ERISA) of 1974 exempted self-insured health plans from state-level health insurance regulations. The passage of ERISA provided an incentive for employers to switch to self-insurance. Today, companies who self-insure employ more than two-thirds all workers who participate in group health insurance plans.

tABle 1.1 u. s. heAlth cARe speNDiNG suMMARy MeAsuRes, VARious yeARs

Year Total spending

(in billions) Percent change1 Percent of GDP Per capita spending

1950 $ 12.7 – 4.5 $ 82 1960 27.2 7.9 5.0 146 1970 74.6 10.6 6.9 354 1980 255.3 13.1 8.9 1,108 1990 721.4 10.9 12.1 2,854 2000 1,369.7 6.6 13.3 4,857 2005 2,035.4 8.1 15.5 6,856 2010 2,595.7 5.0 17.3 8,402 2011 2,696.6 3.9 17.4 8,665 2012 2,799.0 3.8 17.4 8,927 2013 2,877.6 2.8 17.2 9,110 2014 3,029.3 5.3 17.4 9,515 2015 3,205.6 5.8 17.8 9,990 20182 3,785.5 5.7 18.1 11,499 20242 5,425.1 6.2 19.6 15,618

Source: Centers for Medicare and Medicaid Services (CMS) website, http://www.cms.hhs.gov/NationalHealthExpendData/ 02_NationalHealthAccountsHistorical.asp#TopOfPage. Accessed February 1, 2017; and Keehan et al., “National Health Expenditure Projections, 2015–2025,” Health Affairs 35(8), August 2016, 1522–1531. 1Annual rate of change from the previous year listed. 2Projected.

cost shifting The practice of charging higher prices to one group of patients, usu- ally those with health insurance, in order to provide free care to the uninsured or discounted care to those served by Medicare and Medicaid.

employee Retirement income security Act (eRisA) Federal legisla- tion that sets minimum standards on employee benefit plans, such as pension, health insur- ance, and disability. The law also protects employ- ers from certain state regulations. For example, states are not allowed to regulate self-insured plans and cannot man- date that employers pro- vide health insurance to their employees.

self-insurance A group practice of not buying health insurance but setting aside funds to cover the projected losses incurred by mem- bers of the group.

06757_ch01_ptg01_001-024.indd 3 8/4/17 4:44 PM

4 Chapter 1: U.S. Medical Care: An Uncertain Future

The 1980s ushered in a change in direction in health care policy, resulting in a shift away from regulation and planning and toward a greater reliance on market forces. A president who wanted to lower taxes and a Congress that refused to cut spending characterized the era. Federal budget deficits grew dramatically. By the end of the decade, those areas of the bud- get in which spending was mandated—the entitlement programs including Medicare and Medicaid—grew seemingly without limit and came under intense pressure to reduce their rate of growth. During this period, the introduction of alternative payment schemes and deliv- ery systems was significant. Prospective payment, capitation, the use of diagnosis-related groups (DRGs) to pay hospitals, and the introduction of a relative-value scale (RVS) to pay physicians are all examples of these changes. Health maintenance organizations, preferred provider organizations, and other systems of managed care became more common.

The 1990s saw a moderation in the growth in spending. Most experts attribute at least part of the slowdown to the movement of patients into managed care. The annual per- centage increase in nominal spending fell from 15.9 percent in 1981 to around 5.0 per- cent in the mid-1990s. A steady increase in growth rates resulted in an annual change of 9.1 percent in 2002. The expansion of medical care spending as a percentage of GDP remained between 13.0 and 14.0 percent until 2001, when it nudged above 14 percent for the first time.

The federal government has taken more of an activist role in health care policy in the past decade. Although an attempt to restructure the health care system failed in 1994, import- ant legislation was enacted that was expected to improve access to care. At the federal level, Congress established the Health Insurance Portability and Accountability Act (HIPPA) of 1996 providing insurance portability to individuals with health insurance. In 1997, Congress passed the Children’s Health Insurance Program (CHIP), the largest expansion of a federal medical program since its original enactment. Moreover, in late 2003, Congress voted to expand the coverage for outpatient prescription drugs within the Medicare program.

Over the last decade, spending growth has actually slowed from over 9 percent in 2002 to less than 3 percent in 2013. A Kaiser Family Foundation study (2013) attributed 77 per- cent of that decline to the overall slowdown in the economy resulting from the 2007–2009 recession. However, that does not explain the experience prior to the recession. Cutler and Sahni (2013) provide an alternative explanation in a study where they estimated that only 37 percent of the overall decline was due to the recession and 8 percent to the decline in private insurance coverage. Ryu et al. (2013) attribute 20 percent of the decline to changes in benefit design leading to increased cost sharing and more cost conscious decision- making for the insured. Other factors, such as the slower adoption of new technology and improvements in provider efficiency, contributed to the results. Continuation of these trends (all predating the full implementation of the ACA) could have a major impact on the economy in the next decade.

Concern over High and Rising Spending There is widespread consensus that the current path of health care spending growth is unsustainable. Even with the changes resulting from passage of the ACA, success in achiev- ing the triple aim of access, affordability, and quality will be elusive. What are the obsta- cles? Why is success so elusive?

Improvements in affordability and access will remain elusive until we accept certain realities about the problem. In a series of articles, Fuchs (2008, 2013, 2014) shared his insights into the scope of the challenge.

