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In some European countries where there is private insurance and universal health care, such as Germany, Belgium, and The Netherlands, the problem of adverse selection (see Private insurance below) is overcome using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price and there is no advantage to eliminate people with higher risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but then mainly compete on price and service. In some countries the basic coverage level is set by the government and cannot be modified.<ref>[http://goliath.ecnext.com/coms2/browse_R_R016 Goliath - Research in Healthcare Financial Management - Industry & Business News Articles - Article, News, Research, Information<!-- Bot generated title -->]</ref>
In some European countries where there is private insurance and universal health care, such as Germany, Belgium, and The Netherlands, the problem of adverse selection (see Private insurance below) is overcome using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price and there is no advantage to eliminate people with higher risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but then mainly compete on price and service. In some countries the basic coverage level is set by the government and cannot be modified.<ref>[http://goliath.ecnext.com/coms2/browse_R_R016 Goliath - Research in Healthcare Financial Management - Industry & Business News Articles - Article, News, Research, Information<!-- Bot generated title -->]</ref>


Ireland at one time had a "community rating" system through [[VHI]], effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. This resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market which then made higher profits at VHI's expense. The government later re-introduced community rating through a pooling arrangement and at least one main major insurance company, [[BUPA]], then withdrew from the Irish market.
money ti blow Ireland at one time had a "community rating" system through [[VHI]], effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. This resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market which then made higher profits at VHI's expense. The government later re-introduced community rating through a pooling arrangement and at least one main major insurance company, [[BUPA]], then withdrew from the Irish market.


====Private insurance====
====Private insurance====

Revision as of 17:32, 23 November 2009

The Royal Aberdeen Children's Hospital is a specialist children's hospital within NHS Scotland. The National Health Service provides publicly-funded universal health care within the United Kingdom.

Universal health care is health care coverage for all eligible residents of a political region and often covers medical, dental and mental health care. Typically, costs are borne in the majority by publicly-funded programs.

Universal health care systems vary according to the extent of government involvement in providing care and/or health insurance. In some countries, such as the UK, Spain, and the Nordic countries, the government has a high degree of involvement in the commissioning or delivery of health care services and access is based on residence rights not on the purchase of insurance. Others have a much more pluralistic delivery system based on obligatory health with contributory insurance rates related to salaries or income, and usually funded by employers and beneficiaries jointly. Sometimes the health funds are derived from a mixture of insurance premiums and government taxes. These insurance based systems tend to have a higher proportion of private medical providers obtaining reimbursement, often at heavily regulated rates, through mutual or publicly owned medical insurers. A few countries such as the Netherlands and Switzerland operate via privately owned but heavily regulated private insurers. Americans use the term single-payer health care to describe the pooling of health care funds into a single not-for-profit fund for a region or nation.

Universal health care is implemented in all industrialized countries, with the exception of the United States.[1] It is also provided in many developing countries.

History

Germany has the world's oldest universal health care system, with origins dating back to Otto von Bismarck's social legislation, which included the Health Insurance Bill of 1883, Accident Insurance Bill of 1884, and Old Age and Disability Insurance Bill of 1889. In Britain, the National Insurance Act 1911 marked the first steps there towards universal health care, covering most employed persons and their financial dependents and all persons who had been continuous contributors to the scheme for at least five years whether they were working or not. This system of health insurance continued in force until the creation of the National Health Service in 1948 which extended health care security to all legal residents. Most current universal health care systems were implemented in the period following the Second World War as a process of deliberate healthcare reform, intended to make health care available to all, in the spirit of Article 25 of the Universal Declaration of Human Rights of 1948, signed by every country doing so. The US did not ratify the social and economic rights sections, including Article 25's right to health.[2]

Implementation and Comparisons

See also: Health care system

Universal health care is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards. Most implement universal health care through legislation, regulation and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis. Usually some costs are borne by the patient at the time of consumption but the bulk of costs come from a combination of compulsory insurance and tax revenues. Some programs are paid for entirely out of tax revenues. In others tax revenues are used either to fund insurance for the very poor or for those needing long term chronic care. The UK government's National Audit Office in 2003 published an international comparison of ten different health care systems in ten developed countries, nine universal systems against one non-universal system (the U.S.), and their relative costs and key health outcomes.[3] A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004 [4] In some cases, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care.

