The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of health systems and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems. They also describe the institutional framework, process, content, and implementation of health and health care policies, highlighting challenges and areas that require more in-depth analysis. Undoubtedly the dominant issue in the Dutch health care system at present is the fundamental reform that came into effect in 2006. With the introduction of a single compulsory health insurance scheme, the dual system of public and private insurance for curative care became history. Managed competition for providers and insurers became a major driver in the health care system. This has meant fundamental changes in the roles of patients, insurers, providers and the government. Insurers now negotiate with providers on price and quality and patients choose the provider they prefer and join a health insurance policy which best fits their situation. To allow patients to make these choices, much effort has been made to make information on price and quality available to the public. The role of the national government has changed from directly steering the system to safeguarding the proper functioning of the health markets. With the introduction of market mechanisms in the health care sector and the privatization of former sickness funds, the Dutch system presents an innovative and unique variant of a social health insurance system. Since the stepwise realization of the blueprint of the system has not yet been completed, the health care system in The Netherlands should be characterized as being in transition. Many measures have been taken to move from the old to the new system as smoothly as possible. Financial measures intended to prevent sudden budgetary shocks and payment mechanisms have been (and are) continuously adjusted and optimized. Organizational measures aimed at creating room for all players to become accustomed to their new role in the regulated market. As the system is still a "work in progress", it is too early to evaluate the effects and the consequences of the new system in terms of accessibility, affordability, efficiency and quality. Dutch primary care, with gatekeeping GPs at its core, is a strong foundation of the health care system. Gatekeeping GPs are a relatively unusual element in social health insurance systems. The strong position of primary care is considered to prevent unnecessary use of more expensive secondary care, and promote consistency and coordination of individual care. It continues to be a policy priority in The Netherlands. The position of the patient in The Netherlands is strongly anchored in several laws concerning their rights, their relation to providers and insurers, access to information, and possibilities to complain in case of maltreatment. In terms of quality and efficiency of the health care system, The Netherlands is, with some notable exceptions (e.g. implementation of innovations such as day surgery and electronic patient records), an average performer when compared to other wealthy countries. It is too early to tell whether efficiency and quality gains will occur as a result of the 2006 reform.
Medicaid managed care organizations serve as the primary vehicle for delivering behavioral health services to low-income youth. However, market consolidation has shifted enrollment toward a handful of large national parent firms. Understanding the implications of this shift is critical for identifying and closing gaps in adolescent mental health services. Using national Medicaid claims data from 2022, we examined the associations between managed care organization ownership by five major parent firms and measures of youth mental health service use and provider composition. Managed care organizations owned by large national parent firms were characterized by lower mental health screening rates and, for most firms, higher use of emergency department, inpatient, and medication-based care, including psychotropic prescribing without psychotherapy. Provider composition also varied by firm, suggesting differences in how these organizations structure their behavioral health networks, with some relying more heavily on psychiatrists and psychologists and others depending more on master's-level therapists. The growing influence of large national parent firms in shaping behavioral health access for Medicaid-enrolled youth underscores the need for closer scrutiny of how managed care structures serve youth with significant mental health needs.
The Centers for Medicare and Medicaid Services (CMS) is increasingly experimenting with prior authorization in traditional Medicare. In 2016, CMS began using pre-claim review, a prior authorization-like system in which claims are reviewed after the service begins but before the claim is paid, for home health care in Illinois. Beginning in 2019, a modified demonstration program was also implemented in Florida, North Carolina, and Ohio. We studied the effect of pre-claim review on health care spending, using a synthetic control approach and Medicare claims data. Pre-claim review led to an immediate 13 percent decline in home health spending in Illinois, driven by declines in home health spending in Chicago and a decrease in the number of home health users in the state. Pre-claim review did not reduce spending in Florida, North Carolina, or Ohio. Our results suggest that pre-claim review can reduce health care spending in traditional Medicare, although effects may vary considerably across states.
Multiple states have established benchmarks for health care spending growth. Since 2021, spending growth has exceeded most states' benchmarks, prompting concerns about unsustainable growth. However, these benchmarks largely do not adjust when economywide inflation changes. I collected data on states' benchmark-setting processes, targets, and reported health care spending and identified a set of six states that reported data on per capita spending growth in both 2022 and 2023. Meeting benchmark spending targets for these years would have required real (inflation-adjusted) per capita health care spending to decline by an average of 1.6 percent per year. The same nominal spending benchmark targets would have allowed real spending growth of 1.9 percent per year if inflation had stayed at its historical average. Actual real spending growth was only 0.7 percent per year. Consistent with this, health care as a share of gross domestic product for these states remained stable, at 10.9 percent in 2021 and 10.7 percent in 2023. These findings suggest that nominal spending benchmark designs can generate misleading performance signals, which can be reduced by adopting inflation-shock adjustment protocols and routinely reporting both nominal and real spending performance.
