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Country wise Health +Health-Care PDF Print E-mail

 

 

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Arsenic +Other Chemical contamination into our all foods are the delivery-room

of All diseases in our body+mind+spirit, Take care of your 'triple Health' properly.

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Try to improve your Physical, Mental +Spiritual Health

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"No Diseases shall attack you"

You can adopt one or more therapy/treatment to solve the all sorts of Diseases

1. Conventional or allopathic medicines- such as regular Healthcare +medication with more

silent side effects---known +unknown.

2. Homoeopathic medicines : such as fixed time medication upto 6 months +regular Healthcare

with no side effects in future or in the long run.

3. Bio-Chemic Medicines : such as 6 months medication through 6 follow-up +regular Healthcare

with no side effects & 99.9% warranty if you follow Health Rules LIFE-long.

4. Homoeopathy+Bio-chemic: Such as 5 months medication +regular Healthcare for life-long warranty

if you follow the Health-Consciousness rule always.

5. Potentized-Herbal : Such as 6 months medication +regular Healthcare to meet the same

avoiding health-damaging causes regularly, life-long.

6. Food+Nutrient Therapy: Regular Health-Consciousness with balanced food-drinks-medicines to absorb

into your body+mind with regular Personalcare by the advices of DOCTOR.

7. "Health-Membership" for pre-marriage 'Healthcare-Insurance' at Health-Conscious Society

 

 

Country wise Health +Health-Care

Health + Diseases depends on Geographical fact +country-wise food behavior. So, Healthcare in different country depend on various factors to manage. All disease never attack all country Or people simultaneously. As a result, we never forget the history of epidemics +its management. Every authority wants to manage the same so easily +cheaply to safe+advertise him properly as a human friend.

 

 

Health care (or healthcare) is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers. It refers to the work done in providing primary care, secondary care and tertiary care, as well as in public health.

Access to services by health care practitioners varies across countries, groups and individuals, largely influenced by social and economic conditions as well as the health policies in place. Countries and jurisdictions have different policies and plans in relation to the personal and population-based health care goals within their societies. Health care systems are organizations established to meet the health needs of target populations. Their exact configuration varies from country to country. In some countries and jurisdictions, health care planning is distributed among market participants, whereas in others planning is made more centrally among governments or other coordinating bodies. In all cases, according to the World Health Organization (WHO), a well-functioning health care system requires a robust financing mechanism; a well-trained and adequately-paid workforce; reliable information on which to base decisions and policies; and well maintained facilities and logistics to deliver quality medicines and technologies.[1]

Health care can form an enormous part of a country's economy. In 2008, the health care industry consumed an average of 9.0 percent of the gross domestic product (GDP) across the most developed OECD countries.[2] The United States (16.0%), France (11.2%), and Switzerland (10.7%) were the top three spenders.

Health care is conventionally regarded as an important determinant in promoting the general health and wellbeing of peoples around the world. An example of this is the worldwide eradication of smallpox in 1980 - declared by the WHO as the first disease in human history to be completely eliminated by deliberate health care interventions.[3]


Health care delivery: Health care providers

Primary care may be provided in community health centres.

The delivery of modern health care depends on groups of trained professionals and paraprofessionals coming together as interdisciplinary teams.[4][5] This includes professionals in medicine, nursing, dentistry and allied health, plus many others such as public health practitioners, community health workers and assistive personnel, who systematically provide personal and population-based preventive, curative and rehabilitative care services.

While the definitions of the various types of health care vary depending on the different cultural, political, organizational and disciplinary perspectives, there appears to be some consensus that primary care constitutes the first element of a continuing health care process, that may also include the provision of secondary and tertiary levels of care.[6]

Primary care: Primary care: Primary health care



Medical train "Therapist Matvei Mudrov" in Khabarovsk, Russia

Primary care is the term for the health care services which play a central role in the local community. It refers to the work of health care professionals who act as a first point of consultation for all patients within the health care system.[6][7] Such a professional would usually be a primary care physician, such as a general practitioner or family physician. Depending on the locality, health system organization, and sometimes at the patient's discretion, they may see another health care professional first, such as a pharmacist, a nurse (such as in the United Kingdom), a clinical officer (such as in parts of Africa), or an Ayurvedic or other traditional medicine professional (such as in parts of Asia). Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.

Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all manner of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. The International Classification of Primary Care (ICPC) is a standardized tool for understanding and analyzing information on interventions in primary care by the reason for the patient visit.[8]

Common chronic illnesses usually treated in primary care may include, for example: hypertension, diabetes, asthma, COPD, depression and anxiety, back pain, arthritis or thyroid dysfunction. Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations.

In context of global population ageing, with increasing numbers of older adults at greater risk of chonic non-communicable diseases, rapidly increasing demand for primary care services is expected around the world, in both developed and developing countries.[9][10] The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary health care strategy.[6]

Secondary care

Secondary care is the health care services provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, cardiologists, urologists and dermatologists.

It includes acute care: necessary treatment for a short period of time for a brief but serious illness, injury or other health condition, such as in a hospital emergency department. It also includes skilled attendance during childbirth, intensive care, and medical imaging services.

The "secondary care" is sometimes used synonymously with "hospital care". However many secondary care providers do not necessarily work in hospitals, such as psychiatrists or physiotherapists, and some primary care services are delivered within hospitals. Depending on the organization and policies of the national health system, patients may be required to see a primary care provider for a referral before they can access secondary care.

For example in the United States, which operates under a mixed market health care system, some physicians might voluntarily limit their practice to secondary care by requiring patients to see a primary care provider first, or this restriction may be imposed under the terms of the payment agreements in private/group health insurance plans. In other cases medical specialists may see patients without a referral, and patients may decide whether self-referral is preferred.

In the United Kingdom and Canada, patient self-referral to a medical specialist for secondary care is rare as prior referral from another physician (either a primary care physician or another specialist) is considered necessary, regardless of whether the funding is from private insurance schemes or national health insurance.

Allied health professionals, such as occupational therapists, speech therapists, and dietitians, also generally work in secondary care, accessed through either patient self-referral or through physician referral.

Tertiary care: Medicine

Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital.[11]

Examples of tertiary care services are cancer management, neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative, and other complex medical and surgical interventions.[12]

Quaternary care

The term quaternary care is also used sometimes as an extension of tertiary care in reference to medicine of advanced levels which are highly specialized and not widely accessed. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care. These services are usually only offered in a limited number of regional or national health care centres.[12][13]

Home and community care: Public health

Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food safety surveillance, distribution of condoms and needle-exchange programmes for the prevention of transmissible diseases.

They also include the services of professionals in residential and community settings in support of self care, home care, long-term care, assisted living, treatment for substance use disorders, and other types of health and social care services.

Related sectors

For general descriptions of health care financing and delivery systems by country, please see Health care system

Health care extends beyond the delivery of services to patients, encompassing many related sectors, and set within a bigger picture of financing and governance structures.

Health care industry: Health care industry and Health economics

A group of Chilean 'Damas de Rojo' volunteering at their local hospital.

The health care industry incorporates several sectors that are dedicated to providing health care services and products. As a basic framework for defining the sector, the United Nations' International Standard Industrial Classification categorizes health care as generally consisting of hospital activities, medical and dental practice activities, and "other human health activities". The last class involves activities of, or under the supervision of, nurses, midwives, physiotherapists, scientific or diagnostic laboratories, pathology clinics, residential health facilites, or other allied health professions, e.g. in the field of optometry, hydrotherapy, medical massage, yoga therapy, music therapy, occupational therapy, speech therapy, chiropody, homeopathy, chiropractics, acupuncture, etc.[14]

In addition, according to industry and market classifications, such as the Global Industry Classification Standard and the Industry Classification Benchmark, health care includes many categories of medical equipment, instruments and services as well as biotechnology, diagnostic laboratories and substances, and drug manufacturing and delivery.

For example, pharmaceuticals and other medical devices are the leading high technology exports of Europe and the United States.[15][16] The United States dominates the biopharmaceutical field, accounting for three-quarters of the world’s biotechnology revenues.[17][15]

Health care research: List of medical journals and List of health care journals

The quantity and quality of many health care interventions are improved through the results of science, such as advanced through the medical model of health which focuses on the eradication of illness through diagnosis and effective treatment. Many important advances have been made through health research, including biomedical research and pharmaceutical research. They form the basis of evidence-based medicine and evidence-based practice in health care delivery.

For example, in terms of pharmaceutical research and development spending, Europe spends a little less than the United States (‚ā¨22.50bn compared to ‚ā¨27.05bn in 2006). The United States accounts for 80% of the world's research and development spending in biotechnology.[15][17]

In addition, the results of health services research can lead to greater efficiency and equitable delivery of health care interventions, as advanced through the social model of health and disability, which emphasizes the societal changes that can be made to make population healthiers.[18] Results from health services research often form the basis of evidence-based policy in health care systems.

Health care financing: Health care system, Health policy, and Universal health care

For descriptions of health care financing by country, please see Health care system and Universal health care

There are generally five primary methods of funding health care systems:[19]

  1. general taxation to the state, county or municipality
  2. social health insurance
  3. voluntary or private health insurance
  4. out-of-pocket payments
  5. donations

In most countries, the financing of health care services features a mix of all five models, but the exact distribution varies across countries and over time within countries. In all countries and jurisdictions, there are many topics in the politics and evidence that can influence the decision of a government, private sector business or other group to adopt a specific health policy regarding the financing structure.

For example, social health insurance is where a nation's entire population is eligible for health care coverage, and this coverage and the services provided are regulated. In almost every jurisdiction with a government-funded health care system, a parallel private, and usually for-profit, system is allowed to operate. This is sometimes referred to as two-tier health care or universal health care.

Health care administration and regulation: Healthcare provider requisites

The management and administration of health care is another sector vital to the delivery of health care services. In particular, the practice of health professionals and operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance.[20] Most countries have credentialing staff in regulatory boards or health departments who document the certification or licensing of health workers and their work history.[21]

Systems by country: Health care system

Canada: Health care in Canada

In 1984, the Canada Health Act was passed, which guarantees access to primary and other health care services for all citizens, and prohibits extra billing by doctors on patients while at the same time billing the public insurance system. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."[22] The system is for the most part publicly funded, with most services provided through publicly administered hospitals or privately operating practitioners.

Guinea: Health care in Guinea

Guinea has been reorganizing its health system since the Bamako Initiative of 1987 formally promoted community-based methods of increasing accessibility of primary health care to the population, including community ownership and local budgeting, resulting in more efficient and equitable provision of drugs and other essential health care resources.[23]

In June 2011, the Guinean government announced the establishment of an air solidarity levy on all flights taking off from national soil, with funds going to UNITAID to support expanded access to treatment for HIV/AIDS, tuberculosis and malaria.[24] Guinea is among the growing number of countries and development partners using market-based transactions taxes and other innovative financing mechanisms to expand financing options for health care in resource-limited settings.