Americas

Argentina, Brazil (see below), Canada (see below), Chile, Costa Rica, Cuba, Mexico (see below), Panama, Peru (see below), Uruguay, Trinidad and Tobago and Venezuela all have public universal health care provided.

Brazil

Main article: Health care in Brazil

The universal health care system was adopted in Brazil in 1988 after the end of the military regime's rule.

Canada

Main article: Health care in Canada

In 1984, the Canada Health Act was passed, which prohibited 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."[5]

The system is for the most part publicly funded, yet most of the services are provided by private enterprises or private corporations, although most hospitals are public. Most doctors do not receive an annual salary, but receive a fee per visit or service.[6] About 29% of Canadians' health care is paid for by the private sector or individuals.[7] This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and vision care.[8] Many Canadians have private health insurance, often through their employers, that cover these expenses.[9]

The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine.[10][11] The legality of the ban was considered in a decision of the Supreme Court of Canada which ruled in Chaoulli v. Quebec that "the prohibition on obtaining private health insurance, while it might be constitutional in circumstances where health care services are reasonable as to both quality and timeliness, is not constitutional where the public system fails to deliver reasonable services." The appellant contended that waiting times in Quebec violated a right to life and security in the Quebec Charter of Human Rights and Freedoms. The Court agreed, but acknowledged the importance and validity of the Canada Health Act, and at least four of the seven judges explicitly recognized the right of governments to enact laws and policies which favour the public over the private system and preserve the integrity of the public system.

Colombia

Main article: Health in Colombia

In 1993 a reform transformed the health care system in Colombia, trying to provide a better, sustainable, health care system and to reach every Colombian citizen.

Mexico

Further information: Health care in Mexico

On December 1, 2006 the Mexican government created the Health Insurance for a New Generation also known as "life insurance for babies".[12][13][14]

On May 28, 2009 Mexico announced Universal Care Coverage for Pregnant Women.[15]

Peru

On April 9, 2009 the Government of Peru published the Law on Health Insurance to enable all Peruvians to access quality health services, and contribute to regulate the financing and supervision of these services. The law enables all population to access diverse health services to prevent illnesses, and promote and rehabilitate people, under a Health Basic Plan (PEAS).[16][17]

Trinidad and Tobago

Main article: Health care in Trinidad and Tobago

The universal health care system is used in Trinidad and Tobago and is the primary form of health-care available in the country. It is used by the majority of the population seeking medical assistance, as it is free for all citizens.

United States

See also: Health care reform in the United States and Health care in the United States

The United States is the only industrialized nation that does not have a universal health care system.[1] Federal law was changed in 1986 with the Emergency Medical Treatment and Active Labor Act requiring certain hospitals to provide stabilizing treatment for patients with emergency medical conditions including childbirth without first demanding evidence of ability to pay. According to the Institute of Medicine of the National Academies of Science, this unfunded “safety net” mandate has contributed to increasing strain on the health system. Emergency treatment is not free or subsidized and some patients cannot or will not pay their bills. Furthermore, this system encourages use of the emergency facilities for primary care and not just for emergency purposes.[18]

In lieu of a national program, some states and municipalities have made attempts to approach universality of insurance in their respective jurisdictions. The state of Massachusetts implemented a near-universal health care system by mandating that residents purchase health insurance by July 1, 2007.[19] The City of San Francisco is also undertaking a universal health care system for uninsured residents.[20][21] Hawaii has, since 1974, required employers to provide employees working more than 20 hours per week with a comprehensive health insurance plan.[22] California, Maine and Vermont are also considering or seeking to implement universal or near-universal systems.[23] In July, 2009, Connecticut passed into law a plan called SustiNet, with the goal of achieving near-universal healthcare coverage by 2014.[24]

Whether a federal system of universal health care should be implemented in the US remains a hotly debated political topic, with Americans divided in their views. The Congressional Budget Office and related government agencies scored the cost of a universal health care system several times since 1991, and have uniformly predicted cost savings,[25] probably because of the 40% cost savings associated with universal preventative care.[26]

Asia

Bhutan, Brunei, China,[27] Hong Kong SAR, India[citation needed], Kuwait[citation needed], Qatar[citation needed], UAE[citation needed], Saudi Arabia[citation needed], Israel,[28] Japan, Malaysia[citation needed], South Korea, Seychelles[citation needed], Sri Lanka,[29] Taiwan,[30], Pakistan [citation needed] and Thailand [citation needed] have universal health care.

