Health care in Sierra

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Logo of Medicare, Sierra's national insurance program

Health care in Sierra operates under a hybrid system combining universal government-funded public health care with private providers. It is a matter dealt primarily by the provinces, states, and areas of Sierra, where each PSA maintains its own health care systems and standards, although the federal government's involvement has expanded since the Constitution of Sierra declared health care to be a fundamental right in 1994 and several landmark Supreme Court decisions affirmed health care as one of the federal government's priorities and domain.

The Ministry of Health and Human Services is the federal ministry dedicated to overseeing and regulating national health and health care issues. A single-payer health care system (Medicare) coexists with private insurance, with citizens given the opportunity to utilize both systems to improve their options and quality of service in health care. In 27 of the 36 PSAs, residents are required to have health insurance coverage, and there has been a push since the early 2010s towards federally enforced compulsory health insurance coverage. Nearly all hospitals, clinics, and other health care facilities are operated by private owners. A small number of hospitals are run by non-profit organizations or the government, including medical facilities operated by the Ministry of Veteran Affairs. Likewise, the private sector is largely responsible for providing health services and employing practitioners. A number of additional medicare programs exist for military veterans, Amerindian reservation residents, public sector employees, and senior citizens. According to the World Health Organization, Sierra spent $6,974 on health care per capita, and 11.3% on health care as a percentage of its GDP in 2017. Of the 11.1%, government health expenditure accounted for 9.3%, while out-of-pocket expenditure as a proportion of the 2017 health expenditure was 16%.

Sierra's health care system is world renowned in terms of quality of care and affordability, especially for palliative and end-of-life care, but has been criticized for its relatively long wait times. In 2018, Sierra had one of the world's longest life expectancies, with an average of 81.31 years at birth for both men and women. It is home to one of the world's largest communities of centenarians and one of the identified global blue zones (Loma Linda, Inland Empire). In 2017, Sierra had high prevalence or near-high prevalence in motor vehicle accidents, obesity, heart and lung disease, sexually transmitted infections, injuries, adolescent pregnancies, and homicides, especially in the Styxie and Eastern Sierra. Rates of preventable hospitalizations and diseases are often cited as major sources of financial costs in nation's health care system. Federal and provincial programs and services have worked towards driving down medical costs and promoting healthier, safer lifestyles that reduce the risk or need for hospitalization.

Overview[edit]

Health care is a policy issue that involves the government at the federal and provincial level. Although responsibility and oversight of health care is constitutionally deferred to the provinces, states, and areas of Sierra, the federal government has been able to increase its involvement and jurisdictional oversight due to Supreme Court decisions declaring health care to be interprovincial commerce and the Constitution declaring access to health care a fundamental right (Seventeenth Amendment). At the federal level, the Ministry of Health and Human Services is in charge of all affairs related to health care and include various agencies which are responsible for specialized issues within the policy. The Federal Medical Insurance Services Administration (FMISA) is responsible for administrating Sierra's Medicare system and works in conjunction with provincial-level health insurance programs and schemes. The regulation of pharmaceuticals, supplements, health products, and medical instruments is overseen by the Royal Food and Drug Administration (RFDA). Other regulations exist at the provincial level. The Royal Center for Disease Control and Prevention (RCDCP) is the leading public health agency responsible for providing information about public health and safety, and controlling and preventing diseases, injuries, and disabilities. The RCDCP's role is to prevent outbreaks from occurring and controlling the spread of diseases from an existing outbreak. It also runs public awareness campaigns against smoking, drug abuse, occupational hazards, obesity, and other public health concerns.

In each PSA, doctors handle insurance claims against the provincial insurer and private insurers although certain plans require individuals to pay copayment fees, certain deductibles, and premiums. Most prescription drugs, dental care, home car, optical health care, and other costs are not covered under Medicare and is generally covered instead by private insurance. In PSAs where there is compulsory health insurance, citizens are automatically enrolled in the Medicare system if they do not have any private insurance. Private insurance may be purchased independently from a health insurance company or obtained through a group plan that is provided for by an employer.

As of 2018, there was a total of 1,407 registered hospitals and 2,580 health clinics in Sierra, including the Sierran territories. The majority of hospitals in Sierra are acute care or general service facilities with operational trauma and emergency centers. There were 839 community hospitals, which are facilities that are partially funded by the federal government and run at the city or county level. The remainder consists of not-for-profit facilities, privately-owned, for-profit hospitals, and government-run hospitals. The latter is directly and wholly funded by the federal government and generally restricts treatment to certain citizens such as military veterans. Specialized hospitals such as pediatric hospitals or research hospitals are commonly tied to a university or third-party consortium that receives significant amounts of funding from the federal and provincial governments.

