Health care reform is a general rubric used for discussing major health policy creation or changes—for the most part, governmental policy that affects health care delivery in a given place. Health care reform typically attempts to:
A rubric is a word or section of text that is traditionally written or printed in red ink for emphasis. The word derives from the Latin: rubrica, meaning red ochre or red chalk, and originates in Medieval illuminated manuscripts from the 13th century or earlier. In these, red letters were used to highlight initial capitals, section headings and names of religious significance, a practice known as rubrication, which was a separate stage in the production of a manuscript.
Health policy can be defined as the "decisions, plans, and actions that are undertaken to achieve specific healthcare goals within a society". According to the World Health Organization, an explicit health policy can achieve several things: it defines a vision for the future; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people.
Health care or healthcare is the maintenance or improvement of health via the prevention, diagnosis, and treatment of disease, illness, injury, and other physical and mental impairments in human beings. Health care is delivered by health professionals in allied health fields. Physicians and physician associates are a part of these health professionals. Dentistry, midwifery, nursing, medicine, optometry, audiology, pharmacy, psychology, occupational therapy, physical therapy and other health professions are all part of health care. It includes work done in providing primary care, secondary care, and tertiary care, as well as in public health.
The public sector is the part of the economy composed of both public services and public enterprises.
The private sector is the part of the economy, sometimes referred to as the citizen sector, which is run by private individuals or groups, usually as a means of enterprise for profit, and is not controlled by the State.
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United States of America
In the United States, the debate regarding health care reform includes questions of a right to health care, access, fairness, sustainability, quality and amounts spent by government. The mixed public-private health care system in the United States is the most expensive in the world, with health care costing more per person than in any other nation, and a greater portion of gross domestic product (GDP) is spent on it than in any other United Nations member state except for East Timor (Timor-Leste).
Rights are legal, social, or ethical principles of freedom or entitlement; that is, rights are the fundamental normative rules about what is allowed of people or owed to people, according to some legal system, social convention, or ethical theory. Rights are of essential importance in such disciplines as law and ethics, especially theories of justice and deontology.
The United States of America (USA), commonly known as the United States or America, is a country composed of 50 states, a federal district, five major self-governing territories, and various possessions. At 3.8 million square miles, the United States is the world's third or fourth largest country by total area and is slightly smaller than the entire continent of Europe's 3.9 million square miles. With a population of over 327 million people, the U.S. is the third most populous country. The capital is Washington, D.C., and the largest city by population is New York. Forty-eight states and the capital's federal district are contiguous in North America between Canada and Mexico. The State of Alaska is in the northwest corner of North America, bordered by Canada to the east and across the Bering Strait from Russia to the west. The State of Hawaii is an archipelago in the mid-Pacific Ocean. The U.S. territories are scattered about the Pacific Ocean and the Caribbean Sea, stretching across nine official time zones. The extremely diverse geography, climate, and wildlife of the United States make it one of the world's 17 megadiverse countries.
The United Nations (UN) is an intergovernmental organization that was tasked to maintain international peace and security, develop friendly relations among nations, achieve international co-operation and be a centre for harmonizing the actions of nations. The headquarters of the UN is in Manhattan, New York City, and is subject to extraterritoriality. Further main offices are situated in Geneva, Nairobi, and Vienna. The organization is financed by assessed and voluntary contributions from its member states. Its objectives include maintaining international peace and security, protecting human rights, delivering humanitarian aid, promoting sustainable development and upholding international law. The UN is the largest, most familiar, most internationally represented and most powerful intergovernmental organization in the world. In 24 October 1945, at the end of World War II, the organization was established with the aim of preventing future wars. At its founding, the UN had 51 member states; there are now 193. The UN is the successor of the ineffective League of Nations.
Both Hawaii and Massachusetts have implemented some incremental reforms in health care, but neither state has complete coverage of its citizens. For example, data from the Kaiser Family Foundation shows that 5% of Massachusetts and 8% of Hawaii residents are uninsured.To date, The U.S. Uniform Law Commission, sponsored by the National Conference of Commissioners on Uniform State Laws has not submitted a uniform act or model legislation regarding health care insurance or health care reform.