Bhutan

Main article: Health in Bhutan

The Royal Government of Bhutan maintains a policy of free and universal access to primary health care. As hospital facilities in the country are limited, patients with diseases that cannot be treated in Bhutan, such as cancer, are normally referred to hospitals in India for treatment. Such referral treatment is also carried out at the cost of the Royal Government.[31]

People's Republic of China

Main article: Healthcare system reform in the People's Republic of China

Since the founding of the People's Republic of China, the goal of health care programs has been to provide care to every member of the population and to make maximum use of limited health-care personnel, equipment, and financial resources.[citation needed]

China is undertaking a reform on its health care system, which was largely privatized in the 1990s. The New Rural Co-operative Medical Care System (NRCMCS), is a new 2005 initiative to overhaul the healthcare system, particularly intended to make it more affordable for the rural poor. Under the NRCMCS, the annual cost of medical cover is 50 yuan (US$7) per person. Of that, 20 yuan is paid in by the central government, 20 yuan by the provincial government and a contribution of 10 yuan is made by the patient. As of September 2007, around 80% of the whole rural population of China had signed up (about 685 million people). The system is tiered, depending on the location. If patients go to a small hospital or clinic in their local town, the scheme will cover from 70-80% of their bill. If they go to a county one, the percentage of the cost being covered falls to about 60%. And if they need specialist help in a large modern city hospital, they have to bear most of the cost themselves, the scheme would cover about 30% of the bill.[32]

On January 21, 2009, the Chinese government announced that a total of 850 billion yuan will be provided between 2009 and 2011 in order to improve the existing health care system.[33]

Hong Kong SAR
Main article: Healthcare in Hong Kong

Hong Kong is one of the healthiest places in the world.[34] Because of its early health education, professional health services, and well-developed health care and medication system, Hongkongers enjoy a life expectancy of 84 for females and 78 for males,[35] which is the second highest in the world, and 2.94 infant mortality rate, the fourth lowest in the world.[36][37]

There are two medical schools in Hong Kong, and several schools offering courses in traditional Chinese medicine. The Hospital Authority is a statutory body that operates and manages all public hospitals. Hong Kong has high standards of medical practice. It has contributed to the development of liver transplantation, being the first in the world to carry out adult to adult live donor liver transplant in 1993.[38]

India

Main article: Healthcare in India

India has a universal health care system run by the local (state or territorial), governments. The government hospitals, some of which are among the best hospitals in India,[39] provide treatment at taxpayer expense. Most essential drugs are offered free of charge in these hospitals.

Government hospitals provide treatment either free or at minimal charges. For example, an outpatient card at AIIMS (one of the best hospitals in India) costs a one time fee of rupees 10 (Around 20 cents US) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on financial condition of the patient and facilities utilized by him but are usually much less than the private sector. For instance, a patient is waived treatment costs if he is below poverty line. Another patient may seek for an air-conditioned room if he is willing to pay extra for it. The charges for basic in-hospital treatment and investigations are much less compared to the private sector. The cost for these subsidies comes from annual allocations from the central and state governments.

Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These hospitals provide treatment free of cost. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses.[citation needed] Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals).[citation needed] However, the fact that the government sector is understaffed and underfinanced and poor services at state run hospitals forces many people to visit private medical practitioners.

Now organizations like Hindustan Latex Family Planning Promotional Trust and other private organizations have started creating hospitals and clinics in India, which also provide free or subsidized health care and subsidized insurance plans.[citation needed]

Israel

Main article: Health care in Israel

In Israel, the National Health Insurance Law (or National Health Insurance Act) is the legal framework which enables and facilitates basic, compulsory universal health care. The Law was put into effect by the Knesset on January 1, 1995, and was based on recommendations put forward by a National Committee of Inquiry which examined restructuring the health care system in Israel in the late 1980s. Prior to the law's passage approximately 85% of the population was already covered by voluntarily belonging to one of four nation-wide, not-for-profit health maintenance organizations (HMOs/sick funds). However, there were three problems associated with this arrangement. First, membership in the largest HMO, Clalit, required one to belong to the Histadrut labor organization, even if a person did not wish to (or could not) have such an affiliation while other HMOs restricted entry to new members based on age, pre-existing conditions or other factors. Second, different HMOs provided different levels of benefit coverage or services to their members and lastly was the issue mentioned above whereby a certain percentage of the population, albeit a small one, did not have health insurance coverage at all.