1. Growth in health care spending outpaces growth in the rest of the economy. In the past 40 years, health care spending has grown at an annual compound rate of

entitlement program Government assistance programs where eligi- bility is determined by a specified criterion, such as age, health status, and level of income. These programs include Social Security, Medicare, Med- icaid, Temporary Assis- tance for Needy Families (TANF), and many more.

prospective payment Payment determined prior to the provision of services. A feature of many managed care organizations that base payment on capitation.

capitation A payment method providing a fixed, per capita pay- ment to providers for a specified medical ben- efits package. Providers are required to treat a well-defined population for a fixed sum of money, paid in advance, without regard to the number or nature of the services provided to each person.

diagnosis-related group A patient classifi- cation scheme based on certain demographic, dia- gnostic, and thera peutic characteristics developed by Medicare and used to compensate hospitals.

relative-value scale An index that assigns weights to various medical services used to determine the relative fees assigned to them.

managed care A deliv- ery system that originally integrated the financing and provision of medical care in one organization. Now the term encompas- ses different arrangements designed to coor di nate services and control costs.

06757_ch01_ptg01_001-024.indd 4 8/4/17 4:44 PM

Chapter 1: U.S. Medical Care: An Uncertain Future 5

8.0 percent compared to GDP (less health care) that grew at only 5.7 percent per year (see Figure 1.1). Every year health care spending growth on average exceeded GDP growth by over 2 percentage points. It is no wonder that health care represents a larger share of the economy today than in 1976. If the trend continues, the health care sector will continue to absorb an ever-increasing share of GDP in the future.

2. A lot of the increased spending is the result of supply side advances in medicine and the appetite of Americans to consume a more expensive mix of health care services. More specialists, improved diagnostic tools, advances in surgical interventions, improved therapies, and pharmaceuticals that are more effective represent quality improvements that allow us to live longer and better. Newhouse (1993), Ginsburg (2004), and the Congressional Budget Office (2010) have examined the impact of technology growth on spending and conclude that about one-half of the increase in medical spending is due to the introduction of new technology. Few are suggesting that we forego these improvements to save money.

3. Another demand-side factor leading to more spending is the prevalence of health problems associated with obesity and other lifestyle conditions, and the onset of dis- eases related to an aging population. The prevalence of unhealthy lifestyles is another reason for increased health care spending. Poor nutrition, too many calories, and too much fat, along with a lack of exercise have led to an alarming increase in the propor- tion of the population that is overweight and obese. Obesity-related conditions may be responsible for as much as 27 percent of inflation adjusted per capita medical expendi- tures in the United States (Thorpe et al., 2004).

4. There is a link between high spending and relatively high input prices. Prices for pre- scription drugs are about 30 percent higher in the United States than the Organization for Economic Cooperation and Development (OECD) average; U.S. physicians earn considerably higher salaries that their foreign counterparts; and hospitals charge sub- stantially more for their services than is typically charged abroad.

5. Changes in spending growth are often accompanied by developments in the macro economy (economic growth and job creation). Historically, downturns in the economy occur simultaneously with a slowing in the rate of growth in health care spending (evi- denced by the decline in spending growth during downturns in the economy).

6. Insurance coverage has increased dramatically over the past four decades. Insur- ance, both public and private, covered 62.7 percent of all medical spending in 1970. By 2015, almost 90 percent of all medical care was purchased through third-party insurance. As a result, the percentage paid out of pocket has fallen from 37.3 percent

HCE (health care expenditures) GDP (less HCE)

–6.00

–4.00 –2.00

0.00

1971 1976 1981 1986 1991 1996 2001 2006 2011 2016

2.00

4.00

6.00

8.00

10.00

G ro

w th

R at

es (i

n Pe

rc en

FiGuRe 1.1 Growth in Health Care Expenditures and GDP (less heath care), in real terms, 1971–2016

06757_ch01_ptg01_001-024.indd 5 8/4/17 4:44 PM

6 Chapter 1: U.S. Medical Care: An Uncertain Future

of total spending to 10.5 percent over that same period. To determine the extent that increased insurance coverage contributes to overall spending, Finkelstein (2007) examined how the introduction of Medicare in 1965 affected spending by the elderly. She calculated that the overall increase in insurance coverage might be responsible for as much as one-half of the increase in per capita spending from 1950 to 1990.

7. Attributing the growth in spending to waste, fraud, and abuse may be the political scapegoat, but undoubtedly, many of the commonly cited administrative problems result in wasteful spending (Fuchs, 2014). Two commonly cited problems that lead to wasteful spending are billing fraud and defensive medicine. The National Health Care Anti-Fraud Association estimates that each year about 3 percent of health care spend- ing is lost to fraud (Iglehart, 2009). The improper payment rate in the government-run Medicaid program may be as high as 10.5 percent of total spending (federal share only). The Medicare fraud rate is around 8.5 percent.

The fear of litigation creates an atmosphere where physicians may perform unneces- sary tests and procedures to reduce the risk of a malpractice claim. Roberts and Hoch (2009) estimate that 2–10 percent of health care spending is due to physicians practic- ing defensive medicine.

Undoubtedly, all these factors contribute in one way or the other to the overall ineffi- ciencies in health care delivery and finance. Debate over the relative contributions of these factors has contributed to the political divide on the necessary steps to address the spend- ing problem. One thing is certain: To control spending, we must spend our health care dol- lars efficiently. Until everyone—patient, provider, and payer—has the incentive to spend money wisely, the problem will remain.

defensive medicine Medical services that have little or no medical benefit; their provision is simply to reduce the risk of being sued.