Hawaii Prepaid Health Care (PHC) Act (PHCA) is a state law enacted June 12, 1974 in the State of Hawaii to improve health care coverage by employer mandate. The Hawaii Prepaid Health Care Act set a minimum standards of health care benefits for workers. Upon its adoption in 1974, Hawaii became the first U.S. state to require minimum standards of health care benefits by law. Hawaii State Rep. Yoshito Takamine, the longtime chairman of the House Labor Committee, was one of the law's chief architects and proponents.
The Commonwealth of Massachusetts passed a health care reform law in 2006 with the aim of providing health insurance to nearly all of its residents. The law mandated that nearly every resident of Massachusetts obtain a minimum level of insurance coverage, provided free health care insurance for residents earning less than 150% of the federal poverty level (FPL) and mandated employers with more than 10 "full-time" employees to provide healthcare insurance. The law was amended significantly in 2008 and twice in 2010 to make it consistent with the federal Affordable Care Act. Major revisions related to health care industry price controls were passed in August 2012, and the employer mandate was repealed in 2013 in favor of the federal mandate. Because Mitt Romney was the governor of Massachusetts at the time, the law has colloquially been called Romneycare, a reference to the nicknaming of the Patient Protection and Affordable Care Act as "Obamacare".
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Healthcare was reformed in 1948 after the Second World War, broadly along the lines of the 1942 Beveridge Report, with the creation of the National Health Service or NHS. It was originally established as part of a wider reform of social services and funded by a system of National Insurance, though receipt of healthcare was never contingent upon making contributions towards the National Insurance Fund. Private health care was not abolished but had to compete with the NHS. About 15% of all spending on health in the UK is still privately funded but this includes the patient contributions towards NHS provided prescription drugs, so private sector healthcare in the UK is quite small. As part of a wider reform of social provision it was originally thought that the focus would be as much about the prevention of ill-health as it was about curing disease. The NHS for example would distribute baby formula milk fortified with vitamins and minerals in an effort to improve the health of children born in the post war years as well as other supplements such as cod liver oil and malt. Many of the common childhood diseases such as measles, mumps, and chicken pox were mostly eradicated with a national program of vaccinations.
The Beveridge Report, officially entitled Social Insurance and Allied Services, is a government report, published in November 1942, influential in the founding of the welfare state in the United Kingdom. It was drafted by the Liberal economist William Beveridge, who proposed widespread reforms to the system of social welfare to address what he identified as five "Giant Evils" in society: squalor, ignorance, want, idleness, and disease. Published in the midst of World War II, the report promised rewards for everyone's sacrifices. Overwhelmingly popular with the public, it formed the basis for the post-war reforms known as the Welfare State, which include the expansion of National Insurance and the creation of the National Health Service.
The NHS in England, NHS Scotland, NHS Wales, and the affiliated Health and Social Care (HSC) in Northern Ireland were established together in 1948 as one of the major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery. Each service provides a comprehensive range of health services, free at the point of use for people ordinarily resident in the United Kingdom, apart from dental treatment and optical care.
Social services are a range of public services provided by the government, private, profit and non-profit organizations. These public services aim to create more effective organizations, build stronger communities, and promote equality and opportunity.
The NHS has been through many reforms since 1974. The Conservative Thatcher administrations attempted to bring competition into the NHS by developing a supplier/buyer role between hospitals as suppliers and health authorities as buyers. This necessitated the detailed costing of activities, something which the NHS had never had to do in such detail, and some felt was unnecessary. The Labour Party generally opposed these changes, although after the party became New Labour, the Blair government retained elements of competition and even extended it, allowing private health care providers to bid for NHS work. Some treatment and diagnostic centres are now run by private enterprise and funded under contract. However, the extent of this privatisation of NHS work is still small, though remains controversial. The administration committed more money to the NHS raising it to almost the same level of funding as the European average and as a result, there was large expansion and modernisation programme and waiting times improved.