Before the law went into effect, all the HMOs collected premiums directly from members. However, upon passage of the law, a new progressive national health insurance tax was levied through Israel's social security agency which then re-distributes the proceeds to the HMOs based on their membership and its demographic makeup. This ensured that all citizens would now have health coverage. While membership in one of the HMOs now became compulsory for all, free choice was introduced into movement of members between HMOs (a change is allowed once per year), effectively making the various HMOs compete equally for members among the populace. Annually, a committee appointed by the ministry of health publishes a "basket" or uniform package of medical services and prescription formulary which all HMOs must provide as a minimum service to all their members. Achieving this level of equality ensured that all citizens are guaranteed to receive basic healthcare regardless of their HMO affiliation which was one of the principal aims of the law. An appeals process was put in place to handle rejection of treatments and procedures by the HMOs and evaluating cases falling outside the "basket" of services or prescription formulary.

While the law is generally considered a success and Israeli citizens enjoy a high standard of medical care comparatively, with more competition having been introduced into the field of health care in the country, and order having been brought into what was once a somewhat disorganized system, the law nevertheless does have its critics. First and foremost among the criticisms raised is that the "basket" may not provide enough coverage. To partly address this issue, the HMOs and insurance companies (often in conjunction with employers) began offering additional "supplementary" insurance to cover certain additional services not included in the basket. However, since this insurance is optional, critics argue that it goes against the spirit of the new law which stressed equality among all citizens with respect to healthcare. Another criticism is that in order to provide universal coverage to all, the tax income base amount (the maximum amount of yearly earnings that are subject to the tax) was set rather high, causing many high-income taxpayers to see the amount they pay for their health premiums (now health tax) skyrocket. Finally, some complain about the constantly rising costs of copayments for certain services.

Singapore

Main article: Health care in Singapore

Singapore has a universal health care system where government ensures affordability, largely through compulsory savings and price controls, while the private sector provides most care. Overall spending on health care amounts to only 3% of annual GDP. Of that, 66% comes from private sources.[40] Singapore currently has the lowest infant mortality rate in the world (equaled only by Iceland) and among the highest life expectancies from birth, according to the World Health Organization.[41] Singapore has "one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes," according to an analysis by global consulting firm Watson Wyatt.[42] Singapore's system uses a combination of compulsory savings from payroll deductions (funded by both employers and workers) a nationalized health insurance plan, and government subsidies, as well as "actively regulating the supply and prices of healthcare services in the country" to keep costs in check; the specific features have been described as potentially a "very difficult system to replicate in many other countries." Many Singaporeans also have supplemental private health insurance (often provided by employers) for services not covered by the government's programs.[42]

Taiwan (Republic of China)

Main article: Health care in Taiwan

The current health care system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health care dollars. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[43] NHI is mainly financed through premiums, which are based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers.

NHI delivers universal coverage offered by a government-run insurer. The working population pays premiums split with their employers, others pay a flat rate with government help and the poor or veterans are fully subsidized. Taiwan’s citizens no longer have to worry about going bankrupt due to medical bills.[44]

Under this model, citizens have free range to choose hospitals and physicians without using a gatekeeper and do not have to worry about waiting lists. NHI offers a comprehensive benefit package that covers preventive medical services, prescription drugs, dental services, Chinese medicine, home nurse visits and many more. Working people do not have to worry about losing their jobs or changing jobs because they will not lose their insurance. Since NHI, the previously uninsured have increased their usage of medical services. Most preventive services are free such as annual checkups and maternal and child care. Regular office visits have co-payments as low as US $5 per visit. Co-payments are fixed and unvaried by the person’s income.[45]

