avatares de la reforma de salud de obama

AVATARES DE LA REFORMA DE SALUD DE OBAMA

D r . C a r l o s J a v i e r R e g a z z o n i !

21/07/12 10:52Obamacare and the Court

Página 1 de 8http://www.foreignaffairs.com/print/135020

July 16, 2012ESSAY

Obamacare and the CourtHanding Health Policy Back to the People

Barry FriedmanBARRY FRIEDMAN is Jacob D. Fuchsberg Professor of Law at the New York University School of Law. He is theauthor of The Will of the People: How Public Opinion Has Influenced the Supreme Court and Shaped the Meaningof the Constitution.

Chief Justice John Roberts in front of the Supreme Court. (Larry Downing / Courtesy Reuters)

In the weeks and months before the U.S. Supreme Court delivered its ruling on the constitutionality of the AffordableCare Act (ACA) in National Federation of Independent Business v. Sebelius, some pundits dubbed the lawsuit "thecase of the century." Whatever the Court decided, commentators and activists on both sides of the aisle thought thatit would resolve the fate of President Barack Obama's health-care reforms. The ruling would reverberate throughoutthe worlds of law and politics.

Instead, the Court surprised everyone. A five-member majority led by Chief Justice John Roberts upheld the ACA ongrounds that few Court watchers had anticipated. The case may well find its way into the annals of the law. But inthe end, Roberts' opinion removed the Court from the debate about health care and put the conversation back in the

22/06/11 22:37How Health Care Can Save or Sink America

Página 1 de 9http://www.foreignaffairs.com/print/67870

July/August 2011ESSAY

How Health Care Can Save or Sink AmericaThe Case for Reform and Fiscal Sustainability

Peter R. OrszagPETER R. ORSZAG is Vice Chair of Global Banking at Citigroup, an Adjunct Senior Fellow at the Council onForeign Relations, and a columnist for Bloomberg. He was Director of the White House's Office of Management andBudget in 2009-10 and Director of the Congressional Budget Office in 2007-8.

Rising health-care costs are at the core of the United States' long-term fiscal imbalance. The Congressional BudgetOffice (CBO) projects that between now and 2050, Medicare, Medicaid, and other federal spending on health carewill rise from 5.5 percent of GDP to more than 12 percent. (Social Security costs, by comparison, are projected toincrease from five percent of GDP to six percent over the same period.) It is no exaggeration to say that the UnitedStates' standing in the world depends on its success in constraining this health-care cost explosion; unless it does, thecountry will eventually face a severe fiscal crisis or a crippling inability to invest in other areas.

The problem is not limited to the federal government. Over the past 25 years, cost increases in the national Medicareand Medicaid programs have roughly paralleled (and actually been slightly below) cost increases in the rest of thehealth-care system. These trends drive a wide range of problems. State governments have had to divert funds fromeducation to health care, which is partly why salaries for professors at public universities are now often 15 to 20percent lower than those at comparable private universities. Meanwhile, the rising cost of employer-sponsoredhealth insurance has squeezed take-home pay for most U.S. workers at the same time as median wages havestagnated and income inequality has increased.

Another dimension of the problem involves the variation of health-care costs across the United States. A recentanalysis by the Medicare Payment Advisory Commission found that spending in higher-cost areas of the UnitedStates (that is, those in the 90th percentile ranked by cost), even after controlling for various factors, was 30 percenthigher than in lower-cost areas (those in the 10th percentile). This substantial variation is undesirable both becausethe high-cost areas unnecessarily drive up total costs and because the results are often haphazard for patients. Indeed,higher costs typically do not equal better care -- and sometimes they mean the opposite.

15/04/10 08:51Health Reform Vote: Global Impressions - Council on Foreign Relations

Página 1 de 2http://www.cfr.org/publication/21719/health_reform_vote.html?breadcrumb=%2Fpublication%2Fby_type%2Fregion_issue_brief

Expert Brief

Health Reform Vote: Global ImpressionsAuthor: Laurie A. Garrett, Senior Fellow for Global Health

March 23, 2010

People all over the world have followed the political rollercoaster surrounding healthcare reform in the United States,

and millions witnessed Sunday's debate and countdown to midnight in the House of Representatives. The chaos that

we call a "health system" in the United States--featuring some 47 million Americans with no insurance and millions

more who are under-insured and face bankruptcy with catastrophic illness--stuns people overseas, especially in

Western Europe.

Many view passage of healthcare reform as a test of President Barack Obama's mettle, and an unfortunate distraction

for the White House from pressing issues such as the global economy, Iranian nuclear capacity, the wars in Iraq and

Afghanistan, and trade negotiations. The president's decision to postpone until June his planned swing through

Indonesia and Australia in order to be in Washington for the House vote appeared to validate overseas concerns that

the U.S. domestic situation was overwhelming the White House.

It's hard not to wonder how international audiences responded to the image of a pro-life, conservative Democrat

(Representative Bart Stupak of Michigan) apparently being decried as a "baby killer" by Texas Republican Randy

Neugebauer during the weekend's final debate, and whether it reinforced concerns about the deep, often uncivil

divisions in the American body politic.

For Americans engaged in global health efforts, the sorry status of the U.S. healthcare system--its nearly $9,000 per

person annual costs and its lowest-in-the-industrial-world achievements in health outcomes--has been a source of

considerable embarrassment. Even as the United States funds the largest efforts in the world to provide antiretroviral

drugs to people with AIDS in Africa, several U.S. states now have waiting lists for access to the same drugs, for

American citizens. As the United States puts increasing pressure on poor and emerging-market countries to develop

their healthcare infrastructures and meet the medical needs of their people, millions of Americans have lost health

coverage amid layoffs in the financial crisis.

Many overseas friends of America have been befuddled by the anger healthcare reform has evoked inside the United

States--cries that reform equals socialism, the entire Tea Party movement, and the general concept that bringing more

people into the medical system is, somehow, a bad thing. Foreign observers cannot be blamed for their confusion:

Americans, too, are perplexed by the anger and emotions the debate has engendered. It is painful.

