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The United States (U.S.) has one of the largest, complex, and unfortunately, the most expensive health care systems in the world. As of 2016, the U.S. spent $3.3 trillion per year on health care (National Health Accounts History, 2018). Many nations recognize health care as a right of its citizens (Jost, 2006). As an industrialized nation, the U.S. is the only nation where health care for the majority of the people is financed by for-profit private insurance companies. However, this leaves one-sixth of the population uninsured (Quadagno, 2006). Most countries have some sort of government type subsidy and unlike the U.S., they do not make a profit. Financial management is important in health care if our system is to succeed. In our presentation, we discuss the history and structure of health care finance, private coverage and Medicare and Medicaid, universal health care, and the sustainability of such a system. {S.Marquardt}.

History of Health Care Finance

Prior to the establishment of healthcare insurance, physicians were paid for their services out of pocket. During this time, physicians worked autonomously to provide care to their patients. Hospitals were independent and non-profit. At that time, physicians and hospitals were paid based on a fee-for-service program (Conklin, 2002). While this model worked for a time, the demand for healthcare began to strain the system. Many factors including population growth, increase in healthcare technology, and growth of allied health professionals led to an increase in healthcare expenditures (Conklin, 2002). Growing expenses and unregulated fees led to elevated concern that healthcare would become too costly for the general U.S. population to afford. This concern was realized with the Great Depression in 1929. During this time, many hospitals experienced a drop in occupancy rates and a decrease in payment received per patient. Conversely, charity care increased significantly (Morrisey, 2013). [J.Rotter]

Profit vs. Nonprofit Hospitals

In recent years, the U.S. healthcare system began to shift from a nonprofit system to a profit system. This was accelerated by the economic collapse in the early 2000s (George Washington University [GWU], 2018). As a result of the collapse, many nonprofit organizations merged with for-profit systems (GWU, 2018). Hospitals that are nonprofit are exempt from paying property and income taxes (GWU, 2018). They are typically considered charities by the Internal Revenue Service (IRS), serve the community, and are often affiliated with religious organizations (GWU, 2018). For-profit systems are publicly traded businesses that are owned by either shareholders or investors (GWU, 2018). For-profit hospitals provide financial returns to shareholders and investors (Nicholson, Pauly, Burns, Baumritter, and Asche, 2000). Communities are also supported through the taxation of for-profit hospitals (Nicholson, et al, 2000). For-profit hospitals pay real estate taxes, sale taxes on the supplies they purchase, and income taxes on profits. This benefits the community because it can lower taxes on local businesses and the taxes of the citizens.(Nicholson, et al, 2000). (v. murad)

Private Coverage

Private health insurance is defined as a health plan provided through an employer, union, or purchased directly by an individual from an insurance company (Barnett & Berchick, 2017). {K Pace} After the Great Depression, individual states began managing and conducting research on the cost of healthcare. It was determined there was a need to create a way to strengthen and maintain medical care while retaining payments toward medical services (Berkowitz, 2005). After much trial and error, in 1951 came the development of state and community programs such as Blue Cross. At the time, Blue Cross covered over 37 million U.S. citizens (Berkowitz, 2005). However, the federal government felt the need to continue to work towards a national healthcare program. At this point, the government felt that programs run at the state level would not be managed appropriately. [J. Rotter]

In 1973, the Health Maintenance Organization (HMO) Act was established and Medicare statute was amended to provide for HMOs (Centers for Medicare and Medicaid Services [CMS], 2015). By optimizing health through preventative care, reducing overutilization and unnecessary use of expensive health services, and providing standardization for quality by fee-for-service providers, HMOs have significantly controlled healthcare costs and made healthcare more affordable for U.S. citizens (Conklin, 2002). [J. Rotter]

Recent health reform such as the Affordable Care Act (ACA) established specific provisions with the intent to increase the number of insured individuals across the country. Coverage provisions and financial assistance by the ACA affect employers decision to offer coverage. It also affects the decision of employees to accept coverage. Currently, the majority of individuals under age 65 obtain health coverage through an employer-based plan (Long, Rae, Claxton, & Damico, 2016). In 2016, more people in the U.S. were reported to have private health insurance (67.5 percent) than government coverage (37.3 percent) (Barnett & Berchick, 2017). [K Pace]