United Kingdom: Healthcare in the United Kingdom

Each of the Countries of the United Kingdom has a National Health Service that provides public healthcare to all UK permanent residents that is free at the point of need and paid for from general taxation. However private healthcare companies are free to operate alongside the public one. Since health is a devolved matter, considerable differences are developing between the systems in each of the countries.[25]

United States

Health care reform in the United States


The United States currently operates under a mixed market health care system. Government sources (federal, state, and local) account for 45% of U.S. health care expenditures.[26] Private sources account for the remainder of costs, with 38% of people receiving health coverage through their employers and 17% arising from other private payment such as private insurance and out-of-pocket co-pays. Opponents of government intervention into the market generally believe that such intervention distorts pricing as government agents would be operating outside of the corporate model and the principles of market discipline; they have less short and medium-term incentives than private agents to make purchases that can generate revenues and avoid bankruptcy.[citation needed] Health system reform in the United States usually focuses around three suggested systems, with proposals currently underway to integrate these systems in various ways to provide a number of health care options.[citation needed] First is single-payer, a term meant to describe a single agency managing a single system, as found in most modernized countries as well as some states and municipalities within the United States. Second are employer or individual insurance mandates, with which the state of Massachusetts has experimented. Finally, there is consumer-driven health, in which systems, consumers, and patients have more control of how they access care. This is argued[by whom?] to provide a greater incentive to find cost-saving health care approaches. Critics of consumer-driven health say that it would benefit the healthy but be insufficient for the chronically sick, much as the current system operates.[citation needed] Over the past thirty years, most of the nation's health care has moved from the second model operating with not-for-profit institutions to the third model operating with for-profit institutions; the greater problems with this approach have been the gradual deregulation of HMOs resulting in fewer of the promised choices for consumers, and the steady increase in consumer costs that have marginalized consumers and burdened states with excessive urgent health care costs that are avoided when consumers actually have adequate access to preventive health care.[citation needed]

A few states have taken serious steps toward universal health care coverage, most notably Minnesota, Massachusetts and Connecticut, with recent examples being the Massachusetts 2006 Health Reform Statute[27] and Connecticut's SustiNet plan to provide quality, affordable health care to state residents.[28]

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),[29] 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 on sliding scale from 2% to 9.8% of income,[30][31] 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.

See also

Healthcare adopted by WHO:

 

The World Health Organization (WHO), in its World Health Report 2000, provided a framework and measurement approach to examine and compare aspects of health systems around the world.[1] It developed a series of performance indicators to assess the overall level and distribution of health in the populations, and the responsiveness and fair financing of health care services. It was the organization's first ever analysis of the world's health systems.[2] This is the ranking of health care systems (estimates for 1997 among 191 member states) according to the report.

 

World Health Organization Assesses the World's Health Systems

World Health Organization Assesses the World's Health Systems

The World Health Organization has carried out the first ever analysis of the world's health systems. Using five performance indicators to measure health systems in 191 member states, it finds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria and Japan.

The findings are published today, 21 June, in The World Health Report 2000 ‚Äď Health systems: Improving performance*.

*Copies of the Report can be ordered from This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

The U.S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report finds. The United Kingdom, which spends just six percent of GDP on health services, ranks 18 th . Several small countries ‚Äď San Marino, Andorra, Malta and Singapore are rated close behind second- placed Italy.

WHO Director-General Dr Gro Harlem Brundtland says: "The main message from this report is that the health and well- being of people around the world depend critically on the performance of the health systems that serve them. Yet there is wide variation in performance, even among countries with similar levels of income and health expenditure. It is essential for decision- makers to understand the underlying reasons so that system performance, and hence the health of populations, can be improved."

Dr Christopher Murray, Director of WHO's Global Programme on Evidence for Health Policy. says: "Although significant progress has been achieved in past decades, virtually all countries are under- utilizing the resources that are available to them. This leads to large numbers of preventable deaths and disabilities; unnecessary suffering, injustice, inequality and denial of an individual's basic rights to health."

The impact of failures in health systems is most severe on the poor everywhere, who are driven deeper into poverty by lack of financial protection against ill- health, the report says.

"The poor are treated with less respect, given less choice of service providers and offered lower- quality amenities," says Dr Brundtland. "In trying to buy health from their own pockets, they pay and become poorer."

The World Health Report says the main failings of many health systems are:

  • Many health ministries focus on the public sector and often disregard the frequently much larger private sector health care.
  • In many countries, some if not most physicians work simultaneously for the public sector and in private practice. This means the public sector ends up subsidizing unofficial private practice.
  • Many governments fail to prevent a "black market" in health, where widespread corruption, bribery, "moonlighting" and other illegal practices flourish. The black markets, which themselves are caused by malfunctioning health systems, and low income of health workers, further undermine those systems.
  • Many health ministries fail to enforce regulations that they themselves have created or are supposed to implement in the public interest.

Dr Julio Frenk, Executive Director for Evidence and Information for Policy at WHO, says: "By providing a comparative guide to what works and what doesn't work, we can help countries to learn from each other and thereby improve the performance of their health systems."

Dr Philip Musgrove, editor-in-chief of the report, says: "The WHO study finds that it isn't just how much you invest in total, or where you put facilities geographically, that matters. It's the balance among inputs that counts ‚Äď for example, you have to have the right number of nurses per doctor."

Most of the lowest placed countries are in sub-Saharan Africa where life expectancies are low. HIV and AIDS are major causes of ill-health. Because of the AIDS epidemic, healthy life expectancy for babies born in 2000 in many of these nations has dropped to 40 years or less.

One key recommendation from the report is for countries to extend health insurance to as large a percentage of the population as possible. WHO says that it is better to make "pre-payments" on health care as much as possible, whether in the form of insurance, taxes or social security.

While private health expenses in industrial countries now average only some 25 percent because of universal health coverage (except in the United States, where it is 56%), in India, families typically pay 80 percent of their health care costs as "out-of- pocket" expenses when they receive health care.

"It is especially beneficial to make sure that as large a percentage as possible of the poorest people in each country can get insurance," says Dr Frenk. "Insurance protects people against the catastrophic effects of poor health. What we are seeing is that in many countries, the poor pay a higher percentage of their income on health care than the rich."

"In many countries without a health insurance safety net, many families have to pay more than 100 percent of their income for health care when hit with sudden emergencies. In other words, illness forces them into debt."

In designing the framework for health system performance, WHO broke new methodological ground, employing a technique not previously used for health systems. It compares each country's system to what the experts estimate to be the upper limit of what can be done with the level of resources available in that country. It also measures what each country's system has accomplished in comparison with those of other countries.

WHO's assessment system was based on five indicators: overall level of population health; health inequalities (or disparities) within the population; overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts); distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system); and the distribution of the health system's financial burden within the population (who pays the costs).

"We have created a new tool to help us measure performance," says Dr Murray. "As we develop it further and strengthen the raw data used for these measures in the years to come, we believe this will be an increasingly useful tool for governments in improving their own health systems."

Other findings in the annual WHO report include:

  • In Europe, health systems in Mediterranean countries such as France, Italy and Spain are rated higher than others in the continent. Norway is the highest Scandinavian nation, at 11th .
  • Colombia, Chile, Costa Rica and Cuba are rated highest among the Latin American nations ‚Äď 22nd, 33rd, 36th and 39th in the world, respectively.
  • Singapore is ranked 6th , the only Asian country apart from Japan in the top 10 countries.
  • In the Pacific, Australia ranks 32 nd overall, while New Zealand is 41st .
  • In the Middle East and North Africa, many countries rank highly: Oman is in 8 th place overall, Saudi Arabia is ranked 26th , United Arab Emirates 27th and Morocco, 29th.

In 1970, Oman's health care system was not performing well. The child mortality rate was high. But major government investments have proved to be successful in improving system performance. "Oman's success shows that tremendous strides can be accomplished in a relatively short period of time," says Dr Murray.

Information in the WHO report also rates countries according to the different components of the performance index.

Responsiveness: The nations with the most responsive health systems are the United States, Switzerland, Luxembourg, Denmark, Germany, Japan, Canada, Norway, Netherlands and Sweden. The reason these are all advanced industrial nations is that a number of the elements of responsiveness depend strongly on the availability of resources. In addition, many of these countries were the first to begin addressing the responsiveness of their health systems to people's needs.

Fairness of financial contribution: When WHO measured the fairness of financial contribution to health systems, countries lined up differently. The measurement is based on the fraction of a household's capacity to spend (income minus food expenditure) that goes on health care (including tax payments, social insurance, private insurance and out of pocket payments). Colombia was the top-rated country in this category, followed by Luxembourg, Belgium, Djibouti, Denmark, Ireland, Germany, Norway, Japan and Finland.

Colombia achieved top rank because someone with a low income might pay the equivalent of one dollar per year for health care, while a high- income individual pays 7.6 dollars.

Countries judged to have the least fair financing of health systems include Sierra Leone, Myanmar, Brazil, China, Viet Nam, Nepal, Russian Federation, Peru and Cambodia.

Brazil, a middle-income nation, ranks low in this table because its people make high out-of-pocket payments for health care. This means a substantial number of households pay a large fraction of their income (after paying for food) on health care. The same explanation applies to the fairness of financing Peru's health system. The reason why the Russian Federation ranks low is most likely related to the impact of the economic crisis in the 1990s. This has severely reduced government spending on health and led to increased out-of-pocket payment.

In North America, Canada rates as the country with the fairest mechanism for health system finance ‚Äď ranked at 17-19, while the United States is at 54-55. Cuba is the highest among Latin American and Caribbean nations at 23-25.

The report indicates ‚Äď clearly ‚Äď the attributes of a good health system in relation to the elements of the performance measure, given below.

Overall Level of Health: A good health system, above all, contributes to good health. To assess overall population health and thus to judge how well the objective of good health is being achieved, WHO has chosen to use the measure of disability- adjusted life expectancy (DALE). This has the advantage of being directly comparable to life expectancy and is readily compared across populations. The report provides estimates for all countries of disability- adjusted life expectancy. DALE is estimated to equal or exceed 70 years in 24 countries, and 60 years in over half the Member States of WHO. At the other extreme are 32 countries where disability- adjusted life expectancy is estimated to be less than 40 years. Many of these are countries characterised by major epidemics of HIV/ AIDS, among other causes.

Distribution of Health in the Populations: It is not sufficient to protect or improve the average health of the population, if - at the same time - inequality worsens or remains high because the gain accrues disproportionately to those already enjoying better health. The health system also has the responsibility to try to reduce inequalities by prioritizing actions to improve the health of the worse-off, wherever these inequalities are caused by conditions amenable to intervention. The objective of good health is really twofold: the best attainable average level ‚Äď goodness ‚Äď and the smallest feasible differences among individuals and groups ‚Äď fairness. A gain in either one of these, with no change in the other, constitutes an improvement.

Responsiveness: Responsiveness includes two major components. These are (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider).

Distribution of Financing: There are good and bad ways to raise the resources for a health system, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is only concerned with distribution. It is not related to the total resource bill, nor to how the funds are used. The objectives of the health system do not include any particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending there are other possible uses for the resources devoted to health. The level of funding to allocate to the health system is a social choice ‚Äď with no correct answer. Nonetheless, the report suggests that countries spending less than around 60 dollars per person per year on health find that their populations are unable to access health services from an adequately performing health system.

In order to reflect these attributes, health systems have to carry out certain functions. They build human resources through investment and training, they deliver services, they finance all these activities. They act as the overall stewards of the resources and powers entrusted to them. In focusing on these few universal functions of health systems, the report provides evidence to assist policy- makers as they make choices to improve health system performance.

The World Health Report 2000 consists of a message from the WHO's Director-General, an overview, six chapters and statistical annexes. The chapter headings are "Why do health systems matter?", "How well do health systems perform?", Health services: well chosen, well organized?", "What resources are needed?", "Who pays for health systems?", and "How is the public interest protected?"