On Monday, Neugebauer explained his outcry this way: "Last night was the climax of weeks and months of debate on a

support. In the heat and emotion of the debate, I exclaimed the phrase, 'It's a baby killer' in reference to the agreement

reached by the Democratic leadership. While I remain heartbroken over the passage of this bill and the tragic

consequences it will have for the unborn, I deeply regret that my actions were mistakenly interpreted as a direct

reference to Congressman Stupak himself."

Home > By Publication Type > Expert Briefs > Health Reform Vote: Global Impressions

SI EL SISTEMA DE SALUD DE EE.UU. FUESE UN PAÍS, SERÍA LA 7º ECONOMÍA DEL MUNDO

Un sistema donde el todo resulta de la suma de “algunas” de sus partes

LÓGICA SISTÉMICA

R E G L A S

SISTEMA DE SALUD

Recursos !

Procesos !

Resultados !

Expresión Monetaria

Impacto Social •  Humano •  Económico

Gasto en Salud

SIS

TE

MA

DE

SA

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E

N E

E.U

U.

Programas Federales Medicare

Medicaid Chip Veterans Otros

Privados Seguros

Mutuales

Bolsillo

Estados Contribuciones a Prog Federales

Seguros Estaduales

MEDICARE Y MEDICAID Creados por el presidente Lyndon B. Johnson en 1965 Medicare •  Seguro de salud para retirados, con

más de 44 millones de afiliados (2008), y que cuesta $432 mil millones o 3.2% del GDP de EE.UU. en 2007.

Medicaid •  Programa de protección social que

atiende a 40 millones de personas (2007) y cuesta $330 mil millones de dólares, es decir 2,4% del GDP de EE.UU.

U.S. Department of Health and Human

Services

Centers for Medicare and Medicaid Services

Medicare

Medicaid

DESAFÍOS: SISTEMA DE SALUD DE USA

DESAFÍOS

1.  Sub-cobertura 2.  Sub-prestación 3.  Ineficiencia 4.  Deslealtad comercial 5.  Gasto desbordado 6.  Innovación sustentable 7.  Financiamiento

1. SUB-COBERTURA SISTEMA DE SALUD EN USA: DESAFÍOS

PERSONAS SEGÚN COBERTURA!

45 42 37 15

157

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100 120 140 160 180

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“…la disponibilidad de

cuidados médicos varía

inversamente con la

necesidad de los mismos en

la población, hecho que se

magnifica en operando

fuerzas de mercado…”!

LEY DEL CUIDADO INVERSO

Hart JT. The inverse care law. Lancet 1971; i:405-412

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Articles

www.thelancet.com Published online May 10, 2012 DOI:10.1016/S0140-6736(12)60240-2 3

ResultsWe analysed data from 1 751 841 patients (about a third of the Scottish population) from 314 Scottish medical practices. Table 1 shows the demographic characteristics of the study population, the proportion of those with multimorbidity, and the proportion with physical and mental health comorbidity. Men and women were equally represented, as were all deprivation deciles. 42·2% (95% CI 42·1–42·3) of the population had one or more chronic morbidities, 23·2% (23·1–23·2) had multimorbidity, and 8·3% (8·3–8·4) had physical and mental health comorbidity. Of people with at least one morbidity, 54·9% (54·8–55·0) had multimorbidity and 19·8% (19·8–19·9) had physical and mental health comorbidity. Most people with common chronic mor-bidities had at least two, and frequently more, other disorders (appendix).

The number of morbidities and the proportion of people with multimorbidity increased substantially with age (table 1). By age 50 years, half of the population had at least one morbidity, and by age 65 years most were multimorbid (fi gure 1). However, in absolute terms, more people with multimorbidity were younger than 65 years than 65 years and older (210 500 vs 194 966), although older people had more morbidities on average (table 1).

The crude prevalence of multimorbidity increased modestly with the deprivation of the area in which patients lived (19·5%, 95% CI 19·3–19·6, in the most a! uent areas vs 24·1%, 23·9–24·4, in the most deprived; di" erence 4·6%, 95% CI 4·3–4·9; table 1). However, this fi nding should be interpreted with caution because the population in more deprived areas was, on average, younger (median age 37 years [IQR 21–53] in the most deprived areas vs 42 years [IQR 22–58] in the most a! uent areas). People living in more deprived areas were more likely to be multimorbid than were those living in the most a! uent areas at all ages, apart from those aged 85 years and older (fi gure 2). Young and middle-aged adults living in the most deprived areas had rates of multimorbidity equivalent to those aged 10–15 years older in the most a! uent areas (fi gure 2 and appendix).

8·3% (95% CI 8·3–8·4) of all patients, and 36·0% (35·9–36·2) of people with multimorbidity, had both a physical and a mental health disorder. The prevalence of physical and mental health comorbidity was higher in women than in men, and was substantially higher in older people than in younger people (table 1). Although older people were much more likely to have physical–mental health comorbidity, the absolute numbers were greater in younger people (90 139 people <65 years vs 55 912 people #65 years). The crude socioeconomic gradient in physical–mental health comorbidity was greater than that for any multimorbidity, with a near doubling in prevalence in the most deprived versus the most a! uent areas (table 1; di" erence 5·1%, 95% CI 4·9–5·3). In the logistic regres-sion analysis with the presence of any mental health

disorder as the outcome (table 2), we noted a non-linear association with age, so we included an age-squared term in the model. The predicted probability of having a mental health disorder increased with age up until about age 60 years, and then decreased (data not shown). Men were less likely to have a mental health disorder than were women, and those in the most deprived decile were more than twice as likely to have a mental health disorder than were those in the most a! uent decile (adjusted OR 2·28, 95% CI 2·21–2·32). The presence of a mental health disorder was strongly associated with the number of physical disorders that an individual had—eg, people with fi ve or more disorders had an OR of 6·74 (95% CI

0 disorders1 disorder2 disorders3 disorders4 disorders5 disorders6 disorders7 disorders!8 disorders

100

0–4 5–910–14

15–1920–24

25–2930–34

35–3940–4

445–4

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55–5960–6

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970–74

75–7980–8

485+

Age group (years)

Patie

nts (

%)

90

80

70

60

50

40

30

20

10

0

Figure !: Number of chronic disorders by age-group

90

80

70

60

50

40

30

20

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3·0

4·08·0

12·0

16·821·2

26·8

36·8

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Figure ": Prevalence of multimorbidity by age and socioeconomic status On socioeconomic status scale, 1=most a! uent and 10=most deprived.