The Employer Responsibility provision of the ACA requires employers with 50 or more full time employees, to provide coverage to workers and their dependent children. If they do not, they face a financial penalty. The act retains existing structures of Medicare and Medicaid and employer sponsored insurance. It does change, however the individual market. It requires insurers to accept all applications and charge the same rate regardless of any pre-existing conditions (HealthCare.gov). {S. Marquardt} The Individual Mandate Penalty, requires all individuals to apply and purchase a health insurance policy if not offered by employer; if this is not followed the individual is subject to a tax penalty (Long et al., 2016). However, according to Christopher et al. (2018), most of the new private coverage offered through the ACA exchange carry high deductibles. The proportion of employer provided plans with an annual deductible of $2000 or more and has increased 6-fold since 2006 (Christopher et al., 2018). Though the Affordable Care Act has increased the number of Americans with health insurance, some insured families' out-of-pocket costs are exceeding income gains (Christopher et al., 2018). [M. James}

Offering health benefits to employees is believed to be an important factor in the recruitment and retention of workers. However, even though employer sponsored insurance remains the leading source of healthcare for Americans, the long-term stability of this benefit is in question due to rising costs faced by employers (Long et al., 2016).  [K Pace]

Universal Health Coverage

Thirty-two countries have what is called Universal Health Coverage (UHC). Universal Health Care gives every citizen access to essential healthcare services, regardless of their financial circumstances. There are three types of UHC: public insurance, regulated private insurance, and mixed public-private insurance (Seervai, Shah, & Osborn, 2017). Public insurance, also known as single-payer health care, is financed through tax payer revenue. It allows all citizens equal access to medical care (Seervai et al., 2017). Another type of public insurance is known as socialized medicine. Socialized medicine differs from traditional single-payer system in that the government pays for the healthcare. It also provides the services and employs the providers (Montgomery, 2018). This type of insurance is evident in the U.S. through the Veterans Administration (VA) system. The government operates the facilities and pays the bills. {K.Kernan}

Regulated private insurance is the second type of UHC. It is generally funded through benefit plans provided by employers. Examples of private insurance is Blue Cross and Blue Shield, Health Maintenance Organizations (HMO's) and self funded employer sponsored benefit plans. States primarily regulate private health insurance companies with the Federal government also providing laws to govern health insurance (Seervai et al., 2017). {S. Marquardt}

Mixed public-private insurance is a type of insurance coverage that is paid through by both public (government) and private (privately-owned insurance companies) sectors. Americans predominately have private insurance through their employers while some have government-funded benefits such as Medicare and/or Medicaid. [K.Kernan]

The pros of UHC are plentiful. UHC systems lower the cost of care for the economy by giving government the control over prices for medication and medical services (Amadeo, 2018). It also provides standardized billing and coverage of procedures and services making it more streamlined and efficient for providers to be reimbursed for their services. It also eliminates the competitive healthcare market(Amadeo, 2018). UHC systems overall have also been seen to increase preventative care, cutting expenses on unnecessary emergency room visits and providing healthier lifestyle choices (Amadeo, 2018). [K.Kernan]

There are also disadvantages to UHC. The greatest argument against UHC in the U.S. is that it forces healthy individuals to pay for others' medical care. (Amadeo, 2018). This argument is sound. The overall cost of health care will decrease significantly for some, but for others their taxes will rise substantially (Levitt, 2018). Another issue with UHC is prolonged wait times for elective procedures. Unlike private pay countries, those with UHC focus on basic and emergency services before providing medically unnecessary treatment (Amadeo, 2018). The government can also elect to cut spending on medical services with low-success rates. Limiting payment for drugs for rare conditions, and advocating for palliative care vs expensive end-of-life care is also a disadvantage of UHC (Amadeo, 2018). [K.Kernan]

Of the 32 countries with UHC, 12 have adopted a single-payer system and one (the UK) has a socialized medicine system. Six enforce a government mandate on healthcare and require their citizens to purchase healthcare either from the government or through their employer. The other nine have adopted a mixed public-private approach in which citizens are taxed for basic health coverage and can also elect to pay out of pocket for supplemental private insurance (Amadeo, 2018). [K. Kernan]

Universal health care coverage is indeed a controversial issue in the United States. There are ideological divides in the population that fuels debates about the feasibility and applicability of UHC. On the one side, proponents argue that there is a great income and health care access disparity in the US that leaves many without proper care and access to medical attention. On the other hand, fiscal conservatives argue that increasing the tax on the wealthy in order to compensate for the health care coverage of other classes, is not a function of a capitalistic society. Even though the U.S. is considered one of the richest nations in the international arena, the disparity in health care access continues to fuel debate. Boudreau (2017) tackled the plausibility of introducing UHC in the U.S. His analyses were based on the evaluation of the following variables: “1. Affordability; 2. Access to care; 3. Long-term viability; 4. State and federal cooperation; 5. Distribution of funding or services. The proposed plan will address these issues and present some plausible approaches” (n.p.). The author then addresses historical changes, primarily during the 1980s under the Reagan Administration, in which health care facilities and industries became driven by market potential. He writes, “One of the central problems with allowing for a market-driven health care system is that there are fewer providers, hospitals and health care facilities than there is need” (Boudreau, 2017). [S.Ibrahim].