 

 

Healthcare adopted by USA:

 

Health care in the United States is provided by many separate legal entities. Health care facilities are largely owned and operated by the private sector. Health insurance is now primarily provided by the government in the public sector, with 60-65% of healthcare provision and spending coming from programs such as Medicare, Medicaid, TRICARE, the Children's Health Insurance Program, and the Veterans Health Administration.

The U.S. Census Bureau reported that a record 50.7 million residents (which includes 9.9 million non-citizens) or 16.7% of the population were uninsured in 2009.[1][2] More money per person is spent on health care in the USA than in any other nation in the world,[3][4] and a greater percentage of total income in the nation is spent on health care in the USA than in any United Nations member state except for East Timor.[4] Although not all people are insured, the USA has the third highest public healthcare expenditure per capita, because of the high cost of medical care in the country.[clarification needed][5][6] A 2001 study in five states found that medical debt contributed to 46.2% of all personal bankruptcies and in 2007, 62.1% of filers for bankruptcies claimed high medical expenses.[7] Since then, health costs and the numbers of uninsured and underinsured have increased.[8]

Active debate about health care reform in the United States concerns questions of a right to health care, access, fairness, efficiency, cost, choice, value, and quality. Some have argued that the system does not deliver equivalent value for the money spent. The USA pays twice as much yet lags behind other wealthy nations in such measures as infant mortality and life expectancy, though the relation between these statistics to the system itself is debated. Currently, the USA has a higher infant mortality rate than most of the world's industrialized nations.[nb 1][9] In the United States life expectancy is 42nd in the world, after some other industrialized nations, lagging the other nations of the G5 (Japan, France, Germany, UK, USA) and just after Chile (35th) and Cuba (37th).[10]

Life expectancy in the USA is 42nd in the world, below most developed nations and some developing nations. It is below the average life expectancy for the European Union.[11][12] The World Health Organization (WHO), in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study).[13][14] The Commonwealth Fund ranked the United States last in the quality of health care among similar countries,[15] and notes U.S. care costs the most.[16]

The USA is the "only wealthy, industrialized nation that does not ensure that all citizens have coverage" (i.e., some kind of private or public health insurance).[17] In 2004, the Institute of Medicine report observed "lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States."[17] while a 2009 Harvard study estimated that 44,800 excess deaths occurred annually due to lack of health insurance.[18]

On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) became law, providing for major changes in health insurance.[19]


Health care providers: Health care provider

Facilities: Medical centers in the United States

In the United States, ownership of the health care system is mainly in private hands, though federal, state, county, and city governments also own certain facilities.

The non-profit hospitals share of total hospital capacity has remained relatively stable (about 70%) for decades.[20] There are also privately owned for-profit hospitals as well as government hospitals in some locations, mainly owned by county and city governments.

There is no nationwide system of government-owned medical facilities open to the general public but there are local government-owned medical facilities open to the general public. The federal Department of Defense operates field hospitals as well as permanent hospitals (the Military Health System), to provide military-funded care to active military personnel.

The federal Veterans Health Administration operates VA hospitals open only to veterans, though veterans who seek medical care for conditions they did not receive while serving in the military are charged for services. The Indian Health Service operates facilities open only to Native Americans from recognized tribes. These facilities, plus tribal facilities and privately contracted services funded by IHS to increase system capacity and capabilities, provide medical care to tribespeople beyond what can be paid for by any private insurance or other government programs.[21]

Hospitals provide some outpatient care in their emergency rooms and specialty clinics, but primarily exist to provide inpatient care. Hospital emergency departments and urgent care centers are sources of sporadic problem-focused care. "Surgicenters" are examples of specialty clinics. Hospice services for the terminally ill who are expected to live six months or less are most commonly subsidized by charities and government. Prenatal, family planning, and "dysplasia" clinics are government-funded obstetric and gynecologic specialty clinics respectively, and are usually staffed by nurse practitioners.

Medical products, research and development

As in most other countries, the manufacture and production of pharmaceuticals and medical devices is carried out by private companies. The research and development of medical devices and pharmaceuticals is supported by both public and private sources of funding. In 2003, research and development expenditures were approximately $95 billion with $40 billion coming from public sources and $55 billion coming from private sources.[22][23] These investments into medical research have made the United States the leader in medical innovation, measured either in terms of revenue or the number of new drugs and devices introduced.[24][25] In 2006, the United States accounted for three quarters of the world’s biotechnology revenues and 82% of world R&D spending in biotechnology.[24][25] According to multiple international pharmaceutical trade groups, the high cost of patented drugs in the U.S. has encouraged substantial reinvestment in such research and development.[24][25][26]

Health care spending

U.S. healthcare costs exceed those of other countries, relative to the size of the economy or GDP.
Total U.S. healthcare spending as a percent of U.S. GDP (gross domestic product).[27] Click on chart for data.

Current estimates put U.S. health care spending at approximately 16% of GDP, second highest to East Timor (Timor-Leste) among all United Nations member nations.[4] The Health and Human Services Department expects that the health share of GDP will continue its historical upward trend, reaching 19.5% of GDP by 2017.[28][29] Of each dollar spent on health care in the United States, 31% goes to hospital care, 21% goes to physician/clinical services, 10% to pharmaceuticals, 4% to dental, 6% to nursing homes and 3% to home health care, 3% for other retail products, 3% for government public health activities, 7% to administrative costs, 7% to investment, and 6% to other professional services (physical therapists, optometrists, etc).[30]

The Office of the Actuary (OACT) of the Centers for Medicare and Medicaid Services publishes data on total health care spending in the United States, including both historical levels and future projections.[31] In 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person, up from $2.1 trillion, or $7,026 per capita, the previous year.[32] Spending in 2006 represented 16% of GDP, an increase of 6.7% over 2004 spending. Growth in spending is projected to average 6.7% annually over the period 2007 through 2017.

In 2009, the United States federal, state and local governments, corporations and individuals, together spent $2.5 trillion, $8,047 per person, on health care. This amount represented 17.3% of the GDP, up from 16.2% in 2008.[33] Health insurance costs are rising faster than wages or inflation,[34] and medical causes were cited by about half of bankruptcy filers in the United States in 2001.[35]

The Congressional Budget Office has found that "about half of all growth in health care spending in the past several decades was associated with changes in medical care made possible by advances in technology." Other factors included higher income levels, changes in insurance coverage, and rising prices.[36] Hospitals and physician spending take the largest share of the health care dollar, while prescription drugs take about 10%.[37] The use of prescription drugs is increasing among adults who have drug coverage.[38]

One analysis of international spending levels in the year 2000 found that while the U.S. spends more on health care than other countries in the Organisation 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.[39] Economist Hans Sennholz has argued that the Medicare and Medicaid programs may be the main reason for rising health care costs in the U.S.[40]

Health care spending in the United States is concentrated. An analysis of the 1996 Medical Expenditure Panel Survey found that the 1% of the population with the highest spending accounted for 27% of aggregate health care spending. The highest-spending 5% of the population accounted for more than half of all spending. These patterns were stable through the 1970s and 1980s, and some data suggest that they may have been typical of the mid-to-early 20th century as well.[41]

One study by the Agency for Healthcare Research and Quality (AHRQ) found significant persistence in the level of health care spending from year to year. Of the 1% of the population with the highest health care spending in 2002, 24.3% maintained their ranking in the top 1% in 2003. Of the 5% with the highest spending in 2002, 34% maintained that ranking in 2003. Individuals over age 45 were disproportionately represented among those who were in the top decile of spending for both years.[42]

Health care cost rise based on total expenditure on health as % of GDP. Countries are USA, Germany, Austria, Switzerland, United Kingdom and Canada.

Seniors spend, on average, far more on health care costs than either working-age adults or children. The pattern of spending by age was stable for most ages from 1987 through 2004, with the exception of spending for seniors age 85 and over. Spending for this group grew less rapidly than that of other groups over this period.[43]

The 2008 edition of the Dartmouth Atlas of Health Care[44] found that providing Medicare beneficiaries with severe chronic illnesses with more intense health care in the last two years of life‚ÄĒincreased spending, more tests, more procedures and longer hospital stays‚ÄĒis not associated with better patient outcomes. There are significant geographic variations in the level of care provided to chronically ill patients, only 4% of which are explained by differences in the number of severely ill people in an area. Most of the differences are explained by differences in the amount of "supply-sensitive" care available in an area. Acute hospital care accounts for over half (55%) of the spending for Medicare beneficiaries in the last two years of life, and differences in the volume of services provided is more significant than differences in price. The researchers found no evidence of "substitution" of care, where increased use of hospital care would reduce outpatient spending (or vice versa).[44][45]

Increased spending on disease prevention is often suggested as a way of reducing health care spending.[46] Research suggests, however, that in most cases prevention does not produce significant long-term costs savings.[46] Preventive care is typically provided to many people who would never become ill, and for those who would have become ill is partially offset by the health care costs during additional years of life.[46]

In September 2008 The Wall Street Journal reported that consumers were reducing their health care spending in response to the current economic slow-down. Both the number of prescriptions filled and the number of office visits dropped between 2007 and 2008. In one survey, 22% of consumers reported going to the doctor less often, and 11% reported buying fewer prescription drugs.[47]

In 2009, the average private room in a nursing home cost $219 daily. Assisted living costs averaged $3,131 monthly. Home health aides averaged $21 per hour. Adult day care services averaged $67 daily.[48]

Impact on U.S. economic productivity

On March 1, 2010, billionaire investor Warren Buffett said that the high costs paid by U.S. companies for their employees‚Äô health care put them at a competitive disadvantage. He compared the roughly 17% of GDP spent by the U.S. on health care with the 9% of GDP spent by much of the rest of the world, noted that the U.S. has fewer doctors and nurses per person, and said, ‚Äú[t]hat kind of a cost, compared with the rest of the world, is like a tapeworm eating at our economic body.‚ÄĚ[49]

Health care payment

Doctors and hospitals are generally funded by payments from patients and insurance plans in return for services rendered.

Around 84.7% of citizens have some form of health insurance; either through their employer or the employer of their spouse or parent (59.3%), purchased individually (8.9%), or provided by government programs (27.8%; there is some overlap in these figures).[50] All government health care programs have restricted eligibility, and there is no government health insurance company which covers all citizens. Americans without health insurance coverage in 2007 totaled 15.3% of the population, or 45.7 million people.[50]

Among those whose employer pays for health insurance, the employee may be required to contribute part of the cost of this insurance, while the employer usually chooses the insurance company and, for large groups, negotiates with the insurance company.

In 2004, private insurance paid for 36% of personal health expenditures, private out-of-pocket 15%, federal government 34%, state and local governments 11%, and other private funds 4%.[51] Due to "a dishonest and inefficient system" that sometimes inflates bills to ten times the actual cost, even insured patients can be billed more than the real cost of their care.[52]

Insurance for dental and vision care (except for visits to ophthalmologists, which are covered by regular health insurance) is usually sold separately. Prescription drugs are often handled differently than medical services, including by the government programs. Major federal laws regulating the insurance industry include COBRA and HIPAA.

Individuals with private or government insurance are limited to medical facilities which accept the particular type of medical insurance they carry. Visits to facilities outside the insurance program's "network" are usually either not covered or the patient must bear more of the cost. Hospitals negotiate with insurance programs to set reimbursement rates; some rates for government insurance programs are set by law. The sum paid to a doctor for a service rendered to an insured patient is generally less than that paid "out of pocket" by an uninsured patient. In return for this discount, the insurance company includes the doctor as part of their "network", which means more patients are eligible for lowest-cost treatment there. The negotiated rate may not cover the cost of the service, but providers (hospitals and doctors) can refuse to accept a given type of insurance, including Medicare and Medicaid. Low reimbursement rates have generated complaints from providers, and some patients with government insurance have difficulty finding nearby providers for certain types of medical services.