Barnett K, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet, May10, 2012 DOI:10.1016/S0140-6736(12)60240-2

EXPANSIÓN DE LA COBERTURA

El aumento de la cobertura en salud se asocia a reducciones de mortalidad de la población, y al aumento de la accesibilidad.

Dos Ejemplos: 1.  Expansión del Medicaid

2.  Experimento del Seguro de Salud

¿CAMBIÓ ALGO LA EXPANSIÓN DEL MEDICAID?

-Mortalidad adultos ⁄

-Percepción de salud ⁄

-Accesibilidad ⁄

Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after State Medicaid expansions. N Engl J Med, July 25, 2012

5 años 5 años

Expansión del Medicaid: •  Jóvenes 19 – 64 años •  Sin hijos •  Ingresos <100% línea de pobreza

•  Arizona •  Maine •  New York

•  N Hampshire •  Pennsylvania •  Nevada

Año 2000

HEALTH INSURANCE EXPERIMENT

•  2.750 Familias

•  <65 años •  Incluyó niños •  6 lugares, US

Atención Libre

Co-pago Ajus/ingreso

Cooperativa HMO

25%

50%

95%

1971 1982

•  Nivel de uso del médico •  Estado de salud •  Satisfacción •  Internaciones •  Calidad de atención •  Gasto de bolsillo •  Costos de atención

RAND RESEARCH AREAS

THE ARTS

CHILD POLICY

CIVIL JUSTICE

EDUCATION

ENERGY AND ENVIRONMENT

HEALTH AND HEALTH CARE

INTERNATIONAL AFFAIRS

NATIONAL SECURITY

POPULATION AND AGING

PUBLIC SAFETY

SCIENCE AND TECHNOLOGY

SUBSTANCE ABUSE

TERRORISM ANDHOMELAND SECURITY

TRANSPORTATION ANDINFRASTRUCTURE

WORKFORCE AND WORKPLACE

The Health Insurance ExperimentA Classic RAND Study Speaks to the Current Health Care Reform Debate

After decades of evolution and experiment, the U.S. health care system has yet to solve a funda-mental challenge: delivering quality

health care to all Americans at an a! ordable price. In the coming years, new solutions will be explored and older ideas revisited. One idea that has returned to prominence is cost sharing, which involves shifting a greater share of health care expense and responsibil-ity onto consumers. Recent public discussion of cost sharing has often cited a landmark RAND study: the Health Insurance Experi-ment (HIE). Although it was completed over two decades ago, in 1982, the HIE remains the only long-term, experimental study of cost sharing and its e! ect on service use, quality of care, and health. " e purpose of this research brief is to summarize the HIE’s main fi ndings and clarify its relevance for today’s debate. Our goal is not to conclude that cost sharing is good or bad but to illuminate its e! ects so that policymakers can use the information to make sound decisions.

Learning from Experiment: Conducting the HIE In the early 1970s, fi nancing and the impact of cost sharing took center stage in the national health care debate. At the time, the debate focused on free, universal health care and whether the benefi ts would justify the costs. To inform this debate, an interdisciplinary team of RAND researchers designed and car-ried out the HIE, one of the largest and most comprehensive social science experiments ever performed in the United States.

" e HIE posed three basic questions: • How does cost sharing or membership in

an HMO a! ect use of health services com-pared to free care?

• How does cost sharing or membership in an HMO a! ect appropriateness and quality of care received?

• What are the consequences for health?

" e HIE was a large-scale, randomized experiment conducted between 1971 and 1982. For the study, RAND recruited 2,750 families encompassing more than 7,700 indi-viduals, all of whom were under the age of 65. " ey were chosen from six sites across the

This product is part of the RAND Corporation research brief series. RAND research

briefs present policy-oriented summaries of individual

published, peer-reviewed documents or of a body of

published work.

Corporate Headquarters 1776 Main Street

P.O. Box 2138 Santa Monica, California

90407-2138 TEL 310.393.0411

FAX 310.393.4818

© RAND 2006

www.rand.org

Key fi ndings:

• In a large-scale, multiyear experiment, participants who paid for a share of their health care used fewer health services than a comparison group given free care.

• Cost sharing reduced the use of both highly effective and less effective services in roughly equal proportions. Cost sharing did not signifi cantly affect the quality of care received by participants.

• Cost sharing in general had no adverse effects on participant health, but there were exceptions: free care led to improve-ments in hypertension, dental health, vision, and selected serious symptoms. These improvements were concentrated among the sickest and poorest patients. Emmett B. Keeler. Effects of Cost Sharing on Use of Medical Services and Health.

Medical Practice Management, Summer 1992, pp. 317–321

¿Cómo impacta el tipo de seguro sobre la utilización del sistema de salud?


Los pacientes con co-pago:

•  Van menos al médico

RAND RESEARCH AREAS

THE ARTS

CHILD POLICY

CIVIL JUSTICE

EDUCATION




NATIONAL SECURITY


PUBLIC SAFETY


SUBSTANCE ABUSE
















published work.



90407-2138 TEL 310.393.0411

FAX 310.393.4818

© RAND 2006

www.rand.org

Key fi ndings:



• Cost sharing in general had no adverse effects on participant health, but there were exceptions: free care led to improve-ments in hypertension, dental health, vision, and selected serious symptoms. These improvements were concentrated among the sickest and poorest patients.

United States to provide a regional and urban/rural balance. Participants were randomly assigned to one of fi ve types of health insurance plans created specifi cally for the experi-ment. ! ere were four basic types of fee-for-service plans: One type o" ered free care; the other three types involved varying levels of cost sharing—25 percent, 50 percent, or 95 percent coinsurance (the percentage of medical charges that the consumer must pay). ! e fi fth type of health insurance plan was a nonprofi t, HMO-style group cooperative. ! ose assigned to the HMO received their care free of charge. For poorer families in plans that involved cost sharing, the amount of cost sharing was income-adjusted to one of three levels: 5, 10, or 15 percent of income. Out-of-pocket spend-ing was capped at these percentages of income or at $1,000 annually (roughly $3,000 annually if adjusted from 1977 to 2005 levels), whichever was lower. ! e 95 percent coinsur-ance plan in the study closely resembled the high-deductible catastrophic plans being discussed today.