Coverage and access[edit]

Although medical insurance coverage is mandatory in 27 of the 36 PSAs, the federal uninsured rate was 7.3%, with the majority of the uninsured originating from the 9 PSAs that do not require insurance coverage nor automatically enroll citizens into their public medicare systems. Even in PSAs with mandatory coverage laws, private citizens may lack coverage due to administrative errors, refusal to use medical services, and other reasons. NIC holdouts were the number one largest group of uninsured citizens in mandatory insurance and optional insurance PSAs alike. Such citizens often refuse to create or update their family register and apply for services with the Medicare system, which requires proof of NIC possession for citizens or a green card for permanent resident aliens. In 19 of the 27 insurance mandate PSAs, citizens are allowed to opt-out of public medicare system if they have proof that they are covered by a private, third-party insurance plan. However, there are no active mechanisms to check for citizens' insurance coverage in the event they terminate or lose coverage from such insurance plan, and there is no automatic re-enrollment plan in most PSAs.

Uninsured Sierrans are still able to access most medical services, including emergency care. Medical costs are often passed alongside to the government in order to pay for the services of uninsured patients who are unable to pay for their own expenses. The underinsured are Sierrans who are insured but do not have adequate levels of health care satisfactory for their needs due to limited affordability. Often this includes Sierran citizens who are enrolled in the public Medicare system but do not have any accompanying private insurance or plan at all.

Supplemental public medical programs provide additional financial support for citizens with special needs or status. The Pediatric Assistance and Support Program (PASP) provide coverage for children of qualifying low-income families who require additional financial support. The Comprehensive Health Insurance of the Uniformed Services (CHIUS) and Veterans Comprehensive Health Insurance Program (VCHIP) are special public programs that cover active service members, military veterans, and their immediate family members.

Statistics[edit]

Hospitalizations[edit]

According to the Ministry of Health and Human Services' Agency for Health Research, Data, and Statistics, there were 8.2 million hospital stays in Sierra in 2018, with the average length of hospital stays being 4.2 days and costing an average of $9,583 per stay (with more than half of the costs billed to Medicare and its provincial insurers). There were approximately 950 stays per 10,000 population during the 2018 calendar year.

In 2018, about 7.7% of all hospital stays involved patients who were admitted to emergency care or urgent care. In approximately 5.9% of all hospital stays, patients were required to stay at hospitals overnight or remain hospitalized for longer than 8 uninterrupted hours. The total number of outpatient department visits, for any reason or purpose, was 25.3 million. Sierrans made over 307.4 million physician office visits in the same year. On average, Sierrans made at least 3 non-emergency visits to the doctor each year, namely for check-ups, screenings, and vaccinations.

Life expectancy[edit]

According to the World Health Organization, Sierra ranked 5th in the world with a life expectancy for both sexes of 82.7 years as of 2018. When considering health-adjusted life expectancy, it is only 72.5 years, putting it on par with other OECD nations. At birth for males, life expectancy sits at 80.5 while for females, it sits at 84.9. Advances in medicine, technology, and health care led to improvements to national life expectancy numbers during the mid-20th century. Life expectancy is not uniform throughout Sierra however, as the Styxie has a comparatively lower life expectancy for both sexes of just 73.6 years, and even lower at 66.2 years for health-adjusted life expectancy. Life expectancy is the highest in the Pacific Northwest provinces where the average for both sexes is 84.1 years. Sierra is also home to one of the world's recognized Blue Zones: Loma Linda, Inland Empire due to its high concentration of centenarians and rank as the longest-living people in North America. This phenomenon has been attributed to the city's predominantly Seventh-day Adventist population, whose church promotes a health-conscious lifestyle and recommends a vegetarian-based diet.

Obesity[edit]

Obesity affects approximately one-third of Sierrans, with nearly 12% of Sierrans being identified as obese and 21% of Sierrans being identified as overweight. It has been variously described as an epidemic and a major health concern within Sierra and disproportionately affects Sierrans of low socioeconomic status and also manifests visibly along ethnic and racial lines (African Sierrans, Hispanic Sierrans, and Pacific Islanders were far likelier to suffer from obesity compared to their European, Asian, and Middle Eastern cohorts). It has contributed to approximately 45,000–100,000 deaths per year due to resulting diseases or conditions such as cancer, coronary artery disease, diabetes type 2, and stroke, as well as increased costs in medical expenditures. On average, obese citizens or their insurers spent $1,193 more per year to treat obesity and its related complications.

Obesity rates are the highest in the Styxie, Southeastern Sierra, and portions of the Greater Porciúncula Area. San Joaquin had the highest percentage of obese adults, with over 40% of the population suffering from obesity. Among children, the province's rates were similar to that of the adult population, with an upward trend in recent years.