Margaret Hilda Thatcher, Baroness Thatcher, was a British stateswoman who served as Prime Minister of the United Kingdom from 1979 to 1990 and Leader of the Conservative Party from 1975 to 1990. She was the longest-serving British prime minister of the 20th century and the first woman to hold that office. A Soviet journalist dubbed her "The 'Iron Lady'", a nickname that became associated with her uncompromising politics and leadership style. As Prime Minister, she implemented policies known as Thatcherism.
The Labour Party is a centre-left political party in the United Kingdom which has been described as an alliance of social democrats, democratic socialists and trade unionists. The party's platform emphasises greater state intervention, social justice and strengthening workers' rights. Labour is a full member of the Party of European Socialists and Progressive Alliance, and holds observer status in the Socialist International. As of 2017, the party was considered the "largest party in Western Europe" in terms of party membership, with more than half a million members.
New Labour refers to a period in the history of the British Labour Party from the mid-1990s until 2010 under the leadership of Tony Blair and Gordon Brown. The name dates from a conference slogan first used by the party in 1994, later seen in a draft manifesto published in 1996, New Labour, New Life for Britain. It was presented as the brand of a newly reformed party that had altered Clause IV and endorsed market economics. The branding was extensively used while the party was in government between 1997 and 2010. New Labour was influenced by the political thinking of Anthony Crosland, the leadership of Blair and Brown, as well as Peter Mandelson and Alastair Campbell's media campaigning. The political philosophy of New Labour was influenced by the party's development of Anthony Giddens' "Third Way", which attempted to provide a synthesis between capitalism and socialism. The party emphasised the importance of social justice, rather than equality, emphasising the need for equality of opportunity and believed in the use of free markets to deliver economic efficiency and social justice.
The government of Gordon Brown proposed new reforms for care in England. One is to take the NHS back more towards health prevention by tackling issues that are known to cause long term ill health. The biggest of these is obesity and related diseases such as diabetes and cardio-vascular disease. The second reform is to make the NHS a more personal service, and it is negotiating with doctors to provide more services at times more convenient to the patient, such as in the evenings and at weekends. This personal service idea would introduce regular health check-ups so that the population is screened more regularly. Doctors will give more advice on ill-health prevention (for example encouraging and assisting patients to control their weight, diet, exercise more, cease smoking etc.) and so tackle problems before they become more serious. Waiting times, which fell considerably under Blair (median wait time is about 6 weeks for elective non-urgent surgery) are also in focus. A target was set from December 2008, to ensure that no person waits longer than 18 weeks from the date that a patient is referred to the hospital to the time of the operation or treatment. This 18-week period thus includes the time to arrange a first appointment, the time for any investigations or tests to determine the cause of the problem and how it should be treated. An NHS Constitution was published which lays out the legal rights of patients as well as promises (not legally enforceable) the NHS strives to keep in England.
Numerous healthcare reforms in Germany were legislative interventions to stabilise the public health insurance since 1983. 9 out of 10 citizens are publicly insured, only 8% privately. Health care in Germany, including its industry and all services, is one of the largest sectors of the German economy. The total expenditure in health economics of Germany was about 287.3 billion euro in 2010, equivalent to 11.6 percent of the gross domestic product (GDP) this year and about 3,510 euro per capita. Direct inpatient and outpatient care equal just about a quarter of the entire expenditure - depending on the perspective. [ citation needed ]Expenditure on pharmaceutical drugs is almost twice the amount of those for the entire hospital sector. Pharmaceutical drug expenditure grew by an annual average of 4.1% between 2004 and 2010.