Charity care for those who cannot pay is sometimes available, and is usually funded by non-profit foundations, religious orders, government subsidies, or services donated by the employees. Massachusetts and New Jersey have programs where the state will pay for health care when the patient cannot afford to do so.[53] The City and County of San Francisco is also implementing a citywide health care program for all uninsured residents, limited to those whose incomes and net worth are below an eligibility threshold. Some cities and counties operate or provide subsidies to private facilities open to all regardless of the ability to pay, but even here patients who can afford to pay or who have insurance are generally charged for the services they use.

The Emergency Medical Treatment and Active Labor Act requires virtually all hospitals to accept all patients, regardless of the ability to pay, for emergency room care. The act does not provide access to non-emergency room care for patients who cannot afford to pay for health care, nor does it provide the benefit of preventive care and the continuity of a primary care physician. Emergency health care is generally more expensive than an urgent care clinic or a doctor's office visit, especially if a condition has worsened due to putting off needed care. Emergency rooms are typically at, near, or over capacity. Long wait times have become a problem nationally, and in urban areas some ERs are put on "diversion" on a regular basis, meaning that ambulances are directed to bring patients elsewhere.[54]

Private

Share by insurance coverage type, for those under 65 years of age

Most Americans (59.3%) receive their health insurance coverage through an employer (which includes both private as well as civilian public-sector employees) under group coverage, although this percentage is declining. Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation.[34] Workers with employer-sponsored insurance also contribute; in 2007, the average percentage of premium paid by covered workers is 16% for single coverage and 28% for family coverage.[34] In addition to their premium contributions, most covered workers face additional payments when they use health care services, in the form of deductibles and copayments.

Just less than 9% of the population purchases individual health care insurance.[50] Insurance payments are a form of cost-sharing and risk management where each individual or their employer pays predictable monthly premiums. This cost-spreading mechanism often picks up much of the cost of health care, but individuals must often pay up-front a minimum part of the total cost (a ‚Äė‚Äôdeductible‚Äô‚Äô), or a small part of the cost of every procedure (a copayment). Private insurance accounts for 35% of total health spending in the United States, by far the largest share among OECD countries. Beside the United States, Canada and France are the two other OECD countries where private insurance represents more than 10% of total health spending.[55]

Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently.[56] A survey issued in 2009 by America's Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees.[57][58]

Defying many analysts' expectations, PPOs have gained market share at the expense of HMOs over the past decade.[59]

Just as the more loosely managed PPOs have edged out HMOs, HMOs themselves have also evolved towards less tightly managed models. The first HMOs in the U.S., such as Kaiser Permanente in Oakland, California, and the Health Insurance Plan (HIP) in New York, were "staff-model" HMOs, which owned their own health care facilities and employed the doctors and other health care professionals who staffed them. The name health maintenance organization stems from the idea that the HMO would make it its job to maintain the enrollee's health, rather than merely to treat illnesses. In accordance with this mission, managed care organizations typically cover preventive health care. Within the tightly integrated staff-model HMO, the HMO can develop and disseminate guidelines on cost-effective care, while the enrollee's primary care doctor can act as patient advocate and care coordinator, helping the patient negotiate the complex health care system. Despite a substantial body of research demonstrating that many staff-model HMOs deliver high-quality and cost-effective care, they have steadily lost market share. They have been replaced by more loosely managed networks of providers with whom health plans have negotiated discounted fees. It is common today for a physician or hospital to have contracts with a dozen or more health plans, each with different referral networks, contracts with different diagnostic facilities, and different practice guidelines.

Public

Government programs directly cover 27.8% of the population (83 million),[50] including the elderly, disabled, children, veterans, and some of the poor, and federal law mandates public access to emergency services regardless of ability to pay. Public spending accounts for between 45% and 56.1% of U.S. health care spending.[60] Per-capita spending on health care by the U.S. government placed it among the top ten highest spenders among United Nations member countries in 2004.[61]

Government funded programs include:

  • Medicare, generally covering citizens and long-term residents 65 years and older and the disabled.
  • Medicaid, generally covering low income people in certain categories, including children, pregnant women, and the disabled. (Administered by the states.)
  • State Children's Health Insurance Program, which provides health insurance for low-income children who do not qualify for Medicaid. (Administered by the states, with matching state funds.)
  • Various programs for federal employees, including TRICARE for military personnel (for use in civilian facilities)
  • The Veterans Administration, which provides care to veterans, their families, and survivors through medical centers and clinics.[62][63]
  • National Institutes of Health treats patients who enroll in research for free.
  • Government run community clinics
  • Medical Corps of various branches of the military.
  • Certain county and state hospitals

The exemption of employer-sponsored health benefits from federal income and payroll taxes distorts the health care market.[64] The U.S. government, unlike some other countries, does not treat employer funded health care benefits as a taxable benefit in kind to the employee. The value of the lost tax revenue from a benefits in kind tax is an estimated $150 billion a year.[65] Some regard this as being disadvantageous to people who have to buy insurance in the individual market which must be paid from income received after tax.[66]

Health insurance benefits are an attractive way for employers to increase the salary of employees as they are nontaxable. As a result, 65% of the non-elderly population and over 90% of the privately insured non-elderly population receives health insurance at the workplace.[67] Additionally, most economists agree that this tax shelter increases individual demand for health insurance, leading some to claim that it is largely responsible for the rise in health care spending.[67]

In addition the government allows full tax shelter at the highest marginal rate to investors in health savings accounts (HSAs). Some have argued that this tax incentive adds little value to national health care as a whole because the most wealthy in society tend also to be the most healthy. Also it has been argued, HSAs segregate the insurance pools into those for the wealthy and those for the less wealthy which thereby makes equivalent insurance cheaper for the rich and more expensive for the poor.[68] However, one advantage of health insurance accounts is that funds can only be used towards certain HSA qualified expenses, including medicine, doctor's fees, and Medicare Parts A and B. Funds cannot be used towards expenses such as cosmetic surgery.[69]

There are also various state and local programs for the poor. In 2007, Medicaid provided health care coverage for 39.6 million low-income Americans (although Medicaid covers approximately 40% of America's poor),[70] and Medicare provided health care coverage for 41.4 million elderly and disabled Americans.[50] Enrollment in Medicare is expected to reach 77 million by 2031, when the baby boom generation is fully enrolled.[71]

It has been reported that the number of physicians accepting Medicaid has decreased in recent years due to relatively high administrative costs and low reimbursements.[72] In 1997, the federal government also created the State Children's Health Insurance Program (SCHIP), a joint federal-state program to insure children in families that earn too much to qualify for Medicaid but cannot afford health insurance.[73] SCHIP covered 6.6 million children in 2006,[74] but the program is already facing funding shortfalls in many states.[75] The government has also mandated access to emergency care regardless of insurance status and ability to pay through the Emergency Medical Treatment and Labor Act (EMTALA), passed in 1986,[76] but EMTALA is an unfunded mandate.[77]

The uninsured: Health insurance coverage in the United States

Some Americans do not qualify for government-provided health insurance, are not provided health insurance by an employer, and are unable to afford, cannot qualify for, or choose not to purchase, private health insurance. When charity or "uncompensated" care is not available, they sometimes simply go without needed medical treatment. This problem has become a source of considerable political controversy on a national level.

According to the US Census Bureau, in 2007, 45.7¬†million people in the U.S. (15.3% of the population) were without health insurance for at least part of the year. This number was down slightly from the previous year, with nearly 3¬†million more people receiving government coverage and a slightly lower percentage covered under private plans than the year previous.[50] Other studies have placed the number of uninsured in the years 2007‚Äď2008 as high as 86.7¬†million, about 29% of the US population.[78][79]

Among the uninsured population, the Census Bureau says, nearly 37 million were employment-age adults (ages 18 to 64), and more than 27 million worked at least part time. About 38% of the uninsured live in households with incomes of $50,000 or more.[50] According to the Census Bureau, nearly 36 million of the uninsured are legal U.S citizens. Another 9.7 million are non-citizens, but the Census Bureau does not distinguish in its estimate between legal non-citizens and illegal immigrants.[50] Nearly one fifth of the uninsured population is able to afford insurance, almost one quarter is eligible for public coverage, and the remaining 56% need financial assistance (8.9% of all Americans).[80] Extending coverage to all who are eligible remains a fiscal challenge.[81]

A 2003 study in Health Affairs estimated that uninsured people in the U.S. received approximately $35¬†billion in uncompensated care in 2001.[82] The study noted that this amount per capita was half what the average insured person received. The study found that various levels of government finance most uncompensated care, spending about $30.6¬†billion on payments and programs to serve the uninsured and covering as much as 80‚Äď85% of uncompensated care costs through grants and other direct payments, tax appropriations, and Medicare and Medicaid payment add-ons. Most of this money comes from the federal government, followed by state and local tax appropriations for hospitals. Another study by the same authors in the same year estimated the additional annual cost of covering the uninsured (in 2001¬†dollars) at $34¬†billion (for public coverage) and $69¬†billion (for private coverage). These estimates represent an increase in total health care spending of 3‚Äď6% and would raise health care‚Äôs share of GDP by less than one percentage point, the study concluded.[83] Another study published in the same journal in 2004 estimated that the value of health forgone each year because of uninsurance was $65‚Äď$130¬†billion and concluded that this figure constituted "a lower-bound estimate of economic losses resulting from the present level of uninsurance nationally."[84]

Role of government in health care market

Numerous publicly funded health care programs help to provide for the elderly, disabled, military service families and veterans, children, and the poor,[85] and federal law ensures public access to emergency services regardless of ability to pay;[86] however, a system of universal health care has not been implemented nation-wide. However, as the OECD has pointed out, the total U.S. public expenditure for this limited population would, in most other OECD countries, be enough for the government to provide primary health insurance for the entire population.[55] Although the federal Medicare program and the federal-state Medicaid programs possess some monopsonistic purchasing power, the highly fragmented buy side of the U.S. health system is relatively weak by international standards, and in some areas, some suppliers such as large hospital groups have a virtual monopoly on the supply side.[87] In most OECD countries, there is a high degree of public ownership and public finance.[88] The resulting economy of scale in providing health care services appears to enable a much tighter grip on costs.[89] The U.S., as a matter of oft-stated public policy, largely does not regulate prices of services from private providers, assuming the private sector to do it better.[90]

Massachusetts has adopted a universal health care system through the Massachusetts 2006 Health Reform Statute. It mandates that all residents who can afford to do so purchase health insurance, provides subsidized insurance plans so that nearly everyone can afford health insurance, and provides a "Health Safety Net Fund" to pay for necessary treatment for those who cannot find affordable health insurance or are not eligible.[91]

In July 2009, Connecticut passed into law a plan called SustiNet, with the goal of achieving health-care coverage of 98% of its residents by 2014.[92]

Health care regulation and oversight

Healthcare is subject to extensive regulation at both the federal and the state level, much of which "arose haphazardly".[93] Under this system, the federal government cedes primary responsibility to the states under the McCarran-Ferguson Act. Essential regulation includes the licensure of health care providers at the state level and the testing and approval of pharmaceuticals and medical devices by the Food and Drug Administration, and laboratory testing. These regulations are designed to protect consumers from ineffective or fraudulent healthcare. Additionally, states regulate the health insurance market and they often have laws which require that health insurance companies cover certain procedures,[94] although state mandates generally do not apply to the self-funded health care plans offered by large employers, which exempt from state laws under preemption clause of the Employee Retirement Income Security Act. In 2010, the Patient Protection and Affordable Care Act (PPACA) was passed, and includes various new regulations, with one of the most notable being a health insurance mandate which requires all citizens to purchase health insurance. While not regulation per se, the federal government also has a major influence on the healthcare market through its payments to providers under Medicare and Medicard, which in some cases are used as a reference point in the negotiations between medical providers and insurance companies.[93]

At the federal level, United States Department of Health and Human Services oversees the various federal agencies involved in health care. The health agencies are a part of the United States Public Health Service, and include the Food and Drug Administration, which certifies the safety of food, effectiveness of drugs and medical products, the Centers for Disease Prevention, which prevents disease, premature death, and disability, the Agency of Health Care Research and Quality, the Agency Toxic Substances and Disease Registry, which regulates hazardous spills of toxic substances, and the National Institutes of Health, which conducts medical research.