From 2005 to 2023, per capita health care spending was highest and grew most rapidly among Americans in the top income quintile. During this period, age- and health-adjusted real spending grew 1.8 percent per year among people in the highest income quintile compared with no growth among people in the lowest income quintile. Differences among income levels were most prominent in outpatient services and prescription drugs.
By 2034, national health spending is projected to total nearly $9.0 trillion and to represent 20.6 percent of the economy, compared with $5.3 trillion and 18.0 percent in 2024. The rate of national health spending growth during this period is influenced by continued elevated use of medical services and goods through 2026; major legislative changes that affect insurance coverage and spending through 2028; and continued demographic shifts toward public programs, mainly Medicare. The insured share of the population is expected to be 90.5 percent in 2034, compared with 91.8 percent in 2024.
Medicare Advantage (MA) plans receive capitated payments that could lead to greater efficiency compared with traditional Medicare but may also curtail provision of beneficial services. However, MA effects are not fully understood, as most research to date is cross-sectional and could be subject to selection bias. This study investigated a natural experiment in which five states (Alabama, Arizona, Colorado, Connecticut, and New Jersey) shifted health benefits for retired state employees from supplemental plans for traditional Medicare to MA plans during the period 2017-19, leading to 87 percent of the more than 220,000 state retirees in these states shifting to MA. We found increased use of certain outpatient services (annual wellness visits and home evaluation and management visits) and observation stays, along with reduced hospital and postacute care admissions. We found no effect on days spent at home or in the community, or on mortality.
暂无摘要（点击查看详情）
Long COVID has debilitating effects but is inconsistently diagnosed because of subjective criteria, limited treatments, and variations in health care access. We analyzed electronic health records from the National Clinical Cohort Collaborative for patients diagnosed with acute COVID-19 in the US between January 2022 and March 2023. Using six race and ethnicity categories, we evaluated 222 symptoms and long COVID diagnoses (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, code U09.9) within twelve months after infection. We assessed the relationship between race and ethnicity and long COVID diagnosis, adjusting for patient covariates and long COVID symptomatology set to the presence of at least one documented long COVID-associated symptom. Among 2.4 million patients, Black patients were less likely to be diagnosed with long COVID than White patients under a scenario in which a symptom was present and health care monitoring was at least bimonthly. For the remaining racial and ethnic groups, we found no statistically significant differences in long COVID diagnoses compared with White patients. Although the magnitude was small, the difference in diagnosis likelihood suggests the presence of potential diagnostic bias.
During the unwinding of the continuous coverage requirements related to the COVID-19 public health emergency in 2023, as an unprecedented volume of consumers were transitioning out of Medicaid, California launched a facilitated enrollment program for people who lost Medicaid and were eligible for subsidized Marketplace coverage. We conducted a survey in 2023-24 to assess coverage outcomes among Californians who lost Medicaid coverage, were assigned to a default plan, and had thirty days to opt in to coverage under the program. Although national surveys indicate high rates of uninsurance after loss of Medicaid, we found that 85 percent of those who were eligible for an Affordable Care Act Marketplace subsidy had some form of health insurance. Among those without other available coverage, nearly two-thirds opted in to a Marketplace plan. People with a high school education or less were least likely to enroll in Covered California, as were those who rated their health status as poor. Even after we accounted for premium amounts, income, education, health status, and language preference, take-up was higher among Asian/Asian American (84 percent) and White (79 percent) people than among Hispanic/Latino (53 percent) and Black/African American (54 percent) people. Our findings indicate that facilitated enrollment interventions should be strengthened to overcome administrative and other burdens that persist among subpopulations.
Changing late-life disability and care patterns that may accompany population aging have profound consequences for the nation's health and related public policies. Drawing on two cross-sectional rounds of the National Health and Aging Trends Study, we examined trends among US adults ages 65 and older in 2011, when the oldest members of the baby-boom generation turned age 65, and in 2022, when about half of the generation was ages 65-74. We found increases in the percentage of adults ages 65-74 who reported activity limitations, receiving paid care in the community, and having unmet care needs. In contrast, for older age groups, we found declines in the receipt of care overall and in residential settings, particularly nursing care, without increases in unmet care needs. All else equal, had the sociodemographic and health profile of the group ages 65-74 not differed from the preceding cohort-especially in terms of increased educational attainment-the increases experienced by this age group would have been even larger. Findings portend growing challenges in caring for older US adults in the future.