Thailand

Main article: Health care in Thailand

Thailand introduced universal coverage reforms in 2001, becoming one of only a handful of lower-middle income countries to do so. Means-tested health care for low income households was replaced by a new and more comprehensive insurance scheme, originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card which allows them to access services in their health district, and, if necessary, be referred for specialist treatment elsewhere. The bulk of finance comes from public revenues, with funding allocated to Contracting Units for Primary Care annually on a population basis. According to the WHO, 65% of Thailand's health care expenditure in 2004 came from the government, 35% was from private sources.[40] Although the reforms have received a good deal of critical comment, they have proved popular with poorer Thais, especially in rural areas, and survived the change of government after the 2006 military coup. The then Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the UC scheme free. It is not yet clear whether the scheme will be modified further under the coalition government that came to power in January 2008.[46][47][48]

Europe

Virtually all of Europe has publicly sponsored and regulated universal health care. The public plans in some countries provide basic or "sick" coverage only; their citizens can purchase supplemental insurance for additional coverage. Countries with universal health care include Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, the Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal,[49] Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Ukraine[50] and the United Kingdom.[51]

Austria

In Austria, public health care (the care, not the running of hospitals itself) is funded by means of so called "Social insurance contributions" accounting for approx. 24% of the salary, they are therefore no taxes as such. 7% of the contribution is reserved for health coverage in one of Austria's 22 public insurances, but cannot exceed EUR 281,- monthly (USD 399,-). Depending on the job, somebody will be insured at one of the 9 state-run territorial health funds or at job specific insurances, e.g. public employees or farmers have their own (compulsory) health insurance. 22 public insurances for 8 million people is subject to violent criticism, as tremendous savings could be reached by unifying the insurances to one centralized provider. However, no Austrian state is willing to give up its own public insurances as it is sphere of action for electoral campaigns. The operation of hospitals is not paid by social contributions, but by taxes. This means that general health coverage adds up to much more and is therefore more expensive as often depicted. Austria spends approx. 10% of its GDP for health coverage.

Finland

Main article: Healthcare in Finland

In Finland, public medical services at clinics and hospitals are run by the municipalities (local government) and are funded 76% by taxation, 20% by patients through access charges, and 4% by others. Private provision is mainly in the primary care sector. There are a few private hospitals [52]. The main hospitals are either municipally owned (funded from local taxes) or run by the medical teaching universities (funded jointly by the municipalities and the national government). According to a survey published by the European Commission in 2000, Finland's is in the top 4 of EU countries in terms of satisfaction with their hospital care system: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[53] Finnish health care expenditures are below the European average.[citation needed] The private medical sector accounts for about 14 percent of total health care spending. Only 8% of doctors choose to work in private practice, and some of these also choose to do some work in the public sector.[citation needed]

Taxation funding is partly local and partly nationally based. The national social insurance institution KELA reimburses part of patients prescription costs and makes a contribution towards private medical costs (including dentistry) if they choose to be treated in the private sector rather than the public sector. Patient access charges are subject to annual caps. For example GP visits cost €11 per visit with annual €33 cap; hospital outpatient treatment €22 per visit; a hospital stay, including food, medical care and medicines €26 per 24 hours, or €12 if in a psychiatric hospital. After a patient has spent €590 per year on public medical services (including prescription drugs), all treatment and medications thereafter in that year are free.

Germany

Main article: Health care in Germany

Germany has the world's oldest universal health care system, with origins dating back to Otto von Bismarck's Health Insurance Act of 1883.[54] As mandatory health insurance, it originally applied only to low-income workers and certain government employees, but has gradually expanded to cover the great majority of the population.[55] The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population is covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher income workers sometimes choose to pay a tax and opt out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status.[56]

Historically, the level of provider reimbursement for specific services is determined through negotiations between regional physician's associations and sickness funds. Since 1976 the government has convened an annual commission, comprised of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries.[57] The commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. In 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. Although reimbursement of providers is on a fee-for-service basis the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. Capitated care, such as that provided by U.S. health maintenance organizations, has been considered as a cost containment mechanism but would require consent of regional medical associations, and has not materialized.[58] Copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).[59][60] The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[61]

Ireland

Main article: Health care in Ireland

The public health care system of the Republic of Ireland is governed by the Health Act 2004, which established a new body to be responsible for providing health and personal social services to everyone living in Ireland - the Health Service Executive. The new national health service came into being officially on 1 January 2005; however the new structures are currently in the process of being established as the reform programme continues. In addition to the public-sector, there is also a large private healthcare market.