State governments maintain state health departments, and local governments (counties and municipalities) often have their own health departments, usually branches of the state health department. Regulations of a state board may have executive and police strength to enforce state health laws. In some states, all members of state boards must be health care professionals. Members of state boards may be assigned by the governor or elected by the state committee. Members of local boards may be elected by the mayor council. The McCarran‚ÄďFerguson Act, which cedes regulation to the states, does not itself regulate insurance, nor does it mandate that states regulate insurance. "Acts of Congress" that do not expressly purport to regulate the "business of insurance" will not preempt state laws or regulations that regulate the "business of insurance." The Act also provides that federal anti-trust laws will not apply to the "business of insurance" as long as the state regulates in that area, but federal anti-trust laws will apply in cases of boycott, coercion, and intimidation. By contrast, most other federal laws will not apply to insurance whether the states regulate in that area or not.

Self-policing of providers by providers is a major part of oversight. Many health care organizations also voluntarily submit to inspection and certification by the Joint Commission on Accreditation of Hospital Organizations, JCAHO. Providers also undergo testing to obtain board certification attesting to their skills. A report issued by Public Citizen in April 2008 found that, for the third year in a row, the number of serious disciplinary actions against physicians by state medical boards declined from 2006 to 2007, and called for more oversight of the boards.[95]

The Centers for Medicare and Medicaid Services (CMS) publishes an on-line searchable database of performance data on nursing homes.[96]

The regulation is controversial. In 2004, conservative think tank Cato Institute published a study which concluded that regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion.a that health care is the most heavily regulated industry in the United States.[97] The study concluded that the majority of the cost differential arises from medical malpractice, U.S. Food and Drug Administration (FDA) regulations, and facilities regulations.[97]

"Certificates of need" for hospitals

In 1978, the federal government required that all states implement Certificate of Need (CON) programs for cardiac care, meaning that hospitals had to apply and receive certificates prior to implementing the program; the intent was to reduce cost by reducing duplicate investments in facilities.[98] It has been observed that these certificates could be used to increase costs through weakened competition.[93] Many states removed the CON programs after the federal requirement expired in 1986, but some states still have these programs.[98] Empirical research looking at the costs in areas where these programs have been discontinued have not found a clear effect on costs, and the CON programs could decrease costs because of reduced facility construction or increase costs due to reduced competition.[98]

Licensing of providers

American Medical Association (AMA) has lobbied the government to highly limit physician education since 1910, currently at 100,000 doctors per year,[99] which has led to a shortage of doctors[100] and physicians' wages in the U.S. are double those in the Europe, which is a major reason for the more expensive health care.[101]

An even bigger problem may be that the doctors are paid for procedures instead of results.[101]

AMA has also aggressively lobbied for many restrictions that require doctors to carry out operations that might be carried out by cheaper workforce. For example, in 1995, 36 states banned or restricted midwifery even though it delivers equally safe care to that by doctors, according to studies. The regulation lobbied by AMA has decreased the amount and quality of health care, according to the consensus of economist: the restrictions do not add to quality, they decrease the supply of care.[99][102] Moreover, psychologists, nurses and pharmacologists are not allowed to prescribe medicines.[clarification needed] Previously nurses were not even allowed to vaccinate the patients without direct supervision by doctors.

Emergency Medical Treatment and Active Labor Act (EMTALA)

EMTALA, enacted by the federal government in 1986, requires that hospital emergency departments treat emergency conditions of all patients regardless of their ability to pay and is considered a critical element in the "safety net" for the uninsured, but established no direct payment mechanism for such care. Indirect payments and reimbursements through federal and state government programs have never fully compensated public and private hospitals for the full cost of care mandated by EMTALA. In fact, more than half of all emergency care in the U.S. now goes uncompensated.[103] According to some analyses, EMTALA is an unfunded mandate that has contributed to financial pressures on hospitals in the last 20 years, causing them to consolidate and close facilities, and contributing to emergency room overcrowding. According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26%, while in the same period, the number of emergency departments declined by 425.[104]

Mentally ill patients present a unique challenge for emergency departments and hospitals. In accordance with EMTALA, mentally ill patients who enter emergency rooms are evaluated for emergency medical conditions. Once mentally ill patients are medically stable, regional mental health agencies are contacted to evaluate them. Patients are evaluated as to whether they are a danger to themselves or others. Those meeting this criterion are admitted to a mental health facility to be further evaluated by a psychiatrist. Typically, mentally ill patients can be held for up to 72 hours, after which a court order is required.[citation needed]

Overall system effectiveness compared to other countries

The CIA World Factbook ranked the United States 41st in the world for infant mortality rate[105] and 46th for total life expectancy.[106] A study found that between 1997 and 2003, preventable deaths declined more slowly in the United States than in 18 other industrialized nations.[107] For example, the United States was listed as 37th for life expectancy and 41st in low birth weight.[108]

The Organisation for Economic Co-operation and Development (OECD) found that the United States ranked poorly in terms of Years of potential life lost (YPLL), a statistical measure of years of life lost under the age of 70 that were amenable to being saved by health care. Among OECD nations for which data are available, the United States ranked third last for the health care of women (after Mexico and Hungary) and fifth last for men (Slovakia and Poland were also worse). See the table and source at YPLL for details.

Recent studies find growing gaps in life expectancy based on income and geography. In 2008, a government-sponsored study found that life expectancy declined from 1983 to 1999 for women in 180 counties, and for men in 11 counties, with most of the life expectancy declines occurring the Deep South, Appalachia, along the Mississippi River, in the Southern Plains and in Texas. The gap is growing between rich and poor and by educational level, but narrowing between men and women and by race.[109] Another study found that the mortality gap between the well-educated and the poorly educated widened significantly between 1993 and 2001 for adults ages 25 through 64; the authors speculated that risk factors such as smoking, obesity and high blood pressure may lie behind these disparities.[110] In 2011 the United States National Research Council forecasted that deaths attributed to smoking, on the decline in the US, will drop dramatically, improving life expectancy; it also suggested that 1/5 to 1/3 of the life expectancy difference can be attributed to obesity which is the worst in the world and has been increasing.[111] In an analysis of breast cancer, colorectal cancer, and prostate cancer diagnosed during 1990‚Äď1994 in 31 countries, the United States had the highest five-year relative survival rate for breast cancer and prostate cancer, although survival was systematically and substantially lower in black U.S. men and women.[112]

The debate about U.S. health care concerns questions of access, efficiency, and quality purchased by the high sums spent. The World Health Organization (WHO) in 2000 ranked the U.S. health care system first in responsiveness, but 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).[13][14] The WHO study has been criticized by the free market advocate David Gratzer because "fairness in financial contribution" was used as an assessment factor, marking down countries with high per-capita private or fee-paying health treatment.[113] The WHO study has been criticized, in an article published in Health Affairs, for its failure to include the satisfaction ratings of the general public.[114] The study found that there was little correlation between the WHO rankings for health systems and the stated satisfaction of citizens using those systems.[115] Some countries, such as Italy and Spain, which were given the highest ratings by WHO were ranked poorly by their citizens while other countries, such as Denmark and Finland, were given low scores by WHO but had the highest percentages of citizens reporting satisfaction with their health care systems.[115] WHO staff, however, say that the WHO analysis does reflect system "responsiveness" and argue that this is a superior measure to consumer satisfaction, which is influenced by expectations.[116]

A report released in April 2008 by the Foundation for Child Development, which studied the period from 1994 through 2006, found mixed results for the health of children in the U.S. Mortality rates for children ages 1 through 4 dropped by a third, and the percentage of children with elevated blood lead levels dropped by 84%. The percentage of mothers who smoked during pregnancy also declined. On the other hand, both obesity and the percentage of low-birth weight babies increased. The authors note that the increase in babies born with low birth weights can be attributed to women delaying childbearing and the increased use of fertility drugs.[117][118]

System efficiency and equity

Variations in the efficiency of health care delivery can cause variations in outcomes. The Dartmouth Atlas Project, for instance, reported that, for over 20 years, marked variations in how medical resources are distributed and used in the United States were accompanied by marked variations in outcomes.[119]

Efficiency

Value for money

A study of international health care spending levels published in the health policy journal Health Affairs in the year 2000 found that the U.S. spends substantially more on health care than any other country in the Organization for Economic Co-operation and Development (OECD), and that the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study conclude that the prices paid for health care services are much higher in the U.S.[39]

Delays in seeking care and increased use of emergency care

Uninsured Americans are less likely to have regular health care and use preventive services. They are more likely to delay seeking care, resulting in more medical crises, which are more expensive than ongoing treatment for such conditions as diabetes and high blood pressure. A 2007 study published in JAMA concluded that uninsured people were less likely than the insured to receive any medical care after an accidental injury or the onset of a new chronic condition. The uninsured with an injury were also twice as likely as those with insurance to have received none of the recommended follow-up care, and a similar pattern held for those with a new chronic condition.[120] Uninsured patients are twice as likely to visit hospital emergency rooms as those with insurance; burdening a system meant for true emergencies with less-urgent care needs.[121]

In 2008 researchers with the American Cancer Society found that individuals who lacked private insurance (including those covered by Medicaid) were more likely to be diagnosed with late-stage cancer than those who had such insurance.[122]

Shared costs of the uninsured: Uninsured in the United States

The costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost shifting and higher health insurance premiums, or paid by taxpayers through higher taxes.[123] However, hospitals and other providers are reimbursed for the cost of providing uncompensated care via a federal matching fund program. Each state enacts legislation governing the reimbursement of funds to providers. In Missouri, for example, providers assessments totaling $800¬†million are matched ‚ÄĒ $2 for each assessed $1 ‚ÄĒ to create a pool of approximately $2¬†billion. By federal law these funds are transferred to the Missouri Hospital Association for disbursement to hospitals for the costs incurred providing uncompenstated care including Disproportionate Share Payments (to hospitals with high quantities of uninsured patients), Medicaid shortfalls, Medicaid managed care payments to insurance companies and other costs incurred by hospitals.[124] In New Hampshire, by statute, reimbursable uncompensated care costs shall include: charity care costs, any portion of Medicaid patient care costs that are unreimbursed by Medicaid payments, and any portion of bad debt costs that the commissioner determines would meet the criteria under 42¬†U.S.C. section¬†1396r-4(g) governing hospital-specific limits on disproportionate share hospital payments under Title¬†XIX of the Social Security Act.[125]