SPending Somebody elSe’S money

A Wall Street Journal article provides an interesting example of how spending someone else’s money distorts the decision-making process. A 70-year-old man suffering from a ruptured abdominal aortic aneurysm was admitted to the hospital. After several weeks in the intensive care unit—with all the modern technology that goes with it—and a three- month stay in the hospital, the bill approached $275,000, none paid out of pocket by the patient. The man’s physician determined that his poor eating habits, caused by poorly fitting dentures, were contributing to his slow recovery. He requested that the hospital dentist perform the necessary adjustments. Later, the doctor discovered that the man had not allowed the dentist to adjust the dentures. When asked the reason, the man replied, “$75 is a lot of money.” It seems that Medicare would not pay for the adjustment, so it would have been an out-of-pocket expenditure for the patient.

When you are spending somebody else’s money, $275,000 does not seem like a lot. Nevertheless, when you are spending your own money, $75 is a lot. Our reliance on a third-party payment system is the major institutional feature contributing to rising costs and increased spending. Cost-conscious consumers have little or no role in a system dominated by third-party payers.

Source: James P. Weaver, “The Best Care Other People’s Money Can Buy,” Wall Street Journal, November 19, 1992, A14.

third-party payers A health insurance arrangement where the individual, or an agent of the individual, pays a set premium to a third party (an insurance company, managed care organization, or the government), which in turn pays for health care services.

06757_ch01_ptg01_001-024.indd 6 8/4/17 4:44 PM

Chapter 1: U.S. Medical Care: An Uncertain Future 7

Changes in Medical Care Delivery The last 30 years have witnessed major changes that have affected medical care delivery and costs. The shift from private to public sector financing, the shift from out-of-pocket spending to third-party payment, the changes in hospital usage and pricing, and the growth in managed care have all had profound effects on medical care delivery and pricing.

Shift from Private to Public Financing Quite possibly, the single most important change affecting medical care delivery has been the shift from private to public sector financing. Referring to Table 1.2, the private sector was responsible for $3 of every $4 spent in the industry in 1960. The government role in financing was modest, standing at less than 25 cents out of every medical care dollar. The introduction of Medicare and Medicaid in the mid-1960s resulted in an increase in the government’s share of spending to almost 40 percent within 10 years. Since then government’s total share has risen to about half of total spending, while the federal share has more than tripled, from 10 percent in 1960 to approximately 40 percent in 2015. This translates into a federal budgetary obligation that has grown from $2.9 billion to almost $1 trillion in five decades. As the federal share has exploded, the share of state and local governments has remained relatively stable at around 13 percent.

Shift to Third-Party Payment Even as the private share of total spending has fallen, the role of private insurance has expanded. Private insurance paid a little more than 25 percent of the total cost of medical care in 1965, with that share rising to about one-third by 1990, where it has remained since that time. The major change in private spending has been the dramatic decline in private, out-of-pocket spending. Out-of-pocket spending was approximately half of total health care expenditures in 1960. By 2015, that total had fallen to 10.5 percent. With the increased importance of third-party payers such as government and private insurers, the insured patient has relatively little out-of-pocket spending at the point of purchase.

Payment by third parties provides little incentive to control spending on the part of either the provider or the patient. As long as insurance companies are willing to pay the bills, physicians will continue to provide all the care that patients request. Fully insured patients have no incentive to limit their utilization. Even when the expected benefit of a procedure is small, in most cases patients will demand it, because the patient’s share of the cost is small.

It should come as no surprise that the cost of services covered by insurance—public and private—has risen at a faster rate than the cost of services that are not covered. Why? When consumers purchase goods and services at discount prices, they tend to buy more than when charged the full price. What other reasonable explanation would explain the crowds that flock to clearance sales and the enthusiastic consumer acceptance of outlet malls? Health economists refer to this phenomenon as moral hazard. Between 1970 and 2006, hospital spending for services usually covered by insurance increased 20 times, whereas spending on eyeglasses—something typically not covered by insurance—increased only 10 times. Insulating patients from the full cost of medical care has had the effect of desensitizing patients to the prices charged and at the same time has encouraged greater utilization.

Change in Hospital Usage and Pricing Hospital usage has also changed dramati- cally. As seen in Table 1.3, almost every measure of inpatient hospital usage has fallen in the past 30 years, in some cases quite dramatically. The number of hospital beds is down, admissions are down, the average length of stay is down, and occupancy rates have fallen

moral hazard In the context of health care, the risk that individ- ual behavior changes because of insurance coverage. By decreasing the out-of-pocket price of medical services, insurance increases the quantity demanded.

06757_ch01_ptg01_001-024.indd 7 8/4/17 4:44 PM

8 C

hapter 1: U .S. M

edical C are: A

n U ncertain Future

tABle 1.2 FiNANciNG oF heAlth cARe eXpeNDituRes, VARious yeARs iN BillioNs oF DollARs AND peRceNtAGe oF totAl speNDiNG

1965 1970 1980 1990 2000 2010 2015

$ % $ % $ % $ % $ % $ % $ %

Out-of-pocket 18.2 48.9 25.0 37.3 58.1 24.6 137.9 20.5 199.0 15.5 298.7 12.2 338.2 11.1

Private insurance 10.1 27.2 15.5 23.1 69.2 29.4 233.9 34.7 458.5 35.6 863.1 35.2 1,072.1 35.1