On the other hand, one contributor explains that the lack of UHC in the US is actually that public opinion denounces it. The author writes, “Given that universal coverage inherently clashes with this belief in individualism and limited government, it is perhaps not surprising that it has never been enacted in America even as it has been enacted elsewhere” (U.S. News, 2016). While the Obama Administration’s enactment of the Affordable Care Act (ACA) was deemed as a step closer to UHC, many voiced the gaps in effectiveness in such a program. The country continues to debate the acceptability of UHC, and the divide seems to be made between political and social ideologies. [S. Ibrahim].

Finally, the Trump Administration’s attempted to repeal Obamacare and introduce something in its place. The conflict within the Republican party has stifled progress in health care development in the U.S. Holder and Tropey (2017) examined the comparisons between the U.S. and European health care systems, writing “In Germany, the world’s first national health insurance system shows how UHC often evolves from an initial law." “With millions still uninsured [in US] and the financial burden of healthcare still quite high, the current US policy falls short of the WHO threshold” (n.p.). Regardless of whether Americans are for or against complete UHC, it seems clear that progressive legislations to bring up the US’s health care standards are necessary. [S.Ibrahim].

Consider the following statement:

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family. This includes food, clothing, housing and medical care and necessary social services, and the right to security in  the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control" (World Health Organization, 2013). {Christy Goward}

If this nation can configure a way to meet this challenge, it would benefit the lives of so many individuals. The concept of universal health care is a widely debated and controversial issue in America. The World Health Organization (WHO) (2013) attains that, "In reality no country is capable of providing every single person with every health service they need and with full financial protection." This is primarily because all countries face resource constraints in financing their health systems. These nations must make difficult decisions to ration coverage along the three dimensions of population coverage, service availability and quality, and financial protection. The idea of universal health care is a progressive one which requires us to envision the far-future. According to the WHO (2013), "This is a future that extends much beyond the here and now." It requires the understanding that coverage with health services, service quality and financial risk protection will improve over time as more resources become available (WHO, 2013). This, in itself, proves to be an enormous challenge as this is primarily a society interested in individualistic needs. {Christy Goward}

Also according to the World Health Organization (WHO) (2013), there are multiple benefits for countries which achieve universal health care coverage. For example, one recent study of statistical trends from 153 countries found that broader health coverage generally leads to better access to necessary care and improved population health. The largest gains being in poorer communities. This is especially important in countries such as the United States where economic disparity is apparent. The WHO (2013) states that these findings are borne out by recent experiences in  scaling up service coverage with financial risk protection in countries with markedly different income levels. There are also many examples of countries that have significant improvements in population health as a result of initiatives designed to expand or improve coverage. However, it is important to note that in each case the countries continue to struggle with coverage issues of some sort. {Christy Goward}

A study reflecting perceptions on the true meaning of universal healthcare explains that, "despite most European countries having mandates for universal health coverage, individuals who are low income, in poor health, lack citizenship in the country where they reside, 20–30 years old, unemployed and/or female have systematically greater odds of feeling unable to access care" (Cylus, J., & Papanicolas, I., 2015). The outlooks on universal healthcare have a positive stigmatism, with little understanding. The authors also conclude, " Focusing on the role of income, we find that while there is a strong association between low income and perceived access barriers across countries, within many countries, perceptions of difficulties accessing care are not concentrated uniquely among low-income groups"(Cylus, J., & Papnicolas, I., 2015). (M.Jawad)

Medicare & Medicaid

Medicare and Medicaid were signed into law in 1965 by President Lyndon B. Johnson. These programs began as basic insurance programs for Americans who did not have health insurance. Over the years they have evolved into providing a growing number of Americans with access to the quality and affordable healthcare they deserve (CMS, 2018). The original Medicare program included Part A (Hospital Insurance) and Part B (Medical Insurance) (CMS, 2018). Medicaid was originally designed to give medical insurance to those receiving cash assistance (CMS, 2018). It has now expanded to a much larger group. Those covered in this group include: low-income families, pregnant women, people of all ages with disabilities, and people who require long-term care (CMS, 2018). Each state is able to adjust their Medicaid programs to best serve their residents (CMS, 2018). [J. Viau]

