Health care reform

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Health care reform is a general rubric used for discussing major health policy creation or changes—for the most part, governmental policy that affects health care delivery in a given place. Health care reform typically attempts to:

  • Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies
  • Expand the array of health care providers consumers may choose among
  • Improve the access to health care specialists
  • Improve the quality of health care
  • Give more care to citizens
  • Decrease the cost of health care

A recent study shows that no healthcare system is best at everything[1]

United States[edit]

Health care reform in the United States
Legislation
Preceding
Superseded
Proposed
Latest enacted
Reforms
Systems
Third-party payment models
Maximum Out-of-Pocket Premium as Percentage of Family Income (Source: CRS)

In the United States, the debate regarding healthcare reform includes questions of a right to health care, access, fairness, sustainability, quality and amounts spent by government. The mixed public-private health care system in the United States is the most expensive in the world, with health care costing more per person than in any other nation, and a greater portion of gross domestic product (GDP) is spent on it than in any other United Nations member state except for East Timor (Timor-Leste).[2] A study of international health care spending levels in the year 2000, published in the health policy journal Health Affairs, found that while the U.S. spends more on health care than other countries in the Organization for Economic Co-operation and Development (OECD), the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study concluded that the prices paid for health care services are much higher in the U.S.[3]

In spite of the amount spent on health care in the U.S., according to a 2008 Commonwealth Fund report, the United States ranks last in the quality of health care among developed countries.[4] The World Health Organization (WHO), in 2000, ranked the US health care system 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).[5][6] International comparisons that could lead to conclusions about the quality of the health care received by Americans are subject to debate. The US pays twice as much yet lags other wealthy nations in such measures as infant mortality and life expectancy, which are among the most widely collected, hence easily compared, international statistics. Many people are underinsured, for example, in Colorado "of those with insurance for a full year, 36.3% were underinsured."[7][8] About 10.7 million insured Americans spend more than a quarter of their annual paychecks on health care because of the high deductible polices.[9]

The Patient Protection and Affordable Care Act (Public Law 111-148) was signed into law by President Barack Obama on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (signed March 30), the Act is a product of the health care reform efforts of the Democratic 111th Congress and the Obama administration. The law includes health-related provisions to take effect over the next four years, including expanding Medicaid eligibility for people making up to 133% of the federal poverty level (FPL),[10] subsidizing insurance premiums for people making up to 400% of the FPL ($88,000 for family of 4 in 2010) so their maximum "out-of-pocket" payment for annual premiums will be from 2% to 9.5% of income,[11][12] providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre-existing conditions, establishing health insurance exchanges, prohibiting insurers from establishing annual coverage caps, and support for medical research. According to White House and Congressional Budget Office figures, the maximum share of income that enrollees would have to pay for the "silver" healthcare plan would vary depending on their income relative to the federal poverty level, as follows:[11][13] for families with income 133–150% of FPL will be 3-4% of income, for families with income of 150–200% of FPL will be 4-6.3% of income, for families with income 200–250% of FPL will be 6.3-8.05% of income, for families with income 250-300% of FPL will be 8.05-9.5% of income, for families with income from 300 to 400% of FPL will be 9.5% of income.[14][15][16]

The costs of these provisions are offset by a variety of taxes, fees, and cost-saving measures, such as new Medicare taxes for those in high-income brackets, taxes on indoor tanning, cuts to the Medicare Advantage program in favor of traditional Medicare, and fees on medical devices and pharmaceutical companies;[17] there is also a tax penalty for those who do not obtain health insurance, unless they are exempt due to low income or other reasons.[18] The Congressional Budget Office estimates that the net effect of both laws will be a reduction in the federal deficit by $143 billion over the first decade.[19]

The universal health care proposal pending in the U.S. Congress is called the United States National Health Care Act (H.R. 676, formerly the "Medicare for All Act.") The Congressional Budget Office and related government agencies scored the cost of a universal health care system several times since 1991, and have uniformly predicted cost savings,[20] probably because of the 40% cost savings associated with universal preventative care[21] and elimination of insurance company overhead costs.

Hawaii and Massachusetts[edit]

Both Hawaii and Massachusetts have implemented some incremental reforms in health care, but neither state has complete coverage of its citizens. For example, data from the Kaiser Family Foundation shows that 5% of Massachusetts and 8% of Hawaii residents are uninsured.[22] To date, The U.S. Uniform Law Commission, sponsored by the National Conference of Commissioners on Uniform State Laws has not submitted a uniform act or model legislation regarding health care insurance or health care reform.