Medicare 0 – 7.7 11.5 37.4 15.9 110.2 16.3 224.8 17.5 519.3 21.1 646.2 21.2

Medicaid 0 – 5.3 7.9 26.0 11.0 73.7 10.9 200.3 15.6 397.2 16.2 545.1 17.9

Other programs1 2.0 5.4 3.3 4.9 9.7 4.1 21.4 3.2 35.8 2.8 95.6 3.9 121.1 4.0

Other third party2 6.3 16.9 9.0 13.4 28.6 12.1 77.1 11.4 124.9 9.7 204.3 8.3 247.2 8.1

Public health 0.6 1.6 1.4 2.1 6.4 2.7 20.0 3.0 43.1 3.4 75.5 3.1 80.9 2.7

Health care consumption

37.2 100.0 67.0 100.0 235.7 100.0 674.1 100.0 1,286.4 100.0 2,453.7 100.0 3,050.8 100.0

Investment3 4.7 7.8 19.9 47.3 83.3 142.7 154.7

Total health care spending

41.9 74.6 255.3 721.4 1,369.7 2,596.4 3,205.6

Source: Centers for Medicare and Medicaid Services (CMS) website, available at https://www.cms.gov/NationalHealthExpendData/03_NationalHealthAccountsProjected.asp#TopOfPage. Accessed January 8, 2016. 1Children’s Health Insurance, Department of Defense, and Veterans’ Affairs. 2Worksite health care other private revenues, Indian Health Service, Workers’ Compensation, general assistance, maternal and child health, vocational rehabilitation, and other federal programs. 3Research, structures, and equipment.

06757_ch01_ptg01_001-024.indd 8 8/4/17 4:44 PM

Chapter 1: U.S. Medical Care: An Uncertain Future 9

significantly. Some would go so far as to say that hospitals have gone from overcrowded to underused. Another important trend is the shift from inpatient to outpatient care. The number of per capita outpatient visits has tripled since 1970, and outpatient visits per hos- pital admission are almost four times higher.

Cost plus was the standard approach for hospital pricing from the inception of Medi- care until 1983, when pricing shifted to prospective payment using DRGs. Under DRG pricing, payment is fixed in advance and based on the principal diagnosis at the time of hospital admission. In contrast, private insurance pays hospitals negotiated prices based on discounts from billed charges. As a result, the financial risk of treating patients has shifted from the payer to the provider, creating an incentive for providers to limit access to care. Many providers participate in provider networks that offer discounts to group members. Because all must abide by the fee limits placed on them by Medicare and Medicaid, actual transaction prices are deeply discounted from actual billed prices.

The Growth in Managed Care The managed care approach became the prevailing form of insurance in the U.S. market during the decade of the 1990s. By 1999, employer- based group insurance covered nine out of ten employees in a managed care plan (a health maintenance organization, a preferred provider organization, or a point-of-service plan). The rest were still in traditional indemnity insurance plans. The increased popularity of managed care has begun to change the incentive structure within the industry, forcing providers to consider costs more carefully. No longer are physicians’ fees constrained by a pricing model that limits fees to usual, customary, and reasonable (UCR) levels.

In 1986, the federal government established a pricing model for Medicare based on an RVS. The Medicare RVS is an index of resource use for every medical procedure across all specialty areas. It translates into a fee schedule by adjusting resource use by a monetary conversion factor. Most fees charged by physicians are in some way tied to this index.

Many physicians participate in at least one risk-sharing contract with a health plan, in which they receive payment under a capitation arrangement. Capitation is a fixed fee, paid in advance, for all necessary care provided to a well-defined group. Providing care for a

group insurance A plan whereby an entire group receives insur- ance under a single policy. The insurance is actually issued to the plan holder, usually an employer or association.

indemnity insurance Insurance based on the principle that someone suffering an economic loss receives a payment approximately equal to the size of the loss.

tABle 1.3 shoRt-stAy coMMuNity hospitAl chARActeRistics, uNiteD stAtes

Category 1970 1980 1990 2000 2005 2010 2014

Hospitals 5,859 5,904 5,420 4,915 4,936 4,985 4,926

Beds (per 1,000 population)

4.2 4.4 3.7 2.9 2.7 2.6 2.5

Admissions (per 1,000 population)

144.0 159.6 125.4 117.6 118.9 113.8 103.7

Average length of stay (days)

7.7 7.6 7.2 5.8 5.6 5.4 5.5

Outpatient visits (per 1,000 population)

657 893 1,212 1,846 2,198 2,125 2,173

Outpatient visits /admissions

4.6 5.6 9.7 15.8 16.6 18.5 21.0

Outpatient surgeries (% total)

– 16.3 50.5 62.7 63.3 63.6 65.9

Percent occupancy 78.0 75.4 66.8 63.9 67.3 64.5 62.9

Source: Health United States, various years.

06757_ch01_ptg01_001-024.indd 9 8/4/17 4:44 PM

10 Chapter 1: U.S. Medical Care: An Uncertain Future

fixed fee changes the nature of the physician–patient relationship. With cost increasingly an issue, the provider has a stake in eliminating all unnecessary care, which increases the risk that plans may deny potentially beneficial care in the name of cost savings.

The Current Framework and Its Consequences The current medical care delivery system has been shaped by the passage of the ACA. Now that the key components of the law are in place, we have some reckoning of the consequences of the legislation, intended and unintended. The key elements of the ACA are summarized as follows.