Medicare and Medicaid continue to expand their services. In 1997, the Children’s Health Insurance Program (CHIP) was created. This program was developed to provide insurance and preventative care to uninsured children whose parents most likely made too much to be eligible for Medicaid (Centers for Medicare & Medicaid Services, 2018).In 2003, the Medicare Prescription Drug Improvement and Modernization Act (MMA) made the biggest changes to Medicare in many years. Under the MMA, private health plans approved by Medicare became known as Medicare Advantage Plans. These plans are called "Part C" or "MA Plans” (CMS, 2018). In 2006, the MMA expanded Medicare to include optional prescription drug benefits, known as “Part D” (CMS, 2018). These programs are necessary to continue to protect the health and well-being of millions of American families. [J. Viau}

Health Care Compared to Other Countries

The United States health care system can be considered unique among industrialized countries. The US health system is not uniform, it has no universal health care coverage and only within recent years enacted legislation mandating health care coverage through the Affordable Care Act (Dorning, 2016). Instead of operating a national health service, a single-payer national health insurance system, or a multi-payer universal health insurance fund, the U.S. health care system can best be described as a hybrid system (Dorning, 2016). According to Dorning (2016), in 2014, 48% of the U.S. health care spending came from private funds, 28% from households and 20% from private businesses. The federal government accounted for 28% of spending and state local governments contributed 17% (Dorning, 2016). [J. Viau]

Health care models used in other industrialized nations include: the Beveridge model, the Bismarck model, the National Health Insurance, and the out-of-pocket model (Fam, 2013). The Beveridge model is used in Great Britain, Spain, and New Zealand. This model is financed by the government through tax payments and provides health care for all citizens (Fam, 2013). The Bismarck model is found in Germany, France, Belgium, Netherlands, Japan, and Switzerland (Fam, 2013). This model is financed by both employers and employees through payroll deduction (Fame, 2013). Insurance plans through this model, unlike the U.S., do not make a profit and must enable all citizens to have coverage (Fam, 2013). The National Health Insurance model is found in Canada and has components of both the Beveridge and Bismarck models (Fam, 2013). This model utilizes private-sector providers, but payment comes from a government-run insurance program that all citizens fund through a premium or tax (Fam, 2013). Insurance through this model tends to be less expensive and have lower administrative costs compared to the U.S. for profit insurance plans (Fam, 2013). The fourth model, the out-of-pocket model, is found the most throughout the rest of the world. With this model those that have funds and can afford health care get it, and those that cannot stay uninsured (Fam, 2013). This model is utilized in countries that are too poor or unable to organize any form of a national health care system (Fam, 2013). This model is found in rural regions of Africa, India, China, and South America (Fam, 2013). Unfortunately, with this model hundreds of millions of people go their entire live without seeing a doctor once (Fam, 2013). [J. Viau]

Industrialized countries such as Germany, Switzerland, Japan, Belgium and the Netherlands utilize the Bismarck-type health insurance plans which do not make a profit and must include all citizens. These countries rank in the top tier of WHO. The U.S is spread across the board gathering elements from all 4 systems resulting in poor health outcomes and increased spending on healthcare. Wallace (2013) concluded that the systems with the greatest health outcomes is one that covers all citizens from birth to death. (T.Jones)

As the U.S continues to decline in World Health ranking, there needs to be a restructuring of our health care system. There are systems that are working well for other countries. Reforms are needed and they should be modeled after the nations that are successful in balancing the health of its citizens with lower costs. Rice (2018) reports that if the ACA is repealed, 23 million citizens would lose health care coverage. This alone creates apprehension about repealing the ACA. This loss of coverage would create increased costs and tax strain on an already deteriorating health café system. (T.Jones)

When discussing costs of health care we must also touch upon the cost of prescriptions. Some medications are not covered by insurance. According to Kesselheim, Avron, & Sarpatwari (2016) drug prices are higher in the United States than in the rest of the industrialized world because, the US health care system allows manufacturers to set their own price for a given product contrary to other advanced health systems. Between 2013 and 2015, net spending on prescription drugs increased approximately 20% in the United States which has lead to clinical and economic consequences. The U.S continues to overspend on prescription drugs and healthcare yet, the nation continues to decline in World Health and lag much further behind other industrialized nations. Citizens are spending more while comorbidities and mortality continues to increase. (T.Jones)