The Ministry of Health and Human Services has targeted obesity, especially childhood obesity, as one of its top priorities in addressing since 1989. Initially, the Ministry used BMI as an indicator of obesity but has since recommended the use of body adiposity index (BAI). It has also created several iterations of nutrition and dietary guides, including the food pyramid, in order to promote healthy eating and physically active lifestyles to combat and prevent obesity.

Smoking rates[edit]

Restaurant signage prohibiting smoking and vaping

In 2014, roughly 11 million (13%) of Sierrans smoked tobacco cigarettes, cannabis products, or electronic cigarettes, setting a record low since smoking rates have been recorded in Sierra. Cigarette smoking is one of the leading causes of preventable deaths, claiming approximately 75,000 deaths each year. Smoking prevalence was highest in the Styxie (16.5%) and Southwest Corridor (13.3%), and lowest in the Pacific Northwest (9.6%). Cigarette smoking has accounted for $14 billion in direct medical expenses and $18 billion in lost productivity per year.

Governments, lobby groups, and non-profit organizations have coordinated together in driving down smoking rates, discouraging underaged smoking, and encouraging smokers to quit. Various public campaigns have raised awareness of the dangers and health risks associated with smoking, and have successfully translated into written laws ranging from higher taxes on tobacco products to smoking bans at most public spaces and businesses. Tobacco control has been the central focus of the Ministry of Health and Human Services and provincial health agencies in combatting smoking prevalence. Tobacco smoking rates among Sierra's adult population has dropped by 15.7% between 1970 and 2010, when smoking rates peaked at 41.7% in 1967, and is projected to continue declining. Cannabis use and electronic cigarette use has increased however, as the percentage of adult Sierrans 18 years and older who regularly use such products (at least once per week) have reached to 13.1% and 8.2% respectively. The percentage of Sierrans who have tried cannabis at least once in their lifetime was 33.5% in 2018 and those who have tried electronic cigarettes was 23.7% in the same year.

Cancer[edit]

In 2018, there were 373,628 cancer diagnoses made. Approximately 4.5 million Sierrans lived with or survived at least one form of cancer. Most cancer rates were related to smoking or lifestyle choices (e.g. diet). The most prevalent forms of cancer was lung cancer and colon cancer, both which accounted for more than 20% of all cases. Breast cancer, prostate cancer, and skin cancer were also common, and have been rising in diagnoses since 2000. The average mortality rate across all cancer patients in Sierra was 24.7%, with pancreatic cancer patients having the lowest rate of survival (less than 10%) when excluding the most aggressive cancers affecting the brain (i.e. diffuse intrinsic pontine glioma and glioblastoma). Since 1991, cancer mortality rates have fallen from 31.5% to 24.7%, while cancer survivor rates have been increasing due to advances in cancer research, prognosis, and treatment. Mortality rates for specific cancers were not uniform however, as some cancers experienced increased rates while others decreased much more in comparison to the average. Cancer in all of its forms was the leading source of medical costs for Sierra's health care system and the leading form of death after heart disease in 2018.

Most cancer treatments and procedures, including chemotherapy, are covered by Medicare and affiliated programs, although they may be covered through policy riders which may or may not require out-of-pocket payment. Experimental treatments and procedures may be subsidized by the government, which may cover up to 75% of the costs.

Mental health[edit]

According to the Anglo-American Mental Health Institute, about one in seven Sierrans suffered from mental illness. In 2017, mental health ranked as one of the most costly medical conditions and has exhibited an upward trend in diagnoses and treatment since the 1980s. Before the early 2000s, mental health was a major area which lacked coverage. It is estimated that about 60% of Sierran adults who self-identified as sufferers of mental illness did not receive treatment (excluding medications used to treat symptoms). Social stigma and lack of affordable mental health care has contributed to what the Ministry of Health and Human Services describes as a "major epidemic".

Legislation surrounding mental health care and its coverage has mainly originated from provincial legislatures. The Mental Health Equity Care Act of 2008 is widely regarded as the first major federal legislative act that addressed the affordability issue, by listing mental health care treatment in the same class of coverage as standard medical and surgical procedures. Medications used to treat or alleviate symptoms of mental illness are generally not covered under most provincial health care systems, although some coverage may be provided to qualified low-income patients. An estimated 120 public universities and community colleges, including those in the University of Sierra and Sierra National University systems have expanded the coverage of their medical health care plans to include mental health medications under the Student Health and Wellness Initiative, a nationwide campaign.