1. Medicaid expansion. States are provided federal subsidies (100 percent of the cost of the expansion initially and falling to 90 percent by 2020) to set a national eligibility standard for Medicaid qualification. Individuals making less than 138 percent of the federal poverty income level can receive free care through this state-administered and federally funded expansion. (The original intent was that all states would be required to participate in the expansion, but the 2012 Supreme Court decision made the expan- sion voluntary for the states.)

2. Premium subsidies in the insurance exchanges. Electronic marketplaces were established where insurance companies offer qualified health plans to individuals who do not have access to affordable plans through an employer. Premium subsidies are available to individuals earning between 100 and 400 percent of the federal poverty level income making the plans more affordable. States may set up their own marketplaces or use the federal marketplace, Healthcare.gov.

3. Individual mandate. Individuals are required to purchase qualified insurance. Failure to comply will result in penalties (labeled a tax in the 2012 Supreme Court decision declaring the law constitutional).

4. Employer mandate. Firms employing more than 50 full-time workers are required to provide a qualified insurance plan or pay a penalty tax.

5. Expanded insurance regulations. The new law requires guaranteed issue, guaranteed renewability, and eliminates preexisting condition exclusions from all health insur- ance. Adult children can receive coverage on their parents’ plan until they are 26 years old, and there can be no lifetime maximums on spending.

6. Medicare-related changes. As part of the financing package, Medicare spending will be cut by $741 billion over the next decade. One-third of these cuts will be from Medicare Advantage, the premium support program that allows seniors to purchase subsidized private insurance. Further, the Medicare payroll tax increased from 2.9 percent to 3.8 percent on families earning more than $250,000. Medicare benefits were expanded to mirror the features of qualified plans in the rest of the system (free preventive services and expanded prescription drug benefits).

7. New federal taxes. An increase in federal taxes will raise over $1 trillion in additional revenue over the next decade. Taxes will include fees on health insurance premiums, caps on the maximum contribution individuals can make to their tax-exempt flexible- spending accounts, an excise tax on comprehensive health insurance plans (Cadil- lac tax), an additional Medicare tax on family incomes above $250,000, a surtax on investment income (dividends and capital gains), and of course the penalty tax on individuals and firms that do not comply with the insurance mandate.

8. Co-op health plans. Consumer groups used over $2 billion in federal loans to establish 23 nonprofit cooperative health plans in 22 states to compete directly with the plans available from private insurance companies.

Proponents of the ACA point out the increased insurance coverage as the major accom- plishment of the reform. Frean, Gruber, and Sommers (2016) estimate that approximately

policy issue Can medical care be treated like any other commodity for policy purposes, or is it sufficiently different that it must be treated as a special case?

http:// John M. Keynes, author of The General Theory of Employment, Inter- est, and Money, wrote that “practical men, who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct economist. Madmen in authority, who hear voices in the air, are distilling their frenzy from some aca- demic scribbler of a few years back.” The Dead Economists Society is dedicated to the pres- ervation of the insights of classical liberal econ- omists, such as Adam Smith, Friedrich Hayek, Ludwig von Mises, Booker T. Washington, and Benjamin Franklin. Check it out at http:// www.personal.psu.edu /faculty/j/d/jdm114/ oldindex.html.

Key coNcept 6 Supply and Demand

guaranteed renewability A feature of an insurance policy that requires the insurer to guarantee renewal of the policy as long a pre- miums are paid, regard- less of any changes in the health status of the policy holder.

06757_ch01_ptg01_001-024.indd 10 8/4/17 4:44 PM

Chapter 1: U.S. Medical Care: An Uncertain Future 11

20 million Americans who were previously uninsured now have insurance, reducing the percentage of the population uninsured from 16 to 9 percent. Critics point to this same research as proof that the ACA was essentially the Medicaid Expansion Act. Approximately, 63 percent of the newly insured received insurance coverage through Medicaid. Further- more, of the 12.6 million new Medicaid enrollees, almost 70 percent (8.8 million) were eligible for the program under eligibility standards that existed prior to the passage of the ACA. Less than one-third (3.8 million) received coverage under the expanded eligibility standards.

The remaining 7.4 million newly insured gained coverage because of the premium sub- sidies available in the exchanges. Most of these individuals earn less than 250 percent of the federal poverty level (FPL) and are eligible for cost-sharing subsidies, covering a substan- tial portion of their out-of-pocket spending on deductibles and copayments.

Surprisingly, the individual mandate has had little impact on coverage. The penalty is still relatively modest, exemptions common, and enforcement difficult. Over time if the penalty remains in place and increases in size, the mandate may play a larger role in expanding coverage.

Two of the most popular features of the law are the coverage provision for adult children and the exclusion of preexisting conditions from the insurance underwriting process. Together these two features have worked against the creation of workable risk pools in the insurance exchanges. The dependent coverage provision is keeping healthy young people out of the exchanges, and the preexisting conditions exclusion is populat- ing the risk pools with older and sicker individuals. As a result, insurance premiums for the young and healthy who remain are twice as high as they would be otherwise, further discouraging this important demographic cohort from participating in the exchange pools.

Finally, the co-op health plans have not served their intended purpose to provide a reli- able alternative to the for-profit plans in the exchanges. What seemed like a good idea was actually doomed from the outset. Underfunded and staffed with inexperienced adminis- trators, only five of the original 23 were still active by the end of 2016. The other 18 have failed and lost over $2.5 billion in taxpayer funds. Most of the remaining five are losing money and likely to fail. In many ways, the exchange experience of the co-ops is similar to the other insurers. Most insurance companies are losing money on their exchange plans and no longer participate. Over one-third of all counties in the country had only one insur- ance choice in 2017.

