United States of America
ROBERT F. JONES
M. BROWNELL ANDERSON
The American health care system involves several major participants, each with a special role to play. Among these players are physicians in private or group practice and managed care settings, teaching hospitals, Veterans Administration (VA) hospitals, and the federal government.
Reform of the health care system has risen to the top of the American domestic policy agenda. Health care costs appear to be out of control. Between fifteen and twenty percent of the American population are uninsured, with many more under-insured, and there is increasing concern about quality and efficacy of care. Precursors to major reform have already appeared, in the form of incentives to curb utilization of services and changes in the payment system for hospital and physician services.
Teaching hospitals, which serve as sites for clinical education of medical students and residents, contribute uniquely to the nation's health care delivery system by the magnitude and types of services they offer and the patient populations they serve. They account for 18 percent of the beds, 20 percent of the admissions, 23 percent of the outpatient visits, 17 percent of the emergency room visits, and 23 percent of the births for all short-term, nonfederal hospitals in the United States. Over 60 percent of these teaching hospitals are located in urban areas with populations greater than one million; a third are in major metropolitan centers with populations of 2.5 million or greater. Many of these are located in poverty-stricken, inner-city areas. By default, urban teaching hospitals, through their emergency rooms and outpatient clinics, have become the primary providers for the poor and medically indigent and a safety net for their health care needs. Academic medical centers also care for a disproportionately large share of Medicaid patients. The patient populations of urban teaching hospitals present health problems embedded in the social ills that plague large cities, including drug abuse, violence, and homelessness.