Families participated in the experiment for 3–5 years. ! e upper age limit for adults at the time of enrollment was 61, so that no participants would become eligible for Medicare before the experiment ended. To assess partici-pant service use, costs, and quality of care, RAND served as the families’ insurer and processed their claims. To assess participant health, RAND administered surveys at the beginning and end of the experiment and also conducted comprehensive physical exams. Sixty percent of participants were randomly chosen to receive exams at the beginning of the study, and all received physicals at the end. ! e random use of physicals at the beginning was intended to control for possible health e" ects that might be stimulated by the physi-cal exam alone, independent of further participation in the experiment.

Effects on Use of Health Services ! e results showed that cost sharing reduced the use of nearly all health services. Specifi cally,• Averaged across all levels of coinsurance, participants

(including both adults and children) with cost sharing made one to two fewer physician visits annually and had 20 percent fewer hospitalizations than those with free care. Declines were similar for other types of services as well, including dental visits, prescriptions, and mental health treatment (see Figures 1 and 2).

• Consumers in the HMO-style cooperative had 39 percent fewer hospital admissions than consumers with free care in the fee-for-service system, but they had similar use of outpatient services. Spending reductions under the HMO plan were comparable to the e" ects of a higher rate of coinsurance in the fee-for-service system.

• Participants in cost sharing plans spent less on health care; this savings came from using fewer services rather than fi nding lower prices. ! ose with 25 percent coinsur-ance spent 20 percent less than participants with free care, and those with 95 percent coinsurance spent about 30 percent less (see Figure 3).

• Reduced use of services resulted primarily from partici-pants deciding not to initiate care. Once patients entered the health care system, cost sharing only modestly a" ected the intensity or cost of an episode of care.

Effects on Appropriateness of Care and on Quality of Care! e analysis also examined the appropriateness of the services reduced by cost sharing and the technical quality of care

SOURCE: Newhouse and the Insurance Experiment Group, 1993,Tables 3.2 and 3.3.NOTE: Utilization numbers include both adults and children.

Level of coinsurance (%)

4

3

50250 95

2

1

0

5An

nual

face

-to-fa

ce d

octo

rvi

sits p

er ca

pita

Figure 1Participants with Cost Sharing Visited the Doctor Less Frequently



.12

.06

50250 95

.04

.02

0

.14

Annu

al h

ospi

tal

visit

s per

capi

ta .10

.08

Figure 2. . . and Were Admitted to Hospitals Less Often

– 2 –


Los pacientes con co-pago:

•  Se internan menos

RAND RESEARCH AREAS

THE ARTS

CHILD POLICY

CIVIL JUSTICE

EDUCATION




NATIONAL SECURITY


PUBLIC SAFETY


SUBSTANCE ABUSE
















published work.



90407-2138 TEL 310.393.0411

FAX 310.393.4818

© RAND 2006

www.rand.org

Key fi ndings:




United States to provide a regional and urban/rural balance. Participants were randomly assigned to one of fi ve types of health insurance plans created specifi cally for the experi-ment. ! ere were four basic types of fee-for-service plans: One type o" ered free care; the other three types involved varying levels of cost sharing—25 percent, 50 percent, or 95 percent coinsurance (the percentage of medical charges that the consumer must pay). ! e fi fth type of health insurance plan was a nonprofi t, HMO-style group cooperative. ! ose assigned to the HMO received their care free of charge. For poorer families in plans that involved cost sharing, the amount of cost sharing was income-adjusted to one of three levels: 5, 10, or 15 percent of income. Out-of-pocket spend-ing was capped at these percentages of income or at $1,000 annually (roughly $3,000 annually if adjusted from 1977 to 2005 levels), whichever was lower. ! e 95 percent coinsur-ance plan in the study closely resembled the high-deductible catastrophic plans being discussed today.

Families participated in the experiment for 3–5 years. ! e upper age limit for adults at the time of enrollment was 61, so that no participants would become eligible for Medicare before the experiment ended. To assess partici-pant service use, costs, and quality of care, RAND served as the families’ insurer and processed their claims. To assess participant health, RAND administered surveys at the beginning and end of the experiment and also conducted comprehensive physical exams. Sixty percent of participants were randomly chosen to receive exams at the beginning of the study, and all received physicals at the end. ! e random use of physicals at the beginning was intended to control for possible health e" ects that might be stimulated by the physi-cal exam alone, independent of further participation in the experiment.

Effects on Use of Health Services ! e results showed that cost sharing reduced the use of nearly all health services. Specifi cally,• Averaged across all levels of coinsurance, participants

(including both adults and children) with cost sharing made one to two fewer physician visits annually and had 20 percent fewer hospitalizations than those with free care. Declines were similar for other types of services as well, including dental visits, prescriptions, and mental health treatment (see Figures 1 and 2).

• Consumers in the HMO-style cooperative had 39 percent fewer hospital admissions than consumers with free care in the fee-for-service system, but they had similar use of outpatient services. Spending reductions under the HMO plan were comparable to the e" ects of a higher rate of coinsurance in the fee-for-service system.

• Participants in cost sharing plans spent less on health care; this savings came from using fewer services rather than fi nding lower prices. ! ose with 25 percent coinsur-ance spent 20 percent less than participants with free care, and those with 95 percent coinsurance spent about 30 percent less (see Figure 3).

• Reduced use of services resulted primarily from partici-pants deciding not to initiate care. Once patients entered the health care system, cost sharing only modestly a" ected the intensity or cost of an episode of care.