Looking Ahead: An Uncertain Future The 2016 election reopened the health care reform debate. It is difficult to speculate what the Republican reform plan will look like, but if President Trump’s early actions are an indication of his intentions, it is reason- able to expect that he will make every effort to fulfill his campaign promise to repeal and replace Obamacare. Simultaneous action is the most likely approach. Even though repeal is possible (under Senate reconciliation rules), repeal and delay has too many obstacles, namely 48 Senate Democrats, to be a viable option. Moreover, it is unlikely that Senate will change its filibuster rules to accommodate a repeal-now-and-replace- later strategy.

The majority of Americans want to see an incremental approach to reforming the health care system. Moreover, early indications from Republican leadership in the Congress make it clear that incremental change is their preferred strategy. What will the reform plan look like? What follows is my best guess.

■■ A partial repeal of the ACA: Keep most of the insurance regulations and taxes. ■■ Deregulate the insurance exchanges.

06757_ch01_ptg01_001-024.indd 11 8/4/17 4:44 PM

12 Chapter 1: U.S. Medical Care: An Uncertain Future

■■ Simplify the premium subsidy calculation: Age-adjusted tax credits that are advance- able and refundable will replace income-based subsidies. (Expect four age categories, 0–17, 18–34, 35–49, and 50–64.)

■■ Allow individuals who work for small firms (with fewer than 50 employees) to purchase non-group insurance using the tax credits.

■■ The tax exclusion for employer-sponsored insurance will remain in place but with a cap on the maximum exemption. (This will replace the unpopular 40 percent marginal tax on high-premium plans.)

■■ Expand the use of health savings accounts (HSAs) to support high-deductible health plans (HDHP) by providing new enrollees with a one-time tax credit to set up their HSA. Require HDHPs to cover preventive services and maintenance drugs at zero copay.

■■ Provide a one-year window with guaranteed issue for individuals experiencing certain life transitions (newborns, 18 year olds, and 19–25 year olds who had insurance on their parents’ plans).

■■ Coverage provisions for individuals with preexisting conditions during the start-up period. This may be a federally subsidized, high-risk pool or premium tax credits adjusted by health status in addition to the age categories.

■■ Congress will be forced to address Medicaid because of the significant role it has played in expanding coverage to low-income Americans. They will likely allow states to apply for a per-capita allotment (modified block grant) instead of the current matching payment and encourage states to seek waivers to experiment with different coverage options. Enrollees will be free to use the tax credit to purchase private insurance and set up HSAs (similar to the Healthy Indiana Plan or HIP 2.0).

■■ Eventually, Medicare will become part of the conversation: Changes may include adjusting the eligibility age, combining hospital and physicians’ coverage to simplify the administration, providing catastrophic coverage, and replacing the current financial arrangement with premium support.

Recommending changes to Medicare and Medicaid is the well-known third rail of national politics. Go there at your own risk. As we move through the next 15 chapters, we will examine what economics has to say about developing a viable health care system and the specific characteristics of the different reform options will become clearer.

Health Economics Defined Health economics emerged as a subdiscipline of economics in the 1960s with the pub- lication of two important papers by Kenneth Arrow (1963) and Mark V. Pauly (1968), both published in the American Economic Review (AER). Many consider Arrow’s paper the seminal contribution to the field of health economics and health policy. Recognizing its importance, the Journal of Health Politics, Policy, and Law (Peterson, 2001) devoted a special issue to the paper’s important contributions, including a foreword written by Pauly.

Health economists examine a wide range of issues, extending from the nature and production of health to the market for health and medical care to the microeconomic evaluation of health care interventions and strategies. Figure 1.2 provides a diagram- matic overview of the structure of health economics. Beginning with the box labeled “Nature of Health,” we can ask ourselves a number of questions: What does it mean to be healthy? How do we measure health? What is the best possible way to measure

06757_ch01_ptg01_001-024.indd 12 8/4/17 4:44 PM

Chapter 1: U.S. Medical Care: An Uncertain Future 13

quality of life? Because of the nature of the questions, research on this topic is interdis- ciplinary. Even though economists are not the only ones studying these questions, their contributions have been significant. The development of the quality of life measure, called the quality-adjusted life year (QALY), was in part a result of the participation of economists.

Grossman (1972) developed an economic framework for the study of medical care demand in which medical care is simply one of many factors used to produce good health. In this framework, “Production of Health” looks at the determinants of health, including income, wealth, education, genetics, and public health. Our ability to maintain a desired level of health depends largely on the lifestyle choices we make. The topic “Population Health” examines challenges in health care delivery across different groups in a diverse population. For example, differences in tobacco, alcohol, and drug use and differences in obesity rates and rates of sexually transmitted diseases affect our ability to produce similar health outcomes across different populations.

The principle activity of health economists outside the United States is microeconomic evaluation or the evaluation of alternative ways to treat a specific medical condition. Poli- cymakers within fixed-budget systems find it necessary to conduct studies comparing the costs and consequences of diagnosis and treatment options in order to make informed decisions on the optimal allocation of scarce resources. Cost-benefit analysis, with its welfare economics framework, provides the foundation for most of the research in eco- nomic evaluation, and health economists have adapted that framework in developing cost- effectiveness analysis, the evaluation method of choice in medical care decision-making.