These developments have caused numerous healthcare reforms since the 1980s. An actual example of 2010 and 2011: First time since 2004 the drug expenditure fell from 30.2 billion euro in 2010, to 29.1 billion Euro in 2011, i. e. minus 1.1 billion Euro or minus 3.6%. That was caused by restructuring the Social Security Code: manufacturer discount 16% instead of 6%, price moratorium, increasing discount contracts, increasing discount by wholesale trade and pharmacies.
The Netherlands has introduced a new system of health care insurance based on risk equalization through a risk equalization pool. In this way, a compulsory insurance package is available to all citizens at affordable cost without the need for the insured to be assessed for risk by the insurance company. Furthermore, health insurers are now willing to take on high risk individuals because they receive compensation for the higher risks.
A 2008 article in the journal Health Affairs suggested that the Dutch health system, which combines mandatory universal coverage with competing private health plans, could serve as a model for reform in the US.
Following the collapse of the Soviet Union, Russia embarked on a series of reforms intending to deliver better healthcare by compulsory medical insurance with privately owned providers in addition to the state run institutions. According to the OECDnone of 1991-93 reforms worked out as planned and the reforms had in many respects made the system worse. Russia has more physicians, hospitals, and healthcare workers than almost any other country in the world on a per capita basis, but since the collapse of the Soviet Union, the health of the Russian population has declined considerably as a result of social, economic, and lifestyle changes. However, after Putin became president in 2000 there was significant growth in spending for public healthcare and in 2006 it exceed the pre-1991 level in real terms. Also life expectancy increased from 1991-93 levels, infant mortality rate dropped from 18.1 in 1995 to 8.4 in 2008. Russian Prime Minister Vladimir Putin announced a large-scale health care reform in 2011 and pledged to allocate more than 300 billion rubles ($10 billion) in the next few years to improve health care in the country.
Taiwan changed its healthcare system in 1995 to a National Health Insurance model similar to the US Medicare system for seniors. As a result, the 40% of Taiwanese people who had previously been uninsured are now covered.It is said to deliver universal coverage with free choice of doctors and hospitals and no waiting lists. Polls in 2005 are reported to have shown that 72.5% of Taiwanese are happy with the system, and when they are unhappy, it's with the cost of premiums (equivalent to less than US$20 a month).
Employers and the self-employed are legally bound to pay National Health Insurance (NHI) premiums which are similar to social security contributions in other countries. However, the NHI is a pay-as-you-go system. The aim is for the premium income to pay costs. The system is also subsidized by a tobacco tax surcharge and contributions from the national lottery.
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As evidenced by the large variety of different healthcare systems seen across the world, there are several different pathways that a country could take when thinking about reform. In comparison to the UK, physicians in Germany have more bargaining power through professional organizations (i.e., physician associations); this ability to negotiate affects reform efforts.Germany makes use of sickness funds, which citizens are obliged to join but are able to opt out if they have a very high income (Belien 87). The Netherlands used a similar system but the financial threshold for opting out was lower (Belien 89). The Swiss, on the other hand use more of a privately based health insurance system where citizens are risk-rated by age and sex, among other factors (Belien 90). The United States government provides healthcare to just over 25% of its citizens through various agencies, but otherwise does not employ a system. Healthcare is generally centered around regulated private insurance methods.
One key component to healthcare reform is the reduction of healthcare fraud and abuse. In the U.S. and the EU, it is estimated that as much as 10 percent of all healthcare transactions and expenditures may be fraudulent. See Terry L. Leap, Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What to do about It (Cornell University Press, 2011).
Also interesting to notice is the oldest healthcare system in the world and its advantages and disadvantages, see Health in Germany.
In “Getting Health Reform Right: A Guide to Improving Performance and Equity,”Marc Roberts, William Hsiao, Peter Berman, and Michael Reich of the Harvard T.H. Chan School of Public Health aim to provide decision-makers with tools and frameworks for health care system reform. They propose five “control knobs” of health reform: financing, payment, organization, regulation, and behavior . These control knobs refer to the “mechanisms and processes that reformers can adjust to improve system performance” . The authors selected these control knobs as representative of the most important factors upon which a policymaker can act to determine health system outcomes.
