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INTRODUCTION

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Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally.

Principle 8, APTA Code of Ethics

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For some time, health care in the United States has been in crisis, financially and morally. The United States is the last developed country without an effective health-care system for all its citizens. China was the only other major country without universal coverage until it announced in 2008 a major reform that would yield 90% coverage by 2011 and universal coverage by 2020 to its nearly 1.3 billion citizens.1 Many factors created the U.S. crisis, including expensive advances in health-care research, reliance on costly technology, public demand for the best care possible, high administrative costs in health-care organizations, and the dramatic extension of the average American life span, with its accompanying increase in medical intervention.

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The crisis is defined in multiple ways. Over 45 million Americans had no medical insurance for the full year of 2007, and 64.5 million people were uninsured for at least 6 months in 2007 and 2008, either because their companies did not provide it or because they could not afford to pay for it.2 In addition, uncounted millions of people have only partial health-care coverage because of preexisting medical conditions or exclusion clauses in their policies. Not having insurance, or having inadequate insurance, dramatically reduces health-care outcomes. The Institute of Medicine issued six reports between 2001 and 2004 and again in 2009 reviewing health outcomes research. Each concluded that being uninsured is directly related to poor health outcomes, such as increased risk for congestive heart failure, deaths secondary to heart attacks, and higher mortality rates following severe auto accidents.3

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Financially, the rising cost of health care has had dramatic macro-level effects. Even though the United States spends the most of any industrialized country—between 50% and 100% more—its health-care outcomes compare poorly in almost all areas. Employer-based insurance premiums create an overhead expense for products and services that put citizens at an economic disadvantage, locally and in the global economy. At the micro level, medical costs were a factor in 62.1% of all bankruptcies in 2007 compared with 46.2% in 2001.4 In the nearly 75% of the bankruptcies in which medical care was an issue, the individuals had health insurance; most were well educated, owned their homes, and were employed. (These data are prior to the recession that started in 2008 and after the Bankruptcy Abuse Prevention and Consumer Protection Act, which made it more difficult to file for bankruptcy protection.) Being insured did not protect families from financial disaster for several possible reasons. Pre-existing condition clauses in insurance policies can temporarily or permanently exempt those conditions for which a person has a likelihood of an occurrence. High deductibles and low caps can also limit protection. One of the more devastating acts on the part of insurance companies is the practice ...

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