1. Nature of Health

4. Microeconomic

Evaluation

9. Health Policy and Planning

8. Macroeconomic

Evaluation

2. Production of Health

3. Population Health

7. Market Equilibrium

5. Demand for Health Care

6. Supply of Health Care

FiGuRe 1.2 The Structure of Health Economics

Source: Adapted from Alan Maynard and Panos Kanavos, “Health Economics: An Evolving Paradigm,” Health Economics 9, 2000, 183–90.

http:// Familiarize yourself with economic concepts and issues by staying abreast of recent developments in the world of business. A popular business daily newspaper is the Wall Street Journal also available in an online, interactive edition at http://online.wsj.com /public/us.

06757_ch01_ptg01_001-024.indd 13 8/4/17 4:44 PM

14 Chapter 1: U.S. Medical Care: An Uncertain Future

The primary focus of U.S. health economists is the market for health care. The boxes in Figure 1.2 numbered 5 through 7, and the topics covered in them, summarize this emphasis. The “Demand for Health Care” is affected by the elements discussed in boxes 1 and 2, the nature and production of health. The early contribution of economics to the study of health care demand considered improving health to be one way to increase future productivity (Mushkin, 1962). Thus, the demand for health care is not only influ- enced by a desire to feel better when ill, it is also viewed as investment in human capital. Factors affecting the demand for medical care include the socioeconomic characteris- tics of the population, patient demographics, access barriers (including cost- sharing arrangements), and the role of providers in determining the type and level of care prescribed.

The “Supply of Health Care” encompasses a broad spectrum of economics on such topics as production theory, input markets, and industrial organization. Specific issues examined include the cost of production, input substitution, and the nature and role of incentives. Demand and supply interact with one another to establish “Market Equilib- rium.” Markets are able to allocate scarce resources effectively where they are most produc- tive by establishing a price for everything.

Analysis of the overall goals and objectives of the health care system is the subject of “Macroeconomic Evaluation.” How well is the system performing? Is it accessible? Is it affordable? Is quality at the desired level? How does our system compare to those of our neighbors? Finally, “Health Policy and Planning” involves the interaction of private sector, government, and nongovernmental organizations (NGOs) in setting national goals, deter- mining the strategies for reaching those goals, and establishing the rules of the game that regulate how medical care markets work.

Health care systems are constantly changing. Policymakers and planners are always looking for better ways to produce, deliver, and pay for a growing menu of medical care services demanded by an insatiable public. The goal of this book is to provide you with the tools to understand the role of economics in this important task.

Ten Key Economic Concepts Given the complexity of economic theory, it may come as a surprise that a relatively small number of key concepts guide economic thought. These concepts will serve as unifying themes throughout the book.

1. Scarcity and choice address the problem of limited resources and the need to econ- omize. Not enough resources are available to meet all the desires of all the people, making rationing in some form unavoidable. We are forced to make choices among competing objectives—an inescapable result of scarcity.

2. Opportunity cost recognizes that everything and everyone has alternatives. Time and resources used to satisfy one set of desires cannot be used to satisfy another set. The cost of any decision or action is measured in terms of the value placed on the opportu- nity foregone.

3. Marginal analysis is the economic way of thinking about the optimal allocation of resources. Choices are seldom an all-or-nothing proposition—decisions are made at “the margin.” Decision makers weigh the trade-offs, a little more of one thing and a lit- tle less of another. In this environment, the incremental benefits and incremental costs of a decision are considered.

scarcity A situation that exists when the amount of a good or service demanded in the aggregate exceeds the amount available at a zero price.

http:// Differences of opinion among economists have been a constant source of humor. Jokes about economists and economics that even Adam Smith would enjoy can be found at http:// www.ahajokes.com /economist_jokes.html.

06757_ch01_ptg01_001-024.indd 14 8/4/17 4:44 PM

Chapter 1: U.S. Medical Care: An Uncertain Future 15

4. Self-interest is the primary motivator of economic decision makers. Driven by the power of self-interest, people are motivated to pursue efficiency in the production and consumption decisions they make. According to the well-known eighteenth-century economist Adam Smith, this pursuit of self-interest, moderated by market competi- tion, causes each individual to pursue a course of action that promotes the general goals of society.

5. Markets and pricing serve as the most efficient way to allocate scarce resources. The market accomplishes its tasks through a system of prices, what Smith called the “invis- ible hand.” The invisible hand can allocate resources because everyone and everything has a price. When they desire more, prices increase. When they desire less, prices decrease. Firms base their production decisions on relative prices and relative price movements. The price mechanism becomes a way to bring a firm’s output decisions into balance with consumer desires—something that we refer to as equilibrium.

6. Supply and demand serve as the foundation for all economic analysis. Pricing and out- put decisions are based on the forces underlying these two economic concepts. Goods and services are allocated among competing uses by striking a balance, or attaining equilibrium, between consumers’ willingness to pay and suppliers’ willingness to pro- vide. This is rationing via prices.

7. Competition forces resource owners to use their resources to promote the highest pos- sible satisfaction of society, including consumers, producers, and investors. If resource owners do this well, they are rewarded. If they are inept or inefficient, they are penal- ized. Competition takes production out of the hands of the less competent and places it into the hands of the more efficient, constantly promoting more efficient methods of production.

8. Efficiency in economics measures how well resource use promotes social welfare. Inef- ficient outcomes waste resources, but the efficient use of scarce resources enhances social welfare. The fascinating aspect of competitive markets is how the more-or-less independent behavior on the part of thousands of decision makers serves to promote social welfare. Consumers attempt to make themselves better off by allocating limited budgets. Producers seek maximum profits by using cost-minimizing methods.