A report published by the Kaiser Family Foundation in April 2008 found that economic downturns place a significant strain on state Medicaid and SCHIP programs. The authors estimated that a 1% increase in the unemployment rate would increase Medicaid and SCHIP enrollment by 1 million, and increase the number uninsured by 1.1 million. State spending on Medicaid and SCHIP would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion). This increased spending would occur at the same time state government revenues were declining. During the last downturn, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules. The authors conclude that Congress should consider similar relief for the current economic downturn.[126]

Variations in provider practices

The treatment given to a patient can vary significantly depending on which health care providers they use. Research suggests that some cost-effective treatments are not used as often as they should be, while overutilization occurs with other health care services. Unnecessary treatments increase costs and can cause patients unnecessary anxiety.[127] The use of prescription drugs varies significantly by geographic region.[128] The overuse of medical benefits is known as moral hazard -individuals who are insured are then more inclined to consume health care. The way the Health care system tries to eliminate this problem is through cost sharing tactics like co-pays and deductibles. If patients face more of the economic burden they will then only consume health care when it is necessary. According to the RAND health insurance experiment, individuals with higher Coinsurance rates consumed less health care then those with lower rates. The experiment concluded that with less consumption of care there was generally no loss in societal welfare but, for the poorer and sicker groups of people there were definitely negative effects. These patients were forced to forgo necessary preventative care measures in order to save money leading to late diagnosis of easily treated diseases and more expensive procedures later. With less preventative care, the patient is hurt financially with an increase in expensive visits to the ER.The Health Care costs in the U.S will also rise with these procedures as well. More expensive procedures leads to greater costs.[129][130]

One study has found significant geographic variations in Medicare spending for patients in the last two years of life. These spending levels are associated with the amount of hospital capacity available in each area. Higher spending did not result in patients living longer.[44][131]

Care coordination

Primary care doctors are often the point of entry for most patients needing care, but in the fragmented health care system of the U.S., many patients and their providers experience problems with care coordination. For example, a Harris Interactive survey of California physicians found that:

  • Four of every ten physicians report that their patients have had problems with coordination of their care in the last 12 months.
  • More than 60% of doctors report that their patients "sometimes" or "often" experience long wait times for diagnostic tests.
  • Some 20% of doctors report having their patients repeat tests because of an inability to locate the results during a scheduled visit.[132]

According to an article in The New York Times, the relationship between doctors and patients is deteriorating.[133] A study from Johns Hopkins University found that roughly one in four patients believe their doctors have exposed them to unnecessary risks, and anecdotal evidence such as self-help books and web postings suggest increasing patient frustration. Possible factors behind the deteriorating doctor/patient relationship include the current system for training physicians and differences in how doctors and patients view the practice of medicine. Doctors may focus on diagnosis and treatment, while patients may be more interested in wellness and being listened to by their doctors.[133]

Many primary care physicians no longer see their patients while they are in the hospital. Instead, hospitalists are used, which fragments care because hospitalists usually have had no previous relationship with the patient they are treating and do not have a personal knowledge of the patient's medical history.[134][135] The use of hospitalists is sometimes mandated by health insurance companies as a cost saving measure which is resented by some primary care physicians.[136]

Administrative costs

The health care system in the U.S. has a vast number of players. There are hundreds, if not thousands, of insurance companies in the U.S.[65][137] This system has considerable administrative overhead, far greater than in nationalized, single-payer systems, such as Canada's. An oft-cited study by Harvard Medical School and the Canadian Institute for Health Information determined that some 31% of U.S. health care dollars, or more than $1,000 per person per year, went to health care administrative costs, nearly double the administrative overhead in Canada, on a percentage basis.[138]

According to the insurance industry group America's Health Insurance Plans, administrative costs for private health insurance plans have averaged approximately 12% of premiums over the last 40 years. There has been a shift in the type and distribution of administrative expenses over that period. The cost of adjudicating claims has fallen, while insurers are spending more on other administrative activities, such as medical management, nurse help lines, and negotiating discounted fees with health care providers.[139]

A 2003 study published by the Blue Cross and Blue Shield Association also found that health insurer administrative costs were approximately 11% to 12% of premiums, with Blue Cross and Blue Shield plans reporting slightly lower administrative costs, on average, than commercial insurers.[140] For the period 1998 through 2003, average insurer administrative costs declined from 12.9% to 11.6% of premiums. The largest increases in administrative costs were in customer service and information technology, and the largest decreases were in provider services and contracting and in general administration.[141] The McKinsey Global Institute estimated that excess spending on ‚Äúhealth administration and insurance‚ÄĚ accounted for as much as 21% of the estimated total excess spending ($477¬†billion in 2003).[142]

According to a report published by the CBO in 2008, administrative costs for private insurance represent approximately 12% of premiums. Variations in administrative costs between private plans are largely attributable to economies of scale. Coverage for large employers has the lowest administrative costs. The percentage of premium attributable to administration increases for smaller firms, and is highest for individually purchased coverage.[143] A 2009 study published by the Blue Cross and Blue Shield Association found that the average administrative expense cost for all commercial health insurance products was represented 9.18% of premiums in 2008.[144] Administrative costs were 11.12% of premiums for small group products and 16.35% in the individual market.[144]

One study of the billing and insurance-related (BIR) costs borne not only by insurers but also by physicians and hospitals found that BIR among insurers, physicians, and hospitals in California represented 20-22% of privately insured spending in California acute care settings.[145]

Third-party payment problem and consumer-driven insurance

Most Americans pay for medical services largely through insurance, and this can distort the incentives of consumers since the consumer pays only a portion of the ultimate cost.[93] The lack of price information on medical services can also distort incentives.[93] The insurance which pays on behalf of insureds negotiate with medical providers, sometimes using government-established prices such as Medicaid billing rates as a reference point.[93] This reasoning has led for calls to reform the insurance system to create a consumer-driven health care system whereby consumers pay more out-of-pocket.[146] In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act was passed, which encourages consumers to have a high-deductible health plan and a health savings account.

Overall costs

The cost impact of the existing mixed public-private system is subject to debate. The United States spends more as a percentage of GDP than similar countries, and this can be explained either through higher prices for services or more utilization of these services (for example, due to the United States having a more sickly population), or to a combination of the two.[147] The United States has higher prices than other "rich democracies", and this is a major explanation for its increased costs.[147]

Free-market advocates claim that the health care system is "dysfunctional" because the system of third-party payments from insurers removes the patient as a major participant in the financial and medical choices that affect costs. Because government intervention has expanded insurance availability through programs such as Medicare and Medicaid, this has exacerbated the problem.[148] According to a study paid for by America's Health Insurance Plans (a Washington lobbyist for the health insurance industry) and carried out by PriceWaterhouseCoopers, increased utilization is the primary driver of rising health care costs in the U.S.[149] The study cites numerous causes of increased utilization, including rising consumer demand, new treatments, more intensive diagnostic testing, lifestyle factors, the movement to broader-access plans, and higher-priced technologies.[149] The study also mentions cost-shifting from government programs to private payers. Low reimbursement rates for Medicare and Medicaid have increased cost-shifting pressures on hospitals and doctors, who charge higher rates for the same services to private payers, which eventually affects health insurance rates.[150]

Health care costs rising far faster than inflation have been a major driver for health care reform in the United States.

In March 2010, Massachusetts released a report on the cost drivers which it called "unique in the nation".[151] The report noted that providers and insurers negotiate privately, and therefore the prices can vary between providers and insurers for the same services, and it found that the variation in prices did not vary based on quality of care but rather on market leverage; the report also found that price increases rather than increased utilization explained the spending increases in the past several years.[151]

Equity

Coverage

Enrollment rules in private and governmental programs result in millions of Americans going without health care coverage, including children. The U.S. Census Bureau estimated that 45.7 million Americans (15.3% of the total population) had no health insurance coverage in 2007.[50] However, statistics regarding the insured population are difficult to pinpoint for a number of factors, with the Census Bureau writing that "health insurance coverage is likely to be underreported".[8] Further, such statistics do not provide insight into the reason a given person might be uninsured. For example, studies have shown that approximately one third of this 45.7 million person population of uninsured persons is actually eligible for government insurance programmes such as Medicaid/Medicare, but has elected not to enroll. The largest proportion of the population of uninsured Americans is persons earning in excess of $50,000 per annum, with those earning over $75,000 p.a. comprising the fastest-growing segement of the uninsured population. US Citizens who earn too much money to qualify for government assistance with insurance programs but who do not earn enough to purchase a private health insurance plan make up approxmiately 2.7% percent of the total US population (8.2 million of approximately 300 million total population, by 2003 figures).[9]

Some states (like California) do offer insurance coverage for children of low income families, but not for adults; other states do not offer such coverage at all, and so, both parent and child are caught in the notorious coverage "gap." Although EMTALA[152] certainly keeps alive many working-class people who are badly injured, the 1986 law neither requires the provision of preventive or rehabilitative care, nor subsidizes such care, and it does nothing about the difficulties in the American mental health system.

Coverage gaps also occur among the insured population. Johns Hopkins University professor Vicente Navarro stated in 2003, "the problem does not end here, with the uninsured. An even larger problem is the underinsured" and "The most credible estimate of the number of people in the United States who have died because of lack of medical care was provided by a study carried out by Harvard Medical School Professors Himmelstein and Woolhandler (New England Journal of Medicine 336, no. 11, 1997). They concluded that almost 100,000 people died in the United States each year because of lack of needed care."[153] Another study by the Commonwealth Fund published in Health Affairs estimated that 16¬†million U.S. adults were underinsured in 2003. The study defined underinsurance as characterized by at least one of the following conditions: annual out-of-pocket medical expenses totaling 10% or more of income, or 5% or more among adults with incomes below 200% of the federal poverty level; or health plan deductibles equaling or exceeding 5% of income. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes‚ÄĒ73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level.[154] Another study focusing on the effect of being uninsured found that individuals with private insurance were less likely to be diagnosed with late-stage cancer than either the uninsured or Medicaid beneficiaries.[122] A study examining the effects of health insurance cost-sharing more generally found that chronically ill patients with higher co-payments sought less care for both minor and serious symptoms while no effect on self-reported health status was observed. The authors concluded that the effect of cost sharing should be carefully monitored.[155]

Coverage gaps and affordability also surfaced in a 2007 international comparison by the Commonwealth Fund. Among adults surveyed in the U.S., 37% reported that they had foregone needed medical care in the previous year because of cost; either skipping medications, avoiding seeing a doctor when sick, or avoiding other recommended care. The rate was even higher‚ÄĒ 42%‚ÄĒamong those with chronic conditions. The study reported that these rates were well above those found in the other six countries surveyed: Australia, Canada, Germany, the Netherlands, New Zealand, and the UK.[156] The study also found that 19% of U.S. adults surveyed reported serious problems paying medical bills, more than double the rate in the next highest country.