The most prevalent mental health conditions afflicting Sierrans in 2018 were depression, bipolar affective disorder, general anxiety disorder and related anxiety disorders, schizophrenia, and dementia.

Suicide[edit]

Suicide prevention signage at the Golden Gate Bridge

Suicide is a major national public health issue in Sierra. In 2018, there were 27,823 reported suicides. Sierrans aged 17-25 were the likeliest to commit suicide. Suicide was the number three cause of death for those aged between 10 and 39 in 2018. Half of the country's suicide rates occurred in the Styxie alone, with San Joaquin having the highest rate of suicide (11.7 suicides per 100,000 persons). Nearly three-fourths of all suicides were committed by white males, a group which ranks as the most susceptible to suicides. Women, regardless of race, were about 1.5 times more likelier to attempt suicide than men however. Nearly 60% of all suicides used firearms, while other methods included hanging, drug overdose, or carbon monoxide poisoning. Reasons for suicide range from economic trouble, personal depression, alcoholism, drug abuse, to domestic abuse. Suicide has been one of the major factors in lowering national and provincial life expectancies.

Drug-related deaths[edit]

In 2018, 19,382 deaths in Sierra were officially recorded as "drug abuse". Those in the working class and living in counties that are below the federal poverty line were at a higher likelihood of dying to drug abuse. The drugs which were the most responsible for drug overdose cases were oxycodone, fentanyl naloxone, and heroin. Historically, cocaine and methamphetamine were the leading drugs responsible for overdose-induced deaths but widespread crackdowns during the 1980s and 1990s significantly drove down consumption of these drugs, in favor of more accessible drugs.

HIV/AIDS[edit]

The AIDS epidemic, caused by HIV (human immunodeficiency virus), first emerged in Sierra in San Francisco City and surrounding communities in the San Francisco Bay Area during the 1970s and 1980s. Initially, it was mainly concentrated among the city's young gay men community. Today, AIDS affects Sierrans of all sexual orientations, gender identities, races, ages, and socioeconomic statuses, although it continues to disproportionately affect members of the LGBT and racial minorities.

Other sexually transmitted diseases[edit]

Disability[edit]

Mortality[edit]

Spending[edit]

In 2017, Sierra spent 11.3% of its GDP on health care, or $6,974 per person. Major categories of health care costs were hospital care (32%), physician and clinical services (23%), and prescription drugs (11%). Costs and prices, including copayments, have risen in recent years due to increases in administrative costs, labor costs, utilization, and riskier lifestyle choices.

Providers[edit]

Facilities[edit]

Physicians[edit]

Walter Zhou US Porciúncula Medical Center

In order to practice medicine in Sierra, physicians must have a medical education background with an accredited school domestically or internationally, as well as acquire the medical license necessary to practice in a PSA. The Sierra Medical Licensing Examination (SMLE) is required for all prospective physicians which is a comprehensive test with subjects in anatomy, biology, biochemistry, pathology, microbiology, pharmacology, psychology, genetics, nutrition, and aging. Medical students must undergo a year of residency under supervision at a federally recognized health care facility and then another year of unsupervised practice. The majority of physicians have a Doctor of Medicine (M.D.) degree while a minority have a Doctor of Osteopathic Medicine (D.O.). Under federal law, all physicians are required to make the Hippocratic Oath and can be prosecuted indirectly through medical malpractice for breaking it. Chiropractors are not considered physicians under K.S. law despite undergoing similar training and licensing requirements.

Nurses and paramedics[edit]

Public insurance[edit]

Private insurance[edit]

Oversight and regulations[edit]

The Seventeenth Amendment of the Constitution of Sierra declares that access to healthcare is a constitutional right for all Sierran citizens. It reads: "Healthcare, including care to prevent, diagnose, and treat illness, whether physical or mental, is the right of all citizens of the Kingdom to receive and access without hindrance or unjust delay. Parliament shall have power necessary to enforce and implement this article by appropriate legislation."

Wait times[edit]

Limited coverage[edit]

Drugs[edit]

The Sierran Medicine Authority (SMA) is responsible for the regulation, inspection, and approval of human and veterinary drugs in Sierra. It also determines which drugs must be subsidized by the federal and provincial governments. More than 1,200 drugs on the federal schedule are listed as either fully or partially subsidized by the federal government, while provincial public and private insurers make up the remaining difference to cover the costs. Prescription drugs which are only partially subsidized or totally unsubsidized may be subject to prescription costs, although exemptions apply to certain citizens such as the elderly or sufferers of certain diseases and complications.

Dental insurance[edit]

Vision care[edit]

Other medical expenses[edit]

Medical malpractice[edit]

Public opinion[edit]

Criticisms[edit]

See also[edit]