Netherlands

Main article: Health care in the Netherlands

The Netherlands has a dual-level system. All primary and curative care (i.e. the family doctor service and hospitals and clinics) is financed from private compulsory insurance. Long term care for the elderly, the dying, the long term mentally ill etc. is covered by social insurance funded from taxation. According to the WHO, the health care system in the Netherlands was 62% government funded and 38% privately funded as of 2004.[40]

Insurance companies must offer a core universal insurance package for the universal primary, curative care which includes the cost of all prescription medicines. They must do this at a fixed price for all. The same premium is paid whether young or old, healthy or sick. It is illegal in The Netherlands for insurers to refuse an application for health insurance, to impose special conditions (e.g. exclusions, deductibles, co-pays etc or refuse to fund treatments which a doctor has determined to be medically necessary). The system is 50% financed from payroll taxes paid by employers to a fund controlled by the Health regulator. The government contributes an additional 5% to the regulator's fund. The remaining 45% is collected as premiums paid by the insured directly to the insurance company. Some employers negotiate bulk deals with health insurers and some even pay the employees' premiums as an employment benefit). All insurance companies receive additional funding from the regulator's fund. The regulator has sight of the claims made by policyholders and therefore can redistribute the funds its holds on the basis of relative claims made by policy holders. Thus insurers with high payouts will receive more from the regulator than those with low payouts. Thus insurance companies have no incentive to deter high cost individuals from taking insurance and are compensated if they have to pay out more than might be expected. Insurance companies compete with each other on price for the 45% direct premium part of the funding and try to negotiate deals with hospitals to keep costs low and quality high. The competition regulator is charged with checking for abuse of dominant market positions and the creation of cartels that act against the consumer interests. An insurance regulator ensures that all basic policies have identical coverage rules so that no person is medically disadvantaged by his or her choice of insurer.

Hospitals in the Netherlands are also regulated and inspected but are mostly privately run and for profit, as are many of the insurance companies. Patients can choose where they want to be treated and have access to information on the internet about the performance and waiting times at each hospital. Patients dissatisfied with their insurer and choice of hospital can cancel at any time but must make a new agreement with another insurer.

Insurance companies can offer additional services at extra cost over and above the universal system laid down by the regulator, e.g. for dental care. The standard monthly premium for health care paid by individual adults is about €100 per month. Persons on low incomes can get assistance from the government if they cannot afford these payments. Children under 18 are insured by the system at no additional cost to them or their families because the insurance company receives the cost of this from the regulator's fund.

United Kingdom

Main article: 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, since Health is a devolved matter, considerable differences are developing between the systems in each of the countries.[62]

England
Main article: Healthcare in England

The National Health Service (NHS), created by the National Health Service Act 1946 has provided the majority of healthcare in England since its launch on 5 July 1948.

The NHS Constitution for England documents at high level, the objectives of the NHS, the legal rights and responsibilities of the various parties (patients, staff, NHS trust boards) and the guiding principles which govern the service.[63] The NHS constitution makes it clear that it provides a comprehensive service, available to all irrespective of age, gender, disability, race, sexual orientation, religion or belief; that access to NHS services is based on clinical need and not an individual’s ability to pay; and that care is never refused on unreasonable grounds. Patient choice in terms of doctor, care, treatments and place of treatment is an important aspect of the NHS's ambition, and in some cases patients can elect for treatment in other European countries at the NHS's expense. Wait times are low, with most people able to see their primary care doctor on the same day or the following day[64] and only 36.1% of hospital admissions are from a waiting list, with the remainder being either emergencies admitted immediately or else pre-booked admissions or similar (e.g. child birth) [65]. No patient should experience a delay of more than 18 weeks from initial hospital referral to final treatment[66]. This includes the time for all investigative tests and consultations, and two thirds of patients are currently treated in under 12 weeks.[67]

Although centrally funded there is no large central bureaucracy to manage it. Responsibility is highly devolved to geographical areas through Strategic Health Authorities and even more locally through NHS primary care trusts , NHS hospital trusts and increasingly to NHS foundation trusts which are providing even more decentralized services within the NHS framework, with more decision making taken by local people, patients and staff. The central government office, the Department of Health, is not involved in day to day decision making in either the Strategic Health Authorities or the individual local trusts (primarily health, hospital or ambulance) or the national specialist trusts such as NHS Blood and Transplant, but it does lay down general guidelines for them to follow. Local trusts are accountable to their local populations, whilst government ministers are accountable to Parliament for the service overall.