Mental health

A lack of mental health coverage for Americans bears significant ramifications to the U.S. economy and social system. A report by the U.S. Surgeon General found that mental illnesses are the second leading cause of disability in the nation and affect 20% of all Americans.[157] It is estimated that less than half of all people with mental illnesses receive treatment due to factors such as stigma and lack of access to care.[158]

The Paul Wellstone Mental Health and Addiction Equity Act of 2008 mandates that group health plans provide mental health and substance-related disorder benefits that are at least equivalent to benefits offered for medical and surgical procedures. The legislation renews and expands provisions of the Mental Health Parity Act of 1996. The law requires financial equity for annual and lifetime mental health benefits, and compels parity in treatment limits and expands all equity provisions to addiction services. Up to 2008 insurance companies used loopholes and, though providing financial equity, they often worked around the law by applying unequal co-payments or setting limits on the number of days spent in in-patient or out-patient treatment facilities.[159]

Medical underwriting and the uninsurable

In most states in the U.S., people seeking to purchase health insurance directly must undergo medical underwriting. Insurance companies seeking to mitigate the problem of adverse selection and manage their risk pools screen applicants for pre-existing conditions. Insurers may reject some applicants or quote increased rates for those with pre-existing conditions. Diseases that can make an individual uninsurable include serious conditions, such as arthritis, cancer, and heart disease, but also such common ailments as acne, being 20 pounds over or under weight, and old sports injuries.[160] An estimated 5 million of those without health insurance are considered "uninsurable" because of pre-existing conditions.[161]

Proponents of medical underwriting argue that it ensures that individual health insurance premiums are kept as low as possible.[162] Critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from obtaining health insurance.[163]

One large industry survey found that 13% of applicants for individual health insurance who went through medical underwriting were denied coverage in 2004. Declination rates increased significantly with age, rising from 5% for those under 18 to just under one-third for those aged 60 to 64.[164] Among those who were offered coverage, the study found that 76% received offers at standard premium rates, and 22% were offered higher rates.[165] The frequency of increased premiums also increased with age, so for applicants over 40, roughly half were affected by medical underwriting, either in the form of denial or increased premiums. In contrast, almost 90% of applicants in their 20s were offered coverage, and three-quarters of those were offered standard rates. Seventy percent of applicants age 60‚Äď64 were offered coverage, but almost half the time (40%) it was at an increased premium. The study did not address how many applicants who were offered coverage at increased rates chose to decline the policy. A study conducted by the Commonwealth Fund in 2001 found that, among those aged 19 to 64 who sought individual health insurance during the previous three years, the majority found it unaffordable, and less than a third ended up purchasing insurance. This study did not distinguish between consumers who were quoted increased rates due to medical underwriting and those who qualified for standard or preferred premiums.[166] Some states have outlawed medical underwriting as a prerequisite for individually purchased health coverage.[167] These states tend to have the highest premiums for individual health insurance.[168]

Demographic differences: Health disparities and Race and health

In the United States, health disparities are well documented in ethnic minorities such as African Americans, Native Americans, and Hispanics.[169] When compared to whites, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes. Among the disease-specific examples of racial and ethnic disparities in the United States is the cancer incidence rate among African Americans, which is 25% higher than among whites.[170] In addition, adult African Americans and Hispanics have approximately twice the risk as whites of developing diabetes. Minorities also have higher rates of cardiovascular disease and HIV/AIDS than whites.[170] Caucasian Americans have much lower life expectancy than Asian Americans.[171] A 2001 study found large racial differences exist in healthy life expectancy at lower levels of education.[172]

Public spending is highly correlated with age; average per capita public spending for seniors was more than five times that for children ($6,921 versus $1,225). Average public spending for non-Hispanic blacks ($2,973) was slightly higher than that for whites ($2,675), while spending for Hispanics ($1,967) was significantly lower than the population average ($2,612). Total public spending is also strongly correlated with self-reported health status ($13,770 for those reporting "poor" health versus $1,279 for those reporting "excellent" health).[60] Seniors comprise 13% of the population but take 1/3 of all prescription drugs. The average senior fills 38 prescriptions annually.[173]

There is a great deal of research into inequalities in health care. In some cases these inequalities are caused by income disparities that result in lack of health insurance and other barriers to receiving services.[174] According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care.[175] For example, minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic people. In other cases, inequalities in health care reflect a systemic bias in the way medical procedures and treatments are prescribed for different ethnic groups. Raj Bhopal writes that the history of racism in science and medicine shows that people and institutions behave according to the ethos of their times.[176] Nancy Krieger wrote that racism underlies unexplained inequities in health care, including treatment for heart disease,[177] renal failure,[178] bladder cancer,[179] and pneumonia.[180] Raj Bhopal writes that these inequalities have been documented in numerous studies. The consistent and repeated findings were that black Americans received less health care than white Americans ‚ÄĒparticularly when the care involved expensive new technology.[181] One recent study has found that when minority and white patients use the same hospital, they are given the same standard of care.[182][183]

Drug efficacy and safety: Regulation of therapeutic goods in the United States

The Food and Drug Administration (FDA)[184] is the primary institution tasked with the safety and effectiveness of human and veterinary drugs. It also is responsible for making sure drug information is accurately and informatively presented to the public. The FDA reviews and approves products and establishes drug labeling, drug standards, and medical device manufacturing standards. It sets performance standards for radiation and ultrasonic equipment.

One of the more contentious issues related to drug safety is immunity from prosecution. In 2004, the FDA reversed a federal policy, arguing that FDA premarket approval overrides most claims for damages under state law for medical devices. In 2008 this was confirmed by the Supreme Court in Riegel v. Medtronic.[185]

On 30 June 2006, an FDA ruling went into effect extending protection from lawsuits to pharmaceutical manufacturers, even if it was found that they submitted fraudulent clinical trial data to the FDA in their quest for approval. This left consumers who experience serious health consequences from drug use with little recourse. In 2007, opposition was raised in the Congressional House to the FDA ruling, but the Senate upheld the status quo. On 4 March 2009, an important U.S. Supreme Court decision was handed down. In Wyeth v. Levine, the court asserted that state-level rights of action could not be pre-empted by federal immunity and could provide "appropriate relief for injured consumers."[186] In June 2009, under the Public Readiness and Emergency Preparedness Act, Secretary of Health and Human Services Kathleen Sebelius signed an order extending protection to vaccine makers and federal officials from prosecution during a declared health emergency related to the administration of the swine flu vaccine.[187][188]

The impact of drug companies

The United States is one of two countries in the world that allows direct-to-consumer advertising of prescription drugs. Critics note that drug ads costs money which they believe have raised the overall price of drugs.[189]

When health care legislation was being written in 2009, the drug companies were asked to support the legislation in return for not allowing importation of drugs from foreign countries.[190]

Political issues

Prescription drug prices

During the 1990s, the price of prescription drugs became a major issue in American politics as the prices of many new drugs increased exponentially, and many citizens discovered that neither the government nor their insurer would cover the cost of such drugs. Per capita, the U.S. spends more on pharmaceuticals than any other country. National expenditures on pharmaceuticals accounted for 12.9% of total health care costs, compared to an OECD average of 17.7% (2003 figures).[191] Some 25% of out-of-pocket spending by individuals is for prescription drugs.[192]

The U.S. government has taken the position (through the Office of the United States Trade Representative) that U.S. drug prices are rising because U.S. consumers are effectively subsidizing costs which drug companies cannot recover from consumers in other countries (because many other countries use their bulk-purchasing power to aggressively negotiate drug prices).[193] The U.S. position (consistent with the primary lobbying position of the Pharmaceutical Research and Manufacturers of America) is that the governments of such countries are free riding on the backs of U.S. consumers. Such governments should either deregulate their markets, or raise their domestic taxes in order to fairly compensate U.S. consumers by directly remitting the difference (between what the companies would earn in an open market versus what they are earning now) to drug companies or to the U.S. government. In turn, pharmaceutical companies would be able to continue to produce innovative pharmaceuticals while lowering prices for U.S. consumers. Currently, the U.S., as a purchaser of pharmaceuticals, negotiates some drug prices but is forbidden by law from negotiating drug prices for the Medicare program due to the Medicare Prescription Drug, Improvement, and Modernization Act passed in 2003. Democrats have charged that the purpose of this provision is merely to allow the pharmaceutical industry to profiteer off of the Medicare program, which is already in imminent danger of becoming financially insolvent.[194]

Health care debate: Health care reform in the United States

A poll released in March 2008 by the Harvard School of Public Health and Harris Interactive found that Americans are divided in their views of the U.S. health system, and that there are significant differences by political affiliation. When asked whether the U.S. has the best health care system or if other countries have better systems, 45% said that the U.S. system was best and 39% said that other countries' systems are better. Belief that the U.S. system is best was highest among Republicans (68%), lower among independents (40%), and lowest among Democrats (32%). Over half of Democrats (56%) said they would be more likely to support a presidential candidate who advocates making the U.S. system more like those of other countries; 37% of independents and 19% of Republicans said they would be more likely to support such a candidate. 45% of Republicans said that they would be less likely to support such a candidate, compared to 17% of independents and 7% of Democrats.[195][196]

According to the Institute of Medicine of the National Academy of Sciences, the United States is the only wealthy, industrialized nation that does not ensure universal coverage.[17] There is currently an ongoing political debate centering around questions of access, efficiency, quality, and sustainability. Whether a government-mandated system of universal health care should be implemented in the U.S. remains a hotly debated political topic, with Americans divided along party lines in their views of the U.S. health system and what should be done to improve it. Those in favor of universal health care argue that the large number of uninsured Americans creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality.[197] Cato Institute Senior Fellow Alan Reynolds argues that people should be free to opt out of health insurance, citing a study by Economists Craig Perry and Harvey Rosen that found "the lack of health insurance among the self-employed does not affect their health. For virtually every subjective and objective measure of their health status, the self-employed and wage-earners are statistically indistinguishable for each other."[198] Both sides of the political spectrum have also looked to more philosophical arguments,[citation needed] debating whether people have a fundamental right to have health care provided to them by their government.[199][200]

An impediment to implementing any US healthcare reform that does not benefit insurance companies or the private health care industry is the power of insurance company and health care industry lobbyists.[201][202] Possibly as a consequence of the power of lobbyists, key politicians such as Senator Max Baucus have taken the option of single payer health care off the table entirely.[203] In a June 2009 NBC News/Wall Street Journal survey, 76% said it was either "extremely" or "quite" important to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance."[204]

Advocates for single-payer health care often point to other countries, where national government-funded systems produce better health outcomes at lower cost. Opponents deride this type of system as "socialized medicine", and it has not been one of the favored reform options by Congress or the President in both the Clinton and Obama reform efforts.[205][206] It has been pointed out that socialized medicine is a system in which the government owns the means of providing medicine. Britain is an example of socialized system, as, in America, is the Veterans Health Administration. Medicare is an example of a mostly single-payer system, as is France. Both of these systems have private insurers to choose from, but the government is the dominant purchaser.[207]

As an example of how government intervention has had unintended consequences, in 1973, the federal government passed the Health Maintenance Organization Act, which heavily subsidized the HMO business model ‚ÄĒ a model that was in decline prior to such legislative intervention. The law was intended to create market incentives that would lower health care costs, but HMOs have never achieved their cost-reduction potential.[208]

Piecemeal market-based reform efforts are complex. One study evaluating current popular market-based reform policy packages concluded that if market-oriented reforms are not implemented on a systematic basis with appropriate safeguards, they have the potential to cause more problems than they solve.[209]

According to economist and former US Secretary of Labor, Robert Reich, only a "big, national, public option" can force insurance companies to cooperate, share information, and reduce costs. Scattered, localized, "insurance cooperatives" are too small to do that and are "designed to fail" by the moneyed forces opposing Democratic health care reform.[210][211] The Patient Protection and Affordable Care Act, signed into law in March, 2010, did not include such an option.