Effects on Appropriateness of Care and on Quality of Care! e analysis also examined the appropriateness of the services reduced by cost sharing and the technical quality of care



4

3

50250 95

2

1

0

5

Annu

al fa

ce-to

-face

doc

tor

visit

s per

capi

ta

Figure 1Participants with Cost Sharing Visited the Doctor Less Frequently



.12

.06

50250 95

.04

.02

0

.14

Annu

al h

ospi

tal

visit

s per

capi

ta .10

.08

Figure 2. . . and Were Admitted to Hospitals Less Often

– 2 –

2. SUB-PRESTACIÓN SISTEMA DE SALUD EN USA: DESAFÍOS

07 08

09 10 11 11 11 11 11 11 12 12 13

15 16

18 21 21

23 26

36 United States (2006) Spain Portugal Belgium (2006) Denmark Latvia Switzerland (2006) Average France Sweden New Zealand Netherlands (2005) Canada Finland Norway Poland2 (2006) Italy (2006) Ireland United Kingdom Korea Austria (2006)

TASA DE AMPUTACIONES, DIABÉTICOS, OECD 2007!

CALIDAD DE ATENCIÓN: ADULTOS

•  6.712 personas •  Adultos •  12 ciudades

USA •  Contacto tel. •  Acceso a

Historias clínicas

30 Condiciones agudas y crónicas

439 indicadores de calidad de atención

Tratamientos y medidas

preventivas 1998 2000

PARA CADA CONDICIÓN: •  Medición de tratamiento

recibido •  Comparación con tratamiento

recomendado

RAND RESEARCH AREAS

THE ARTS

CHILD POLICY

CIVIL JUSTICE

EDUCATION




NATIONAL SECURITY


PUBLIC SAFETY


SUBSTANCE ABUSE
















published work.



90407-2138 TEL 310.393.0411

FAX 310.393.4818

© RAND 2006

www.rand.org

Key fi ndings:



• Cost sharing in general had no adverse effects on participant health, but there were exceptions: free care led to improve-ments in hypertension, dental health, vision, and selected serious symptoms. These improvements were concentrated among the sickest and poorest patients. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The Quality of Health

Care Delivered to Adults in the United States. N Engl J Med 2003;348:2635-45.

CALIDAD DE ATENCIÓN

35 41 42 42 45 50 55 55 60 90

0%

20%

40%

60%

80%

100%

Proporción del tratamiento teóricamente recomendado, efectivamente recibido por los pacientes.

EE.UU., 12 áreas metropolitanas, 2003. RAND, The First National Report Card on Quality of Health Care in America

No recivido Recivido

RAND RESEARCH AREAS

THE ARTS

CHILD POLICY

CIVIL JUSTICE

EDUCATION




NATIONAL SECURITY


PUBLIC SAFETY


SUBSTANCE ABUSE
















published work.



90407-2138 TEL 310.393.0411

FAX 310.393.4818

© RAND 2006

www.rand.org

Key fi ndings:




3. INEFICIENCIA SISTEMA DE SALUD EN USA: DESAFÍOS

EFICIENCIA DEL GASTO EN SALUD

AUS

AUT

BEL

BRA

CAN

CHL

CHN

CZE

DNK

EST

FIN

FRA

DEU

GRC

HUN

ISL

IND

IDN

IRL

ISR

ITA JPN

KOR

LUX

MEX

NLD NZL NOR

POL

PRT

RUS

SVK

SVN

ESP

SUE CHE

TUR

GBR USA

R! = 0,69

64

68

72

76

80

84

0 2000 4000 6000 8000

Life

Exp

ecta

ncy

(yea

rs)

Source: OECD Health Data 2011; World Bank and national sources for non-OECD countries.

Health spending per capita (USD PPP)

Health at a Glance 2011: OECD Indicators - © OECD 20111. HEALTH STATUS - Life expectancy at birth1.1.1. Life expectancy at birth, 2009, and years gained since 1960 (or nearest year)Version 1 - Last updated: 28-Oct-2011

1.1.1. Life expectancy at birth, 2009 (or nearest year), and years gained since 1960

JapanSwitzerland

ItalySpain

Australia

Life expectancy at birth, 2009 Years gained, 1960-2009

United KingdomGermanyGreeceKorea

IsraelIcelandSwedenFranceNorway

New Zealand

PolandMexicoEstonia

Slovak Republic

CanadaLuxembourg

OECDDenmark

NetherlandsAustria

BelgiumFinlandIreland

Portugal

ChinaBrazil

SloveniaChile

United StatesCzech Republic

IndonesiaRussian Fed.

IndiaSouth Africa

HungaryTurkey

83,0 82,3 81,8 81,8 81,6 81,6 81,5 81,4 81,0 81,0 80,8 80,7 80,7 80,6 80,4 80,4 80,3 80,3 80,3 80,0 80,0 80,0 79,5 79,5 79,0 79,0 78,4 78,2 77,3

75,8 75,3 75,0 75,0 74,0 73,8 73,3 72,6

71,2 68,7

64,1 51,7

40 50 60 70 80 90 Years

15,2 10,9

12,0 12,0

10,7 9,9

8,6 8,3

10,7 7,2

9,7 9,4

11,3 7,1

11,7 9,6

11,2 10,4 27,9

10,2 11,0

10,0 15,6

11,2 6,6

10,5 21,4

8,3 6,7

8,0 17,8

6,5 4,4

6,0 25,5

26,7 18,1 30,0

0,0 21,7

2,6

0 5 10 15 20 25 30 Years

EXPE

CTA

TIVA

DE

VID

A G

AN

AD

A, O

ECD

COSTO-EFICIENCIA

A

B

0

50

100

150

200

250

0 20 40 60 80 100

Nivel de Gasto !

Nivel de salud!

DESEMPEÑO!

Práctica EE.UU. Promedio OECD -Médicos 2,4/1.000 hab 3,1/1.000 hab -Consultas médicas 4/cápita/año 7/cápita/año -Camas de hospital agudo 2,7/1.000 hab 4/1.000 hab -Altas/año 126/1.000 hab/año 158/1.000 hab/año -Estadía promedio 5,5 días 6,5 días

OECD Economic Data 2009, OECD

En Estados Unidos, •  Hay menos médicos y camas que en la OECD •  Se generan menos consultas e internaciones •  Dos posibilidades:

•  O bien la gente se enferma menos •  O bien la gente no recibe la asistencia necesaria

4. DESLEALTAD COMERCIAL SISTEMA DE SALUD EN USA: DESAFÍOS

PRÁCTICAS DE ASEGURADORAS

•  Prácticas de aseguradoras: •  No aceptar personas con pre-existencias. •  Suspender seguros a edades avanzadas. •  No cubrir determinadas patologías.