The NHS provides, among other things, primary care, in-patient care, long-term healthcare, psychiatric care and treatments ophthalmology and dentistry. All treatment is free with the exception of certain charges for prescriptions, dentistry and ophthalmology (which themselves are free to children, the elderly, the unemployed and those on low incomes). Eighty-nine percent of NHS prescriptions are obtained free of charge, mosly children, pensioners and pregnat women. Others pay a flat rate of £7.20[68], and others may cap their annual charges. Private health care has continued parallel to the NHS, paid for largely by private insurance. Private insurance accounts for only 4 percent of health expenditure and covers little more than a tenth of the population. [69]. Private insurers in the UK only cover acute care from specialists. They do not cover generalist consultations, pre-existing conditions, medical emergencies, organ transplants, chronic conditions such as diabetes or conditions such as pregnancy or HIV. [70] Most NHS general practitioners are private doctors who contract to provide NHS services but most hospitals are publicly owned and run through NHS Trusts. A few NHS medical services such as "surgicentres") are sub-contracted to private providers [71] as are some non-medical services (such as catering). Some capital projects such as new hospitals have been funded through the Private Finance Initiative, enabling investment without excessive strain on the public sector borrowing requirement.

Northern Ireland
Main article: Health and Social Care in Northern Ireland

Health and Social Care in Northern Ireland is the designation of the national public health service in Northern Ireland.

Scotland
Main article: Healthcare in Scotland

NHS Scotland, created by the National Health Service (Scotland) Act 1947, was also launched on 5 July 1948 though it has always been a separate organisation. Since devolution, NHS Scotland follows the policies and priorities of the Scottish Government, including the phasing out of all prescription charges by 2011.

Wales
Main article: Healthcare in Wales

NHS Wales was originally formed as part of the same NHS structure created by the National Health Service Act 1946 but powers over the NHS in Wales came under the Secretary of State for Wales in 1969[72], in turn being transferred under devolution to what is now the Welsh Assembly Government.

Oceania

Australia

File:Medicare brand.svg
Medicare's logo
Main article: Medicare (Australia)

In Australia, Medibank — as it was then known — was introduced, by the Whitlam Labor government on 1 July 1975, through the Health Insurance Act 1973. The Australian Senate rejected the changes multiple times and they were passed only after a joint sitting after the 1974 double dissolution election. However, Medibank was supported by the subsequent Fraser Coalition (Australia) government and became a key feature of Australia’s public policy landscape. The exact structure of Medibank/Medicare, in terms of the size of the rebate to doctors and hospitals and the way it has administered, has varied over the years. The original Medibank program proposed a 1.35% levy (with low income exemptions) but these bills were rejected by the Senate, and so Medibank was funded from general taxation. In 1976, the Fraser Government introduced a 2.5% levy and split Medibank in two: a universal scheme called Medibank Public and a government-owned private health insurance company, Medibank Private.

During the 1980s, Medibank Public was renamed Medicare by the Hawke Labor government, which also changed the funding model, to an income tax surcharge, known as the Medicare Levy, which was set at 1.5%, with exemptions for low income earners.[73] The Howard Coalition government introduced an additional levy of 1.0%, known as the Medicare Levy Surcharge, for those on high annual incomes ($70,000) and do not have adequate levels of private hospital coverage.[74] This was part of an effort by the Coalition to encourage take-up of private health insurance. According to WHO, government funding covered 67.5% of Australia's health care expenditures in 2004; private sources covered the remaining 32.5% of expenditures.[40]

New Zealand

Main article: Health care in New Zealand

As with Australia, New Zealand's healthcare system is funded through general taxation. According to the WHO, government sources covered 77.4% of New Zealand's health care costs in 2004; private expenditures covered the remaining 22.6%.[40]

Economics

Main article: Health care economics

Funding models

Universal health care in most countries has been achieved by a mixed model of funding. General taxation revenue is the primary source of funding, but in many countries it is supplemented by specific levies (which may be charged to the individual and/or an employer) or with the option of private payments (either direct or via optional insurance) for services beyond that covered by the public system.