Health Care Reform

Health care reform in the United States

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The Patient Protection and Affordable Care Act (Public Law 111-148) is a health care reform bill that was signed into law in the United States by President Barack Obama on March 23, 2010. Along with the Health Care and Education Reconciliation Act of 2010 (passed March 25), the Act is a product of the health care reform agenda of the Democratic 111th Congress and the Obama administration.

The law includes a large number of health-related provisions to take effect over the next four years, including expanding Medicaid eligibility for people making up to 133% of FPL,[212] subsidizing insurance premiums for peoples making up to 400% of FPL ($88,000 for family of 4) so their maximum "out-of-pocket" pay will be from 2% to 9.8% of income for annual premium,[213][214] 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 spending caps and support for medical research. The costs of these provisions are offset by a variety of taxes, fees, and cost-saving measures, such as new Medicare taxes for 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;[215] there is also a tax penalty for citizens who do not obtain health insurance (unless they are exempt due to low income or other reasons).[216] The Congressional Budget Office estimates that the net effect (including the reconciliation act) will be a reduction in the federal deficit by $143 billion over the first decade.[217]

Health Insurance Coverage of Immigrants

Of the 26.2 million foreign immigrants living in the US in 1998, 62.9% were non-citizens. In 1997, 34.3% of non-citizens living in America did not have health insurance coverage opposed to the 14.2% of native-born Americans who do not have health insurance coverage. Among those immigrants who became citizens, 18.5% were uninsured as opposed to non citizens who are 43.6% uninsured. In each age and income group, immigrants are less likely to have health insurance.[218]

See also

 

 

 

 

Healthcare adopted by Bangladesh:

 

 

Health Care Facilities

Bangladesh Table of Contents

The Ministry of Health and Family Planning was responsible for developing, coordinating, and implementing the national health and mother-and-child health care programs. Population control also was within the purview of the ministry. The government's policy objectives in the health care sector were to provide a minimum level of health care services for all, primarily through the construction of health facilities in rural areas and the training of health care workers. The strategy of universal health care by the year 2000 had become accepted, and government efforts toward infrastructure development included the widespread construction of rural hospitals, dispensaries, and clinics for outpatient care. Program implementation, however, was limited by severe financial constraints, insufficient program management and supervision, personnel shortages, inadequate staff performance, and insufficient numbers of buildings, equipment, and supplies.

In the late 1980s, government health care facilities in rural areas consisted of subdistrict health centers, union-level health and family welfare centers, and rural dispensaries. A subdistrict health center in the mid-1980s typically had a thirty-one-bed hospital, an outpatient service, and a home-service unit staffed with field workers. Some of the services, however, were largely nonoperative because of staffing problems and a lack of support services. Health services in urban areas also were inadequate, and their coverage seemed to be deteriorating. In many urban areas, nongovernment organizations provide the bulk of urban health care services. Programming and priorities of the nongovernment organizations were at best loosely coordinated.

A union-level health and family welfare center provided the first contact between the people and the health care system and was the nucleus of primary health care delivery. As of 1985 there were 341 functional subdistrict health centers, 1,275 rural dispensaries (to be converted to union-level health and family welfare centers), and 1,054 union-level health and family welfare centers. The total number of hospital beds at the subdistrict level and below was 8,100.

District hospitals and some infectious-disease and specialized hospitals constituted the second level of referral for health care. In the mid-1980s, there were 14 general hospitals (with capacities ranging from 100 to 150 beds), 43 general district hospitals (50 beds each), 12 tuberculosis hospitals (20 to 120 beds each), and 1 mental hospital (400 beds). Besides these, there were thirty-eight urban outpatient clinics, forty-four tuberculosis clinics, and twenty-three school health clinics. Ten medical college hospitals and eight postgraduate specialized institutes with attached hospitals constituted the third level of health care.

In the mid-1980s, of the country's 21,637 hospital beds, about 85 percent belonged to the government health services. There was only about one hospital bed for every 3,600 people. In spite of government plans, the gap between rural and urban areas in the availability of medical facilities and personnel remained wide. During the monsoon season and other recurrent natural disasters, the already meager services for the rural population were severely disrupted.

 

 

Nobel Peace Prize winner Muhammad Yunus of Bangladesh is developing a health care network for the poor in his country that will operate at low cost using mobile phone technology. Yunus is working with U.S. medical experts to help Bangladeshi villagers transmit their medical information to doctors in far-away cities for better treatment.

Muhammad Yunus won the Nobel Peace Prize in 2006 for setting up a bank in his native Bangladesh to provide small loans to impoverished women to help them to become entrepreneurs.

In recent years, he has expanded the work of his Grameen Bank to focus on improving health care for the 40 percent of Bangladeshis who live on less than a dollar a day.

On a visit to Washington this week, Yunus told an international health conference that Grameen Health, an affiliate of Grameen Bank, has 51 clinics that offer low-cost treatment to villagers who pay an insurance premium of just $2 a year.

But he says many doctors who run the rural clinics want to stay only a few months before returning to the cities, which forced him to rethink the operation. "One of the alternatives we decided on finally is that maybe we should not even try to bring the doctors in the village. And that is what we now are working on - redesigning the system," he said.

Yunus says he is working with U.S. medical experts to create health care centers that allow villagers to transmit their medical information over the Internet using cellular telephones to a far-away doctor's computer.

"He can see it on the screen and decide what the advice should be in this particular case and pick up the mobile phone and tell the health management center what is the next step to take, what precautions, whatever advice they have," he said.

Yunus began his partnership with the U.S. health care providers last September to help to make his Bangladeshi clinics more cost-efficient and self-supporting.

One of his partners, Pfizer - the world's biggest pharmaceutical maker - is helping to evaluate Grameen's health care delivery systems. Another is General Electric, the world's top maker of medical imaging devices such as ultrasound machines. GE is working with villagers to make diagnostic equipment less complex and easier to carry to people's homes. And the Mayo Clinic, a leading nonprofit medical provider, is training village doctors and nurses how to use state of the art medical equipment.

Yunus says another way to make his health care network sustainable is to encourage Bangladeshi women to train as nurses and become part of the Grameen health care system.

"In Bangladesh, we are in a very strange situation where there are three doctors per nurse because the shortage of nurses is so big. So we thought we could turn it around. You have plenty of girls with good quality education. We can run them through the nursing colleges, and they become good health care workers and they will fill up the gap," he said.

If Yunus's health care system succeeds in Bangladesh, he says he hopes the model can be replicated to help millions of people throughout the developing world.

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Country Health System Profile

Bangladesh

Bangladesh

Bhutan

DPR Korea

India

Indonesia

Maldives

Myanmar

Nepal

Sri lanka

Thailand

Timor-Leste

5. DEVELOPMENT OF THE HEALTH SYSTEM

5.1 Health policies and strategies

The cornerstone of national health policy is the Health and Population Sector Strategy introduced in 1998. Priority is given to ensuring universal accessibility to and equity in healthcare, with particular attention to the rural population. MCH receives priority in the public sector, and reproductive health has recently become a priority concern. There has been improvement in the government financial allocation for health. Efforts are being made to develop a package of essential services based on the priority needs of clients, to be delivered from a static service point, rather than providing door to door visits by community health workers. This is a major shift in strategy and will require complete reorganization of the existing service structure. This is expected to reduce costs and increase efficiency as well as meet "peoples' demand". Privatization of medical care at the tertiary level, on a selective basis, is also being considered.

 

Related Links

Ministry of Health

Millennium Development Goals (MDGs)

Health Policy ‚Äď WHO/HQ

 

Progress made towards achievement of health related MDGs is given at Annex-2

 

5.2 Inter-sectoral cooperation

Inter-sectoral committees at the different levels from the national level to the periphery are formed, whenever the need for cooperation exists. At national level, for example, nutrition and population councils are chaired by the prime minister. At the district and thana levels, inter-sectoral coordination committees also exist, while at the lowest administrative level (union), similar committees are formed, e.g., for water and sanitation projects.

 

5.3 Organization of the health system

Committees have been formed, including an inter-ministerial committee, to integrate/merge the health and the family planning departments. Functionally, health and family planning personnel work closely at Thana, union and outreach levels, but a dichotomy exists at the district and national levels. More decentralization of management is also being considered.

 

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Director General of Health Service

Ministry of Health ‚Äď Organgram

WHO-Bangladesh

Health System ‚Äď WHO/SEARO

 

5.4 Managerial process

The government decided to formulate a national health policy during 1997, for which a health policy committee and five subcommittees were formed. There was a change from a top-down planning process for health to a participatory approach involving the stakeholders in the health sector. The first product that was formulated utilizing this approach was the health sector perspective plan. The health and population sector strategy document was also prepared following the same process.

A new approach to program implementation, which is product oriented and emphasizes on outputs rather than inputs is being tried out with WHO assistance. Decentralization of the management process is also being considered.

 

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Ministry of Health ‚Äď Organgram

 

5.5 Health information system

A weekly epidemiological surveillance and outbreak control reporting system for selected communicable diseases have been initiated throughout the country. The routine HMIS is functioning with some limitation, though activities have been undertaken to strengthen it. Information support is not yet adequate. Use of data remains limited. Strengthening of the HMIS through training, use of data collection tools already designed, and the establishment of information networks with computer support have been planned.

Related Links

Director General of Health Services

WHO-Bangladesh

 

5.6 Community action

The roles of the individual, family and community are emphasized in the intensified action programme for PHC implementation, which involves decentralized planning at thana and union level. A total of 12 districts (86 thanas) are now in the intensified PHC programme. Through intersectoral collaboration and community participation, a joint action plan has been implemented involving 60,000 village health volunteers (one each for 50 households). The participation of teachers and religious leaders is encouraged. The information department and mass media inputs are also utilized to support IEC activities.

 

Related Links

Director General of Health Service

 

5.7 Emergency preparedness

Currently, there is no legislation in the country that underpins the management of natural disasters at national and sub-national levels. In the absence of any legislation, the Ministry of Disaster Management and Relief in 1997 issued revised "standing orders for disasters." These provide guidelines and instructions to various line departments and ministries. There are separate standing orders for different hierarchical levels of the health sector, which include coordination committees; contingency plans for manpower deployment, essential medical relief supplies and maintaining a database; training in emergency preparedness and response; a communication network; and budgetary allocation for emergency management. A draft "Disaster Management Act" is currently under review.

 

Related Links

EHA - WHO/SEARO

EHA ‚Äď WHO/HQ

 

5.8 Health research and technology.

Three organizations [the Bangladesh Medical Research Council (BMRC), the Institute for Cholera and Diarrhoeal Disease Research, Bangladesh (ICDDRB), and Essential National Health Research (ENHR)] spearhead biomedical and operational research. They undertake training and provide research grants. Many of the research findings are helpful in making policy decisions. Research units have also been opened by BMRC in medical colleges. Field study stations have been established by BMRC and ICDDRB. BMRC has reorganized itself internally to cope with the growing demands of young researchers. Literature search systems in BMRC and ICDDRB have been modernized.

Health systems research (HSR) is not handled as a separate, independent entity. Individual faculty members and other relevant people have been trained in HSR, but there is no coordination among researchers. Health training institutions have yet to include HSR in their curricula. The research culture is developing in Bangladesh, and there is no effective critical mass of researchers to form a strong advocacy group. Coordination and networking among researchers and funding agencies are yet to be developed.