Farmers and ranchers are on the front lines of climate change, facing escalating production pressures, economic uncertainty, and profound psychological impacts. Drawing on first-person experience and research in agricultural communities, this Commentary uses narrative to illuminate how climate grief-grief experienced in response to actual or anticipated loss resulting from climate change-affects farmers and ranchers and shapes their capacity for climate adaptation. In addition to this experiential framing, the authors include an illustrative example of a team-developed intervention designed to support farmers' and ranchers' mental health; this example is offered not as original research but as a practice-based case to stimulate the broader policy conversation. Taken together, these perspectives underscore the need to integrate mental health support into agricultural climate resilience efforts. Although programs such as the Department of Agriculture's Farm and Ranch Stress Assistance Network represent important progress, current initiatives remain fragmented and underresourced. Research on mental health interventions related to climate change in general is sparse. Increasing investment and coherent policy are essential to ensuring that climate adaptation strategies address the full spectrum of challenges that farmers and ranchers face-physical, economic, and psychological.
Responding to patient-initiated portal messages is a growing source of work for physicians, yet little is known about how these messages are distributed across patients and physicians. Understanding the distribution is critical for developing interventions to reduce burden and for designing reimbursement policy. Using data from 487,442 patients at University of California San Francisco (UCSF) Health and national electronic health record (EHR) metadata from 224,068 ambulatory care physicians in the US, we examined the distribution of patient-initiated medical advice request messages across patients and physicians. The distribution was highly skewed at both the patient and physician levels. The top 5 percent of UCSF Health patients accounted for 52.8 percent of all messages. Among physicians nationally, primary care physicians received a median of 9.6 messages per week, whereas the top quartile received 53.3 messages per week. Physicians with higher visit volume received fewer messages per visit, and higher message volume was associated with greater EHR work outside of work. These findings highlight the need for targeted interventions and payment models that account for the uneven distribution of asynchronous portal-based care.
Between 2019 and 2021, six states expanded Medicaid through voter-approved ballot initiatives, overcoming legislative opposition. We used 2016-23 data from the American Community Survey to compare health insurance coverage outcomes in these six ballot initiative states with those in ten nonexpansion states. We estimated stacked event study regression models to account for variation in expansion timing and control for socioeconomic differences. Overall, ballot initiative expansions increased Medicaid enrollment by 3.2 percentage points and decreased uninsurance by 2.2 percentage points among nonelderly adults two years after expansion. Among low-income adults, Medicaid coverage increased by 10.1 percentage points, and uninsurance fell by 6.2 percentage points. These findings show that Medicaid expansions enacted through ballot initiatives significantly increased coverage, even in politically resistant environments. However, sustaining these gains may be difficult amid ongoing state-level opposition and new federal mandates. As opportunities for future ballot-driven expansions narrow, this study highlights both the potential and the limitations of direct democracy in advancing health policy.
There were well-documented changes in health care use during the COVID-19 pandemic. Little is known about whether there were any associated decreases in claims-based comorbidity ascertainment that might have relevance to health services and policy research. To quantify differences in claims-based comorbidity assessment in Medicare beneficiaries pre- vs post-COVID-19. This cross-sectional study analyzed data from the 30 Chronic Conditions Warehouse 1- or 2-year lookback claims algorithms to ascertain each comorbidity with exact date ranges for all fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries. Data were analyzed from April 2025 to April 2026. The first quarter (Q1) of 2019 and 2022 were evaluated as pre- and post-COVID-19, respectively. The main outcomes were comorbidities per beneficiary and association between each comorbidity and mortality in 2019 vs 2022. The changes in prevalence of each comorbidity between 2019 and 2022 were analyzed and fit models within disjoint population subgroups were combined via multilevel meta-analysis models to determine whether each comorbidity's association with mortality changed over time. This study included 59 514 042 beneficiaries in 2019 (32 351 732 females [54.4%]; 50 814 834 aged 65 years or older [85.4%]) and 63 202 599 beneficiaries in 2022 (34 377 560 females [54.4%]; 55 197 435 aged 65 years or older [87.3%]). The mean number of coded comorbidities per beneficiary decreased from 3.85 to 3.62 for FFS and 4.54 to 4.39 for MA (-0.15) between 2019 and 2022. In FFS, 19 comorbidities (63.3%) decreased, 2 (6.7%) were unchanged, and 9 (30%) increased. In MA, 14 comorbidities (46.7%) decreased, 7 (23.3%) were unchanged, and 9 (30%) increased. In multivariable analyses pooled across FFS and MA, 11 comorbidities (36.7%) were more positively associated with mortality, and 4 (13.3%) were more negatively associated with mortality in Q1 2022 than in Q1 2019. Coded levels of many comorbidities in Medicare were lower postpandemic than prepandemic, and the association of these codes with mortality changed. This suggests that across the COVID-19 pandemic comorbidity capture was affected by utilization changes, and the association between comorbidities and mortality changed as a result. Analyses that include immediately pre- or post-COVID-19 data and condition inferences on membership in utilization-based disease groups, or use claims-based risk adjustment, may be subject to bias.