United Kingdom[edit]

Health care was reformed in 1948 after the Second World War, broadly along the lines of the 1942 Beveridge Report, with the creation of the National Health Service or NHS. It was originally established as part of a wider reform of social services and funded by a system of National Insurance, though receipt of health care was never contingent upon making contributions towards the National Insurance Fund. Private health care was not abolished but had to compete with the NHS. About 15% of all spending on health in the UK is still privately funded but this includes the patient contributions towards NHS provided prescription drugs, so private sector health care in the UK is quite small. As part of a wider reform of social provision it was originally thought that the focus would be as much about the prevention of ill-health as it was about curing disease. The NHS for example would distribute baby formula milk fortified with vitamins and minerals in an effort to improve the health of children born in the post war years as well as other supplements such as cod liver oil and malt. Many of the common childhood diseases such as measles, mumps, and chicken pox were mostly eradicated with a national program of vaccinations.

The NHS has been through several reforms since 1948 although it is probably fair to say that the system has been through phases of evolutionary change. The Conservative Thatcher administrations attempted to bring competition into the NHS by developing a supplier/buyer role between hospitals as suppliers and health authorities as buyers. This necessitated the detailed costing of activities, something which the NHS had never had to do in such detail, and some felt was unnecessary. The Labour Party generally opposed these changes, although after the party became New Labour, the Blair government retained elements of competition and even extended it, allowing private health care providers to bid for NHS work. Some treatment and diagnostic centres are now run by private enterprise and funded under contract. However, the extent of this privatisation of NHS work is still very very small, though remains controversial. The administration committed more money to the NHS raising it to almost the same level of funding as the European average and as a result, there has been a large expansion and mordernisation programme and waiting times are now much more acceptable than they once were.

The government of Gordon Brown has announced several new reforms for care in England. One is to take the NHS back more towards health prevention by tackling issues that are known to cause long term ill health. The biggest of these is obesity and related diseases such as diabetes and cardio-vascular disease. The second reform is to make the NHS a more personal service, and it is negotiating with doctors to provide more services at times more convenient to the patient, such as in the evenings and at weekends. This personal service idea would introduce regular health check-ups so that the population is screened more regularly. Doctors will give more advice on ill-health prevention (for example encouraging and assisting patients to control their weight, diet, exercise more, cease smoking etc.) and so tackle problems before they become more serious. Waiting times, which have already fallen considerably under Blair (median wait time is about 6 weeks for elective non-urgent surgery) are also in focus. The NHS will from December 2008, ensure that no person waits longer than 18 weeks from the date that a patient is referred to the hospital to the time of the operation or treatment. This 18 week period thus includes the time to arrange a first appointment, the time for any investigations or tests to determine the cause of the problem and how it should be treated. An NHS Constitution for England has recently been published which lays out the legal rights of patients as well as promises (not legally enforceable) the NHS strives to keep in England.

Germany[edit]

Numerous health care reforms in Germany were legislative interventions to stabilise the public health insurance since 1983. 9 out of 10 citizens are publicly insured, only 8% privately. Health care in Germany, including its industry and all services, is one of the largest sectors of the German economy. The total expenditure in health economics of Germany was about 287.3 billion euro in 2010, equivalent to 11.6 percent of the gross domestic product (GDP) this year and about 3,510 euro per capita. Direct inpatient and outpatient care equal just about a quarter of the entire expenditure - depending on the perspective.[23] Expenditure on pharmaceutical drugs is almost twice the amount of those for the entire hospital sector. Pharmaceutical drug expenditure grew by an annual average of 4.1% between 2004 and 2010.

These developments have caused numerous health care reforms since the 1980s. An actual example of 2010 and 2011: First time since 2004 the drug expenditure fell from 30.2 billion euro in 2010, to 29.1 billion Euro in 2011, i. e. minus 1.1 billion Euro or minus 3.6%. That was caused by restructuring the Social Security Code: manufacturer discount 16% instead of 6%, price moratorium, increasing discount contracts, increasing discount by wholesale trade and pharmacies.[24]

The Netherlands[edit]

The Netherlands has introduced a new system of health care insurance based on risk equalization through a risk equalization pool. In this way, a compulsory insurance package is available to all citizens at affordable cost without the need for the insured to be assessed for risk by the insurance company. Furthermore, health insurers are now willing to take on high risk individuals because they receive compensation for the higher risks.[25]

A 2008 article in the journal Health Affairs suggested that the Dutch health system, which combines mandatory universal coverage with competing private health plans, could serve as a model for reform in the US.[26][27]

A video (in Dutch and English) is available which explains the reforms. Subtitles in English are available by clicking the 'T' control on the video control after clicking this link.