•  Consecuencia: •  Salida del sistema del más vulnerable.

5. GASTO DESBORDADO SISTEMA DE SALUD EN USA: DESAFÍOS

COMPARACIÓN: GASTO EN SALUD, 1980–2006!

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!+%"""##

$,-"#$,-$#$,-&#$,-'#$,-(#$,-)#$,-*#$,-+#$,--#$,-,#$,,"#$,,$#$,,&#$,,'#$,,(#$,,)#$,,*#$,,+#$,,-#$,,,#&"""#&""$#&""&#&""'#&""(#&"")#&""*#

./0123#415126#72895/:#;5/535#<21=28>5/36#?85/@2#AB6185>05#./0123#C0/D3E9#

Average spending on health per capita ($US PPP*)!

GASTO EN SALUD: INCREMENTO ANUAL Y PARTICIPACIÓN EN EL PBI, USA, 1961-2009

0% 2% 4% 6% 8%

10% 12% 14% 16% 18% 20%

NHE as a Share of GDP

Increase in National Health Expenditures

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2009; file nhegdp2009.zip).

VARIACIÓN: GASTO EN SALUD (NHE) E ÍNDICE DE PRECIOS AL CONSUMIDOR (CPI), 1980-2009

14,2%

11,7%

9,2%

8,4%

6,3%

7,9%

11,0% 10,6%

8,0%

6,2%

4,4% 4,5% 4,5%

5,4% 6,1%

7,4% 8,4%

7,3% 5,9%

5,4%

3,8%

13,5%

10,3%

6,2%

3,2% 4,3%

1,9%

3,6%

4,8% 4,2%

3,0% 3,0% 2,6%

2,8% 2,3%

1,6% 2,2%

3,4%

1,6% 2,3%

3,4% 2,8%

3,8%

-0,4% -2%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Annual Increase in NHE per Capita

Annual Increase in CPI

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip), and CPI data from Bureau of Labor Statistics at ftp://ftp.bls.gov/pub/special.requests/cpi/cpiai.txt (All Urban Consumers, All Items, 1982-1984=100, Not Seasonally Adjusted, U.S. city average).

CRECIMIENTO ANUAL PROMEDIO PER CÁPITA, NHE Y GDP, USA

9,6%

6,8%

4,3% 2,9%

5,8%

3,9%

11,8%

9,8%

5,4% 5,6%

8,2%

5,3%

0%

2%

4%

6%

8%

10%

12%

14%

1970s 1980s 1990s 2000-2010 1970-2010 2011-2020

GDP Per Capita NHE Per Capita

Source: Historical data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, January 2012, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2010; file nhegdp10.zip). Projections from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, July 2011, “National Health Expenditures 2010-2020,” Table 1, https://www.cms.gov/NationalHealthExpendData/downloads/proj2010.pdf.

DISTRIBUTION OF NATIONAL HEALTH EXPENDITURES, BY TYPE OF SERVICE (IN BILLIONS), 2010

Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc.

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).

NHE Total Expenditures: $2,593.6 billion

Nursing Care Facilities & Continuing Care Retirement

Communities, $143.1 (5.5%)

6. INNOVACIÓN SUSTENTABLE SISTEMA DE SALUD EN USA: DESAFÍOS

I N N O V A C I Ó N M É D I C A

The Lancet Commissions

www.thelancet.com Vol 380 August 4, 2012 521

Evidence for the importance of patents is debated. One study159 from 2003, showed that only 17 of the 319 medicines classifi ed by WHO as essential for low-income and middle-income countries could be patented in developing countries, although it has been criticised for selection bias because the WHO essential medicines list contains mainly o! -patent low-cost drugs.160 Only 31% of possible cases had a patent, presumably because of the tradeo! between the complexity and cost of getting a patent compared with the potential market and the perceived protection a! orded by such a patent.

MDG 8E advocates better cooperation between the public and private sectors to improve access to a! ordable drugs in developing countries.161 Although this co oper-ation has successfully reduced costs of fi rst-line HIV regimens, the costs of second-line regimens ($572–1545 per person per year in low-income and middle-income countries for key regimens)162 and novel biotechnology products such as pegylated interferon remain high. In addition to the increased cooperation envisaged in MDG 8, innovative fi nancing could im prove access to novel technologies. Two strategies seem especially promising. First is the development of pricing mechan-isms that enable research and development costs to be recouped separately, rather than passing them on to low-income country purchasers. Second is tiered pricing, which is currently used for many innovative products, whereby pharmaceutical companies price their new products on the basis of a countries’ purchasing power parity, so that the drug is more a! ordable in resource-poor settings.

International issues of patents and lack of research into tropical diseases suggest that a solution is needed to improve research and development for technologies for health. Since 2003, a series of attempts have been made to reach a global consensus, including an independent Commission on Intellectual Property Rights, Innovation and Public Health.163 These e! orts have culminated in the publication of a report by WHO’s Consultative Expert Working Group on Research and Development: Financing and Coordination, which calls for the estab-lishment of a research and development convention that will address fi nancing, coordination, and govern ance.164 Although intellectual property and fi nancing of research and development for neglected topics are still challenging issues in global health diplo macy,165 an international convention has the potential to provide the needed comprehensive global approach, by establishment of binding obligations and commitments, such as the proposal that all countries spend 0·01% of GDP on government-funded research to meet the health needs of developing countries, which equates to $6 billion a year. The 2012 World Health Assembly has resolved to consult members on the feasibility of the report’s conclusions.

Product standards are less high profi le than are patents, but are also important. International standards for some health technologies are inappropriate for low-income countries. For example, international standards require defi brillator batteries to operate at –10°C (not a common temperature in tropical regions).16 Such specifi cations increase pro duction costs for products destined for markets in low-income and middle-income countries.