Primary care is essential to advancing population health, yet it has faced underinvestment and workforce shortages in the US. Private equity (PE) investments could expand access by facilitating participation in value-based contracts and enhancing information technology capacity. However, PE's emphasis on short-term profitability may impose productivity pressures on physicians, with uncertain implications for patient care. Using a stacked difference-in-differences design and national Medicare claims data, we examined 225 PE acquisitions of primary care practices during the period 2016-22. PE acquisition increased the number of services billed and patients seen by primary care physicians by 30 percent and 11 percent, respectively. Patients in PE-acquired practices received 12.9 percent more additional services, driven by laboratory testing and the Medicare annual wellness visit. PE acquisitions also increased the total number of primary care physicians and advanced practice providers, with the latter growing at a faster rate. Taken together, our results suggest that PE investments have the potential to increase the use of primary care services, in part through greater reliance on advanced practice providers.
This article tells the story of vulnerable tenants in South Los Angeles, California, and their work with a community-based organization to advance policies that address climate change while also protecting tenant rights. Climate change is having a disproportionately negative impact on low-income renters in South Los Angeles, where housing is often crowded, unaffordable, and poorly maintained, and extreme heat events can make indoor living unbearable. Cooling mandates and improvements such as building decarbonization can help. Because landlords have used remodeling and renovations as an excuse for harassment or eviction, tenants have been wary of these policies' unintended consequences. But with ongoing education and partnership with a community organization, tenants are now supporting and successfully advocating for policies that address the root causes of climate change and create healthier homes while providing protections that preserve tenants' access to safe and affordable housing.
Vertical integration between Medicare Advantage (MA) plans and hospital providers is increasingly common, but little is known about how vertically integrated plans pay affiliated providers for medical services. Providers may accept lower prices from affiliated plans to give those plans a competitive edge in the MA market. Conversely, plans may pay vertically integrated providers higher prices to increase their medical loss ratios-a measure of revenues spent directly on health care required by the Centers for Medicare and Medicaid Services. Using a novel data set of vertically integrated MA plans matched with negotiated hospital pricing data, we found that in 2024, 66-73 percent of hospitals charged similar prices to affiliated and unaffiliated plans, but prices differed at a sizeable minority of hospitals. On average, affiliated plan prices were 5.3 percent higher than unaffiliated plan prices for the same procedure at the same hospital. Affiliated plan prices were higher relative to unaffiliated plan prices in the inpatient (rather than outpatient) setting, in more concentrated MA markets, and where MA hospital prices were lower relative to traditional Medicare hospital prices. Our results suggest that vertically integrated MA plans behave differently from standard MA plans, but strategies vary by market and hospital characteristics.
Medicare Advantage (MA) has become a major source of dental coverage for older US adults. However, little is known about enrollment in plans with dental coverage or about the scope and continued availability of coverage over time. Using Centers for Medicare and Medicaid Services Plan Benefit Package and enrollment data, we examined county-level variation in dental plan enrollment, generosity of benefits, and continuity of dental plan availability across conventional MA plans and MA Special Needs Plans (SNPs) during the period 2010-25. Enrollment in conventional MA plans with any dental benefits rose from 50.3 percent in 2010 to 97.1 percent in 2025. Enrollment in SNPs with dental benefits increased from 68.6 percent to 93.5 percent during this period. Among plans continuously available for at least five years, benefit generosity rose after 2019, but plan continuity declined after 2021 as a result of plan exits and the withdrawal of dental benefits. Net losses of insurers offering dental benefits in conventional MA plans were more likely in counties with relatively high percentages of Black and Hispanic residents, in dental Health Professional Shortage Areas, and in areas with midlevel social deprivation. These findings underscore the need for strong oversight of MA dental benefits and strategies to achieve sustained and equitable access to dental coverage.