Russia[edit]

Following the collapse of the Soviet Union, Russia embarked on a series of reforms intending to deliver better health care by compulsory medical insurance with privately owned providers in addition to the state run institutions. According to the OECD [28] none of 1991-93 reforms worked out as planned and the reforms had in many respects made the system worse. Russia has more physicians, hospitals, and health care workers than almost any other country in the world on a per capita basis,[29][30] but since the collapse of the Soviet Union, the health of the Russian population has declined considerably as a result of social, economic, and lifestyle changes. However, after Putin became president in 2000 there was significant growth in spending for public healthcare[31] and in 2006 it exceed the pre-1991 level in real terms.[31] Also life expectancy increased from 1991-93 levels, infant mortality rate dropped from 18.1 in 1995 to 8.4 in 2008.[32] Russian Prime Minister Vladimir Putin announced a large-scale health-care reform in 2011 and pledged to allocate more than 300 billion rubles ($10 billion) in the next few years to improve health care in the country.[33] He also said that obligatory medical insurance tax paid by companies for compulsory medical insurance will increase from current 3.1% to 5.1% starting from 2011.[33]

Taiwan[edit]

Taiwan changed its health care system in 1995 to a National Health Insurance model similar to the US Medicare system for seniors. As a result, the 40% of Taiwanese people who had previously been uninsured are now covered.[34] It is said to deliver universal coverage with free choice of doctors and hospitals and no waiting lists. Polls in 2005 are reported to have shown that 72.5% of Taiwanese are happy with the system, and when they are unhappy, it's with the cost of premiums (equivalent to less than US$20 a month).[35]

Employers and the self-employed are legally bound to pay National Health Insurance (NHI) premiums which are similar to social security contributions in other countries. However, the NHI is a pay-as-you-go system. The aim is for the premium income to pay costs. The system is also subsidized by a tobacco tax surcharge and contributions from the national lottery.[citation needed]

Elsewhere[edit]

As evidenced by the large variety of different health care systems seen across the world, there are several different pathways that a country could take when thinking about reform. In comparison to the UK, physicians in Germany have more bargaining power through professional organizations (i.e., physician associations); this ability to negotiate has an impact on reform efforts.[36] Germany makes use of sickness funds, which citizens are obliged to join but are able to opt out if they have a very high income (Belien 87). The Netherlands used a similar system but the financial threshold for opting out was lower (Belien 89). The Swiss, on the other hand use more of a privately based health insurance system where citizens are risk-rated by age and sex, among other factors (Belien 90). The United States government provides health care to just over 25% of its citizens through various agencies, but otherwise does not employ a system. Health care is generally centered around regulated private insurance methods.

One key component to health care reform is the reduction of health care fraud and abuse. In the U.S. and the EU, it is estimated that as much as 10 percent of all health care transactions and expenditures may be fraudulent. See Terry L. Leap, Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What to do about It (Cornell University Press, 2011).

Also interesting to notice is the oldest health care system in the world and its advantages and disadvantages, see Health in Germany.

See also[edit]

Topics on status quo in health care[edit]

U.S. and other national approaches to health care reform[edit]

References[edit]

