JANUARY

UNITED STATES
adopted at least a basic EHR system, representing an eightfold increase since 2008 (Heisey-Grove and Patel,
2015; Charles et al., 2015).
The Meaningful Use Incentive Program is designed to gradually raise the threshold for EHR functionality above
which providers receive incentives and avoid penalties. The current focus is on information exchange.
How are costs contained?
Annual per capita health expenditures in the United States are the highest in the world ($9,086 in 2013), despite
a recent slowdown in spending (OECD, 2015). Payers have attempted to control cost growth through a
combination of selective provider contracting, price negotiations and controls, utilization control practices, risksharing
payment methods, and managed care. Recently, both public and private payers have focused more
attention on value-based purchasing and other models that reward effective and efficient health care delivery.
A movement toward favoring generic drugs over brand-name drugs, meanwhile, has led to a slowdown in
pharmaceutical spending in recent years, although growth rebounded in 2014. Another growing trend is the
increase in private insurance plans with high deductibles.
A number of reforms included in the ACA attempt to develop payment methods in the Medicare and Medicaid
programs that reward high-quality, efficient care. Some of these use pay-for-performance mechanisms, whereas
others rely on bundled payments, shared savings, or global budgets to incentivize integration and coordination
among health care providers.
Despite a recent slowdown in health care spending, the latest data, through August 2015, show that spending
grew 5.7 percent in the past year (Altarum Institute, 2015).
What major innovations and reforms have been introduced?
The Affordable Care Act, which ushered in a sweeping series of insurance and health system reforms aimed
at achieving near-universal coverage, improved affordability, higher quality, greater efficiency, lower costs,
strengthened primary and preventive care, and expanded community resources, has survived. There have been
modifications to the law, however, as a result of several Supreme Court decisions since 2010. Perhaps most
notable was the 2012 ruling that made the expansion of Medicaid optional for states: because of that decision,
only 30 of 50 states (in addition to the District of Columbia) have pursued expansion as of late 2015.
Still, since implementation of the ACA in 2013, the number of uninsured adults has declined by historic proportions
(Collins et al., 2015). Groups that have been long been at greatest risk of being uninsured—young adults, Hispanics,
blacks, and those with low income—have made the greatest coverage gains (Blumenthal et al., 2015).
In 2015, the Department of Health and Human Services announced a goal to move 50 percent of Medicare
payments to alternative payment models, including ACO-based arrangements, by 2018 (Blumenthal et al.,
2015; Muhlestein, 2015). Medicare also has begun paying for doctors to coordinate the care of patients with
chronic conditions. To be eligible for an extra $40 per patient, doctors must draft and help carry out a
comprehensive plan of care for each patient who signs up for one. Under federal rules, those patients have
access to doctors or other health care providers on a doctor’s staff 24 hours a day, seven days a week, to deal
with “urgent chronic care needs” (Edwards and Landon, 2014).
In April 2015, the Senate passed the Medicare “doc fix,” averting an imminent cut in Medicare physician fees
that was scheduled to occur under the now-repealed sustainable growth rate (SGR) formula. While the SGR was
designed to counter the tendency toward spending growth inherent in the fee-for-service model, it was a flawed
model. It was replaced by an approach focusing on rewarding high-performing providers and supporting
alternative payment models (Guterman, 2015).
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The Commonwealth Fund