Almost all European systems are financed through a mix of public and private contributions.[75] The majority of universal health care systems are funded primarily by tax revenue (e.g. Portugal[75] and Spain). Some nations, such as Germany, France[51] and Japan[76] employ a multi-payer system in which health care is funded by private and public contributions. However, much of the non-government funding is by defined contributions by employers and employees to regulated non-profit sickness funds. These contributions are compulsory and vary according to a person's salary, and are effectively a form of hypothecated taxation.

A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency.

Universal health care systems are modestly redistributive. Progressivity of health care financing has limited implications for overall income inequality.[77]

Single-payer

Main article: Single-payer health care

The term single-payer health care is used in the United States to describe a funding mechanism meeting the costs of medical care from a single fund. Although the fund holder is usually the government, some forms of single-payer employ a public-private system.

Public

Some countries (notably the United Kingdom, Italy and Spain) have eliminated insurance entirely and choose to fund health care directly from taxation. Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation, either by directly paying their medical bills or by paying for insurance premiums for those affected.

Compulsory insurance

This is usually enforced via legislation requiring residents to purchase insurance, though sometimes, in effect, the government provides the insurance. Sometimes there may be a choice of multiple public and private funds providing a standard service (e.g. as in Germany) or sometimes just a single public fund (as in Canada).

In some European countries where there is private insurance and universal health care, such as Germany, Belgium, and The Netherlands, the problem of adverse selection (see Private insurance below) is overcome using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price and there is no advantage to eliminate people with higher risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but then mainly compete on price and service. In some countries the basic coverage level is set by the government and cannot be modified.[78]

money ti blow Ireland at one time had a "community rating" system through VHI, effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. This resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market which then made higher profits at VHI's expense. The government later re-introduced community rating through a pooling arrangement and at least one main major insurance company, BUPA, then withdrew from the Irish market.

Private insurance

In some countries with universal coverage, private insurance often excludes many health conditions which are expensive and which the state health care system can provide. For example in the UK, one of the largest private health care providers is BUPA which has the following list of general exclusions[79].

Dental/oral treatment (such as fillings, gum disease, jaw shrinkage, etc)†; pregnancy and childbirth†; temporary relief of symptoms†; convalescence, rehabilitation and general nursing care†; drugs and dressings for out-patient or take-home use†; screening and preventive treatment; birth control, conception, sexual problems and sex changes†; allergies or allergic disorders; chronic conditions†; eyesight†; physical aids and devices†; *deafness; cosmetic, reconstructive or weight loss treatment† ; ageing, menopause and puberty ; dialysis† ; complications from excluded or restricted conditions/ treatment ; HRT and bone densitometry†; learning difficulties, behavioural and developmental problems ; overseas treatment and repatriation ; AIDS/HIV† ; pre-existing or special conditions ; experimental drugs and treatment† ; sleep problems and disorders ; speech disorders†

all of which (except overseas repatriation) are available for free or very low cost from the NHS. († indicates that treatment may be provided in certain circumstances)

Where voluntary insurance (often private) is predominant, such as in the U.S., medical (health) insurance is subject to the well-known economic problem of adverse selection which may also be referred to as a market failure.[citation needed] Adverse selection in insurance markets occurs because those providing insurance have limited information with which to estimate the health risks on which they may need to pay future claims.[citation needed] In simple terms, those with poor health are more likely to apply for insurance and more likely to need treatments requiring high insurance company payouts.[citation needed] Those with good health may find the cost of insurance too high for the perceived benefit, and some will remove themselves from the risk pool.[citation needed] This adverse selection concentrates the risk pool, thereby further raising costs.[citation needed] In practical terms, the potential for adverse selection means that private insurers have an economic incentive to use medical underwriting to 'weed out' high cost applicants in order to avoid adverse selection.[citation needed] Among the potential solutions posited by economists are single payer systems as well as other methods of ensuring that health insurance is universal, such as by requiring all citizens to purchase insurance and limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.[80][81]


See also

References

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