  1. ^ http://www.youtube.com/watch?v=K7mnJBWb-rE
  2. ^ WHO (May 2009). "World Health Statistics 2009". World Health Organization. Retrieved 2009-08-02. 
  3. ^ Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey and Varduhi Petrosyan, "It’s The Prices, Stupid: Why The United States Is So Different From Other Countries", Health Affairs, Volume 22, Number 3, May/June 2003. Accessed February 27, 2008.
  4. ^ Health care in US ranks lowest among developed countries
  5. ^ World Health Organization assess the world's health system. Press Release WHO/44 21 June 2000.
  6. ^ Health system attainment and performance in all Member States, ranked by eight measures, estimates for 1997
  7. ^ "Underinsurance in Primary Care". 
  8. ^ Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families—Findings from the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2007. From the report: "In 2007, nearly two-thirds of U.S. adults, or an estimated 116 million people, struggled to pay medical bills, went without needed care because of cost, were uninsured for a time, or were underinsured (i.e., were insured but not adequately protected from high medical expenses)."
  9. ^ Report Finds Insurance Coverage Inadequate: Even Those Who Are Insured Struggle Making Medical Payments. From the statement, "Kathleen Stoll, health policy director at the Families USA consumer advocacy group, said 10.7 million insured Americans spend more than a quarter of their annual paychecks on health care."
  10. ^ "5 key things to remember about health care reform". CNN. March 25, 2010. 
  11. ^ a b "Policies to Improve Affordability and Accountability". The White House. 
  12. ^ "Health Care Reform Bill 101". The Christian Science Monitor. 
  13. ^ "An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Care Act". 
  14. ^ "Health Insurance Premiums (DHHS)". DHHS, see history at http://www.samhsa.gov/Financing/post/Health-Insurance-Premiums-Past-High-Costs-Will-Become-the-Present-and-Future-Without-Health-Reform.aspx. January 28, 2011. 
  15. ^ "Private Health Insurance Provisions in PPACA (P.L. 111-148)". Congressional Research Service. April 15, 2010. 
  16. ^ "Health Insurance Premium Credits Under PPACA". =Congressional Research Service. April 28, 2010. 
  17. ^ Peter Grier, Health care reform bill 101: Who will pay for reform?, Christian Science Monitor (March 21, 2010).
  18. ^ Grier, Peter (March 19, 2010). "Health care reform bill 101: Who must buy insurance?". Christian Science Monitor (Washington, D.C.). Retrieved 2010-04-07. 
  19. ^ Congressional Budget Office, Cost Estimates for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation) (March 20, 2010).
  20. ^ Physicians for a National Health Program (January, 2008) "Single Payer System Cost?" pnhp.org
  21. ^ Hogg, W., et al. (2005) "Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost-consequences analysis" BMC Health Services Research 5:20
  22. ^ Kaiser Family Foundation. "Health Coverage & Uninsured." www.statehealthfacts.org
  23. ^ Andreas J. W. Goldschmidt: Der 'Markt' Gesundheitswesen. In: M. Beck, A. J. W. Goldschmidt, A. Greulich, M. Kalbitzer, R. Schmidt, G. Thiele (Hrsg.): Management Handbuch DRGs, Hüthig / Economica, Heidelberg, 1. Auflage 2003 (ISBN 3-87081-300-8): S. C3720/1-24, with 3 revisions / additional deliveries until 2012
  24. ^ B. Häusler, A. Höer, E. Hempel: Arzneimittel-Atlas 2012. Springer, Berlin u. a. 2012 (ISBN 978-3-642-32586-1)
  25. ^ http://www.minvws.nl/en/themes/health-insurance-system/ Ministry of Health, Welfare and Sport
  26. ^ Wynand P.M.M. van de Ven and Frederik T. Schut, "UniversalMandatory Health Insurance In The Netherlands: AModel For The United States?," Health Affairs, Volume 27, Number 3, May/June 2008
  27. ^ Helen Garey and Deborah Lorber "Universal Mandatory Health Insurance in The Netherlands: A Model for the United States?," In the Literature, the Commonwealth Fund, May 13, 2008
  28. ^ OECD: HEALTHCARE REFORM IN RUSSIA: PROBLEMS AND PROSPECTS (2006)
  29. ^ Field, M. G. The health and demographic crisis in post-Soviet Russia: a two-phase development in "Russia’s Torn Safety Nets", edited by Field M. G., Twigg J. L. (eds). 2000:11–42: St. Martin’s Press. 
  30. ^ "Highlights on Health in the Russian Federation" (PDF). World Health Organization. November 1999. Archived from the original on 2007-07-29. Retrieved 2007-12-27. 
  31. ^ a b "Public Spending in Russia for Healthcare". 
  32. ^ "Russian State Institute of Demography". 
  33. ^ a b "Putin says Russia needs major health care reform". 
  34. ^ PBS Taiwan: A New System They Copied From Others
  35. ^ PBS: Sick Around the World
  36. ^ Freeman, Richard. The Politics of Health in Europe. 1999 (Manchester: Manchester University Press)

External links[edit]