9. Market failure arises when the free market fails to promote the efficient use of resources by either producing more or less than the optimal level of output. Sources of market failure include natural monopoly, externalities in production and consumption, and public goods. Other market imperfections, such as incomplete information and immobile resources, also contribute to this problem.

10. Comparative advantage explains how people benefit from voluntary exchange when production decisions are based on opportunity cost. The individual or entity that has the lowest opportunity cost of production has the comparative advantage.

equilibrium The market-clearing price at which every consumer wanting to purchase the good finds a willing seller.

http:// “Health Economics— Places to Go” provides links to sites related to health economics, health policy, managed care, and more. http:// www.healtheconomics .com/resource/health- economics-places-to-go/.

Summary and Conclusions goods and services than either defense or automobiles. It may be difficult to imagine, but the economic output of the U.S. medical care industry was larger than the entire French economy.

As shown in Figure 1.3, a potpourri of public and private sources finances U.S. medical care. The pub- lic sector directly finances over 45 percent of total

The medical care industry in the United States is large and growing in relative size. Medical care is one of the largest industries in the vast U.S. economy. At more than $3.2 trillion, it was four-and-one-half times larger than the domestic auto industry and four times larger than the total defense budget in 2015. In addition, med- ical care employed more people and exported more

public good A good that is nonrival in distri- bution and nonexclusive in consumption.

opportunity cost The cost of a decision based on the value of the fore- gone opportunity.

06757_ch01_ptg01_001-024.indd 15 8/4/17 4:44 PM

16 Chapter 1: U.S. Medical Care: An Uncertain Future

Americans. The legislation has introduced a modest measure of portability in the market for group health insurance, and denying coverage to individuals with preexisting health conditions is no longer possible.

The system also has its strengths, and its defenders argue that quality is unquestionably high. Citing evi- dence from polls, they note that around 70 percent of Americans are happy with the quality of the medical care they receive personally. Over one-third of the same individuals would give the overall health care system a failing grade (Kleckley et al., 2010). The U.S. system has progressed much faster than its European counterparts in developing quality assessment and output measures. The United States is still the world leader in innova- tion, research, and the development of state-of-the-art technology.

The growth in medical care spending has moderated somewhat since 1990. It could be that the aggressive action by employers and state governments to reverse the escalation in spending is finally paying off or pos- sibly that the threat of government intervention at the

spending. Private health insurance and private philan- thropy finance 43 percent, leaving about 11 percent to come from direct, out-of-pocket payments from individuals.

Most of the money Americans spend on medical care covers either hospital or physicians’ services (see Figure 1.4). The percentage of total spending in these two areas has remained at around 55 percent. Phar- maceutical spending amounts to 10.6 percent of total spending. Other personal and professional services, home health, medical products, and nursing home care combine for approximately one-fourth of the total spending. The other 10 percent is due to administration and public health spending.

The U.S. system of medical care delivery is far from perfect. Critics claim there are too few primary care physicians and too many specialists, leading to greater reliance on acute and specialty care and underutiliza- tion of primary and preventive care. Policymakers designed the ACA to close some of the gaps in health insurance coverage that limit reliable access for many

Get Professional Assignment Help Cheaply

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason may is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Our essay writers are graduates with diplomas, bachelor’s, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college diploma. When assigning your order, we match the paper subject with the area of specialization of the writer.

Why Choose Our Academic Writing Service?

Plagiarism free papers
Timely delivery
Any deadline
Skilled, Experienced Native English Writers
Subject-relevant academic writer
Adherence to paper instructions
Ability to tackle bulk assignments
Reasonable prices
24/7 Customer Support
Get superb grades consistently

How It Works

1. Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2. Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3. Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4. Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

Get Professional Assignment Help Cheaply
Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?
Whichever your reason may is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.
Our essay writers are graduates with diplomas, bachelor’s, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college diploma. When assigning your order, we match the paper subject with the area of specialization of the writer.
Why Choose Our Academic Writing Service?

How It Works
1.      Place an order
You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.
2.      Pay for the order
Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
3.      Track the progress
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
4.      Download the paper
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

PLACE THIS ORDER OR A SIMILAR ORDER WITH Essay fount TODAY AND GET AN AMAZING DISCOUNT

The post U.S. Medical Care appeared first on Essay fount.

What Students Are Saying About Us

.......... Customer ID: 12*** | Rating: ⭐⭐⭐⭐⭐
"Honestly, I was afraid to send my paper to you, but you proved you are a trustworthy service. My essay was done in less than a day, and I received a brilliant piece. I didn’t even believe it was my essay at first 🙂 Great job, thank you!"

.......... Customer ID: 11***| Rating: ⭐⭐⭐⭐⭐
"This company is the best there is. They saved me so many times, I cannot even keep count. Now I recommend it to all my friends, and none of them have complained about it. The writers here are excellent."

U.S. Medical Care

What Students Are Saying About Us

"Order a custom Paper on Similar Assignment at essayfount.com! No Plagiarism! Enjoy 20% Discount!"

About us

Quick Links

Our Policies

Contact Us

What Students Are Saying About Us

"Order a custom Paper on Similar Assignment at essayfount.com! No Plagiarism! Enjoy 20% Discount!"

Related posts:

About us

Quick Links

Our Policies

Contact Us

Cookie and Privacy Settings