139 461 106 365USA

24 831 21 827Germany

Medical device patentsPharmaceuticals patentsSelected OECD countriesRest of the world

59 778 68 695Selected OECD countries*

41 758 40 155Rest of the world

13 688 50 976 China

52 398 27 042Japan

Figure !: Country of origin of patent applicationsOECD=Organisation for Economic Co-operation and Development. *Australia, Canada, Switzerland, Finland, France, UK, Italy, South Korea, Netherlands, and Sweden.

Howitt P, Darzi A, et al. Technologies for global health. Lancet 2012; 380: 507–35

62 75 75 76

79 81 82 82 82

85 86

86 87 88

91

0 20 40 60 80 100

Poland Czech Republic

Korea Ireland

United Kingdom OECD (14)

Norway New Zealand

Denmark France

Netherlands Finland Japan

Sweden Canada Iceland

United States

Age-standardised rates (%)

Sobrevida a 5 años, Cáncer de mama, OECD

38 47

52 52 54 57 57 58 58 58 60 61 61 62

66 66 67

0 20 40 60 80 100

Age-standardised rates (%)

Japan (1999-2004)

Iceland (2003-2008)

United States (2000-2005)

Finland (2002-2007)

New Zealand (2002-2007)

Canada (2000-2005)

Sweden (2003-2008)

Korea (2001-2006)

Netherlands (2001-2006)

Norway (2001-2006)

OECD

France (1997-2002)

Denmark (2002-2007)

Ireland (2001-2006)

United Kingdom (2002-2007)

Czech Republic (2001-2006)

Poland (2002-2007)

SOBREVIDA A 5 AÑOS DEL CÁNCER DE COLON, OECD!

7. FINANCIAMIENTO SISTEMA DE SALUD EN USA: DESAFÍOS

COSTO DE SALUD Y ECONOMÍA

0

20

40

60

80

100

x x + 1

Cos

to e

n Sa

lud

P e r í o d o

¿Quién asume el aumento? •  EL SALARIO DEL TRABAJADOR?

o  Mayor cuota? o  Co-pagos?

•  EL INGRESO DEL EMPRESARIO? o  Mayor cuota patronal?

•  EL ESTADO? o  Más impuestos?

Eithoven AC, Fuchs VR. Employment-based health insurance: past, present, and future. Health Affairs 2006; 25:1538-1547


0

20

40

60

80

100

x x + 1

Cos

to e

n Sa

lud

Período

¿Quién asume el aumento? •  EL SALARIO DEL TRABAJADOR?

o  Mayor cuota trabajador o  Co-pagos



0

20

40

60

80

100

x x + 1

Cos

to e

n Sa

lud

Período

¿Quién asume el aumento? •  EL INGRESO DEL EMPRESARIO?

o  Mayor cuota patronal



0

20

40

60

80

100

x x + 1

Cos

to e

n Sa

lud

Período

¿Quién asume el aumento? •  EL ESTADO?

o  Más impuestos


COBERTURA EN SALUD

Figure 2Percentage of Children Under Age 18 With Employment-Based Health

Benefits, Medicaid, and Without Health Insurance, 1994–2007

58.9% 59.3%62.9% 63.7% 64.5% 65.2% 65.9%

64.4% 63.4% 61.6%

58.4% 57.9% 57.1% 56.8%

23.2% 23.5% 22.1%20.8%

20.1% 20.3% 20.9%22.7% 23.9%

26.4% 27.0% 26.7% 27.1% 28.1%

11.0%11.2%11.3%11.6%12.5%13.9%13.6%13.6%12.7%13.1% 10.5% 10.9% 11.7% 11.0%

0%

10%

20%

30%

40%

50%

60%

70%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Employment-Based Coverage

Medicaid

Uninsured

Source: Employee Benefit Research Institute estimates from the Current Population Survey, March 1995–2008 Supplements.

Figure 3Percentage of Adults, Ages 18–64, With Employment-Based Health

Benefits, Medicaid, and Without Health Insurance, 1994–2007

64.3%64.2%64.6%65.0%65.7%66.7%68.2%69.3%69.0%68.4%67.6%

67.4%66.9%66.9%

8.2%8.0%8.2%8.1%7.3%7.0%6.8%6.4%6.4%6.5%7.0%7.9%7.9%8.0%

19.7%20.3%19.8%19.5%

17.1% 17.6% 17.2% 17.7% 17.7% 17.3% 17.2% 17.9% 18.9% 19.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Employment-Based Coverage

Medicaid

Uninsured

Source: Employee Benefit Research Institute estimates from the Current Population Survey, March 1995–2008 Supplements.

EBRI Issue Brief No. 321 • September 2008 • www.ebri.org 6

GOBIERNO Y GASTO EN SALUD

VR Fuchs. Government Payment for Health Care — Causes and Consequences. N Engl J Med 2010; 363: 2181-83

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

1960 1970 1980 1990 2000 2007

Participación en el gasto personal en salud, según fuente de financiamiento, EE.UU.

Privado Gobierno

GASTO EN MEDICAMENTOS, SEGÚN FINANCIADOR, USA, 1999-2009

29,5% 28,1% 26,5% 26,0% 25,8%

25,1% 25,1% 22,7% 22,8% 21,9% 21,2%

49,5% 50,2% 50,9% 50,3% 48,9% 48,9% 49,4% 45,1% 44,1% 43,6% 43,4%

21,0% 21,7% 22,7% 23,6% 25,2%

26,0% 25,5%

32,1% 33,1% 34,6% 35,4%

0%

10%

20%

30%

40%

50%

60%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Notes: Percentages may not total 100% due to rounding.

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2009; file nhe2009.zip).