Overall, the U.S. health care approach is dysfunctional when compared to other advanced industrialized nations (Dorning, 2016). The U.S. may be considered to have some of the best specialists in the world, but treatment is unjust, overspecialized, and neglects primary and preventative care (Dorning, 2016). According to Dorning (2016), in a 2014 comparison with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., the U.S. ranked last overall. The U.S. ranked fifth in quality of care, but ranked last in terms of efficiency, equity, and healthiness of citizens’ lives (Dorning, 2016). [J. Viau]            

Sustainability            

A key component to the future of the U.S. healthcare system is that of sustainability.  Will our system continue to work for the U.S.? Will change and improvement ensure sustainability or hinder it?  {S. Scorzelli}

At this point in time, universal health coverage is endangered (Liaropoulos & Goranitis, 2015).  It is important to investigate who must pay for healthcare and how such a task will be done.  Unfortunately, relying on out-of-pocket expenditures is unrealistic due to equity and financial protection (Liaropoulos & Goranitis, 2015). With the ever-increasing cost of healthcare in the U.S., taxation may be the only way to cover such expenses (Liaropoulos & Goranitis, 2015).  Labor contributions legislated over 30 years ago have been found to be insufficient to cover today's medical costs (Liaropoulos & Goranitis, 2015) However, contributions that would cover these costs in the future would increase the cost of labor to an extreme (Liaropoulos & Goranitis, 2015).  Savings in the form of taxes on all incomes produced by society, including wealth and capital seem to be the most realistic and reliable plan (Liaropoulos & Goranitis, 2015).  {S. Scorzelli}

Social health insurance has a negative effect on the labor markets and competition due to higher labor costs (Liaropoulos & Goranitis, 2015).  Also, unemployment rates put additional pressure on health care budgeting and public infrastructure (Liaropoulos & Goranitis, 2015). Evidence has shown that health systems financed through taxation can be more responsive to economic pressures and even more effective in areas such as health expenditure consolidation (Liaropoulos & Goranitis, 2015).  {S. Scorzelli}

Sustainability has been demonstrated in other countries with contrasting health care systems.  In Canada, healthcare is financed primarily through taxation (Laropoulos & Goranitis, 2015). Additionally, evidence suggests that patient satisfaction, hospital performance, and health outcomes were maintained even through financial strains (Liaropoulos & Goranitis, 2015).  It can be concluded that employment contributions to finance the healthcare system are not sustainable (Liaropoulos & Goranitis, 2015).  The proposition of general taxation has the potential to boost economic growth through increased competition (Liaropoulos & Goranitis, 2015).   {S. Scorzelli}                        

Conclusion

Health care in the United States has a rich history and has evolved over the years. The establishment of the Health Maintenance Organization (HMO) and the Medicare statute in 1973 lead to optimizing health through preventative care and standards were set in place for standardization for quality of care provided (Conklin, 2002). Today, the Affordable Care Act is set in place to establish provisions with the intent to increase the number of insured individuals across the country. Medicare and Medicaid are also available to help provide health coverage for low-income families, pregnant women, people of all ages with disabilities, and people requiring long-term care (Centers for Medicare & Medicaid Services, 2018). Unlike the USA, citizens of other countries around the world have access to essential healthcare services regardless of their financial situation through the use of Universal Health Care systems. The implementation of Universal Health Care systems has many benefits such as lower cost for the economy, increased rates of preventative care and standardized billing and coverage of procedures and services (Amadeo, 2018). The U.S. Health Care system is considered a hybrid system, where most of the funding comes from private funds. In 2016, 67.5 % of people in the U.S had private health insurance and only 37.3% had government coverage (Barnett & Berchick, 2017). That same year, $3.3 trillion were spent on health care, making the health care system in America the most expensive system in the world (National health Accounts History, 2018). [K. Denkovska]

In conclusion, even though the implementation of the Affordable Care Act aimed at expanding the access to health care coverage, increase consumer protection and emphasize prevention, there are many people who remain without insurance, and those that are insured face high deductibles and premium costs (Dorning, 2013). From 2005 to 2015, the average annual health insurance premiums for family coverage increased 61 percent, while workers contributions towards those plans increased 83 percent (Dorning, 2013). Even though the United States Health Care has some of the best specialists in the world, the U.S approach to health care is poor when compared to other countries (Dorning, 2013). Financing through progressive taxation can help increase economic growth, achieve equity, financial protection, quality and lead to more sustainable and responsive health systems (Liaropoulos & Goranitis, 2015).  [K. Denkovska]

References:                        

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