entire spectrum available, including but not limited to all surgical specialties (orthopedists, neurosurgeons, hand surgeons, burn surgeons, etc.), emergency care physicians, family practice physicians, radiologists, physiatrists, internists, and so forth. Nurses and nurse practitioners are frequently involved in the treatment of work-related injuries, especially the minor ones. Finally, other practitioners are also involved in providing care to injured workers: chiropractors, physical therapists, occupational therapists, and acupuncturists, to name only a few. One of the continuing issues between injured workers and employers has been the control of who selects the health care providers.

Changes in the ways in which health care is delivered thus have the potential to affect not only workers’ access to care but also the cost and quality of that care. The U.S. health care system underwent dramatic changes during the decade of the 1990s. These changes were fundamental in nature and had enormous effects. They occurred rapidly and without an overall “game plan” to guide them. Three factors catalyzed the changes: the rising cost of health care, a lack of access to health care by a large and growing segment of the population, and concerns over the quality of health care.

In regard to cost, the U.S. health care system is the most expensive in the world, outstripping by more than half again the health care expenditures of any other country (Iglehart, 1999a). In 1997, U.S. health care expenditures totaled $1.092 trillion, representing 13.5 percent of the gross domestic product (GDP) (Levit et al., 1998) (Figure 6-1). Of the total, 46 percent was spent by federal, state, and local governments, with the private sector financing the rest. Premiums paid by employers and employees to purchase health insurance constituted 60 percent of the component paid by the private sector (Levit et al., 1998). In contrast to the 1980s and the early 1990s, when the annual rate of increase in U.S. health care expenditures was often in double digits, there has been a decrease in the rate of growth during the past 5 years. In 1997, for example, U.S. health care spending rose only 4.8 percent—the slowest rate of growth in more than 35 years (Iglehart, 1999a). Many are predicting, however, that this slower rate of growth will not continue. A recent study by the Health Care Financing Administration has concluded that national spending on health care will again increase at a faster rate than the rate of growth of the economy as a whole and that by 2002 it will total $2.1 trillion, or 16.6 percent of GDP (Smith et al., 1998), perhaps creating additional pressure to cut costs.

Even though the United States spends almost one-seventh of its GDP on health care, a rising number of Americans either lack health insurance or are underinsured. In 1998, 44.2 million Americans had no health insurance. This figure represented 16.3 percent of the population, an increase



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