Seguro Privado

De Bolsillo

Fondos Públicos

0 2 4 6 8 10 12 14 16 18

United States Netherlands (2)

France Germany Denmark

Canada Switzerland

Austria Belgium (1)

New Zealand Portugal (2008)

Sweden United Kingdom

Iceland Greece (2007)

Norway Ireland OECD Spain

Italy Slovenia

Finland Slovak Republic Australia (2008)

Japan (2008) Chile

Czech Republic Israel

Hungary Poland Estonia

Korea Luxembourg (2008)

Mexico Turkey (2008)

GASTO TOTAL EN SALUD, COMO PORCENTAJE DEL PBI, 2009. OECD

Public Private

EE.UU. posee: -Menor participación pública en el gasto en salud. -Pero mayor gasto total en salud

DINERO PÚBLICO A LA SALUD Producción

$

Impuestos

Gobierno

Gasto Salud

Gasto en

Salud

Gas

to P

úblic

o

Prec

io

Uso (Cantidad)

Gasto Público -Cuanto mayor la participación del Estado en el gasto en salud, mayor necesidad de contención de costos

GASTO EN SALUD Y DÉFICIT SOBERANO

21/09/09 22:26Economist.com

Página 1 de 3http://www.economist.com/world/unitedstates/PrinterFriendly.cfm?story_id=14258740

Illustration by David Simonds

Health reform

The labours of SisyphusAug 20th 2009 | NEW YORK From The Economist print edition

Opposition to health-care reform is mounting. Barack Obama must now decide whether toscale back his approach

DO THE Republicans scent blood? One sign that they might came this week, in the form of a sharpletter from John Boehner, leader of the Republicans in the House of Representatives, to the head ofthe Pharmaceutical Research and Manufacturers of America (PhRMA) lobby—long a good friend to theparty. Mr Boehner denounced as “appeasement” the lobby’s decision to support Barack Obama’s plansfor health-care reform. But that decision was made months ago; attacking it now is surely a sign thatthe Republicans think Mr Obama is suddenly in trouble.

And with some justification. First, the Democrats failed to meet the president’s deadline for gettinghealth bills out of both the House and the Senate by August. Next, as politicians headed home toconduct town-hall meetings during this month’s recess, they encountered many constituents angryabout the dangers—real or imagined—to be wrought by health reform. Some of these grumblers wereplanted by conservative groups, but many others were genuinely afraid or upset.

La reforma posible en una compleja trama de intereses.

PUNTOS ESENCIALES DE LA REFORMA

PERSONAS SEGÚN COBERTURA!

45 42 37 15

157

0 20 40 60 80

100 120 140 160 180

No asegurados


!"##$%

&'()&(*&

+'$%

,'(-.

/01(

Tipo de cobertura

Se estiman 45 millones de personas sin seguro de salud

REFORMA Reforma

Cobertura

Financiamiento

Práctica

REFORMA: COBERTURA Cobertura Reforma de los Seguros

Expansión del Aseguramiento

Expansión del Medicaid

Ampliación de cobertura al Medicare

REFORMA: COBERTURA!REFORMA DE LOS SEGUROS

•  Prohibir pre-existencias •  Prohibir bajas arbitrarias o por edad

COBERTURA •  Obligatoriedad del seguro de salud: individuos y empleadores

(>50 trabajadores), efectivo en 2014 •  Multas por incumplimiento

•  Ampliación del Medicaid, si ingreso<138% de la línea de pobreza •  Extender el seguro paterno hasta los 26 años.

MEDICARE •  Congelamiento de precios a aseguradoras que prestan servicios al

Medicare •  Cerrar gap de cobertura de medicamentos en el 2020 ($2,5000-$4,500)

Reuters, 16/04/10, Donna Smith, Deborah Charles

REFORMA: COBERTURA!

45 42 37 15

157

0

50

100

150

200

No asegurados


!"##$%

&'()&(*&

+'$%

,'(

-./0

1(Principio político: cobertura para todos

Ampliación Subsidios y Mercados de seguros Obligatoriedad de empleadores y Créditos fiscales

Mayor gasto federal

Mayor gasto federal

-Mayor negocio -Mayor exigencia de cobertura

15 M 24 M

Dinero Federal Mercado

Aseguradoras

Mayor gasto federal

REFORMA: FINANCIAMIENTO Financiamiento Nuevos recursos federales

-Nuevos Impuestos y Tarifas

Subsidios federales si ingreso >138% y <400% de línea de pobreza

-Al mercado asegurador

Fondos federales para expansión del Medicaid

-A los Estados

REFORMA: FINANCIAMIENTO: NUEVOS RECURSOS!

!  Impuesto a los seguros más elevados (2018)

! Aumentar impuestos al ingreso actualmente destinados al Medicare

!  Fees a las prótesis, medicamentos de marca, y compañías aseguradoras

REFORMA: GASTO Y EQUIDAD

0

10

20

30

40

50

60

0 500

1000 1500 2000 2500 3000 3500 4000 4500 5000

No

aseg

urad

os (m

illon

es)

Gas

to N

acio

nal e

n S

alud

(U$S

mile

s de

m

illon

es)

Proyecciones de Gasto y Población No Asegurada, con y sin Reforma. EE.UU.

Andrea M. Sisko, Christopher J. Truffer, et al. National Health Spending Projections: The Estimated Impact Of Reform Through 2019. HEALTH AFFAIRS 29, NO. 10 (2010): 1933–

1941

Gasto Ley Anterior

Gasto Reforma

No asegurados (Ley anterior)

No asegurados (Reforma)

REFORMA: PRÁCTICA

Práctica Patient Centered-Outcomes Research Institute

Creación de mercados de seguros

REFORMA LUEGO DE LA CORTE

REFORMA LUEGO DE LA CORTE SUPREMA!

45 42 37 15

157

0

50

100

150

200

No asegurados


!"##$%

&'()&(*&

+'$%

,'(

-./0

1(

Ampliación Subsidios y Mercados de seguros Obligatoriedad de empleadores y Créditos fiscales

15 M 24 M

Dinero Federal Mercado

Aseguradoras

CORTE SUPREMA: AMPLIACIÓN MEDICAID!

45 42 37 15

157

0

50

100

150

200

No asegurados


!"##$%

&'()&(*&

+'$%

,'(

-./0

1(

Ampliación

Mayor gasto federal

Residentes 100 – 138% de la línea de pobreza.

15 M

100 90

2014-2016 2020

Federal

Estado

avatares de la reforma de salud de obama

News & Politics

health system

health insurance

health carewill

essayhow health care

salud en usa

america health reform

handing health policy

salud r e g