Their method emphasizes the importance of “identifying goals explicitly, diagnosing causes of poor performance systematically, and devising reforms that will produce real changes in performance”. The authors view health care systems as a means to an end. Accordingly, the authors advocate for three intrinsic performance goals of the health system that can be adjusted through the control knobs. These goals include:
The authors also propose three intermediate performance measures, which are useful in determining the performance of system goals, but are not final objectives. These include:
While final performance goals are largely agreed upon, other frameworks suggest alternative intermediate goals to those mentioned here, such as equity, productivity, safety, innovation, and choice.
|Control knobs framework||Efficiency |
|Framework for assessing behavioural healthcare||Effectiveness |
|EGIPSS model||Productivity |
Volume of care and services
Quality of care and services
|WHO Performance framework||Access |
|Commonwealth Fund framework||High-quality care |
System and workforce innovation and improvement
|WHO Building Blocks Framework||Access |
|Systems Thinking||Equity |
The five proposed control knobs represent the mechanisms and processes that policy-makers can use to design effective health care reforms. These control knobs are not only the most important elements of a healthcare system, but they also represent the aspect that can be deliberately adjusted by reforms to affect change. The five control knobs are:
The five control knobs of health care reform are not designed to work in isolation; health care reform may require the adjustment of more than one knob or of multiple knobs simultaneously. Further, there is no agreed-upon order of turning control knobs to achieve specific reforms or outcomes. Health care reform varies by setting and reforms from one context may not necessarily apply in another. It is important to note that the knobs interact with cultural and structural factors that are not illustrated within this framework, but which have an important effect on health care reform in a given context.
In summary, the authors of “Getting Health Reform Right: A Guide to Improving Performance and Equity”propose a framework for assessing health systems that guides decision-makers’ understanding of the reform process. Rather than a prescriptive proposal of recommendations, the framework allows users to adapt their analysis and actions based on cultural context and relevance of interventions. As noted above, many frameworks for health care reform exist in the literature. Using a comprehensive yet responsive approach such as the control knobs framework proposed by Roberts, Hsiao, Berman, and Reich allows decision-makers to more precisely determine the “mechanisms and processes” that can be changed in order to achieve improved health status, customer satisfaction, and financial risk protection.
Socialized medicine is a term used in the United States to describe and discuss systems of universal health care: medical and hospital care for all by means of government regulation of health care and subsidies derived from taxation. Because of historically negative associations with socialism in American culture, the term is usually used pejoratively in American political discourse. The term was first widely used in the United States by advocates of the American Medical Association in opposition to President Harry S. Truman's 1947 health-care initiative.
A health system, also sometimes referred to as health care system or as healthcare system, is the organization of people, institutions, and resources that deliver health care services to meet the health needs of target populations.
Publicly funded healthcare is a form of health care financing designed to meet the cost of all or most healthcare needs from a publicly managed fund. Usually this is under some form of democratic accountability, the right of access to which are set down in rules applying to the whole population contributing to the fund or receiving benefits from it.
The healthcare industry is an aggregation and integration of sectors within the economic system that provides goods and services to treat patients with curative, preventive, rehabilitative, and palliative care. It includes the generation and commercialization of goods and services lending themselves to maintaining and re-establishing health. The modern healthcare industry is divided into many sectors and depends on interdisciplinary teams of trained professionals and paraprofessionals to meet health needs of individuals and populations.
Health insurance is an insurance that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over a large number of persons. By estimating the overall risk of health care and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity.
Two-tier healthcare is a situation in which a basic government-provided healthcare system provides basic care, and a secondary tier of care exists for those who can pay for additional, better quality or faster access. Most countries have both publicly and privately funded healthcare, but the degree to which it creates a quality differential depends on the way the two systems are managed, funded, and regulated.
Single-payer healthcare is a type of universal healthcare financed by taxes that covers the costs of essential healthcare for all residents, with costs covered by a single public system.
The term managed care or managed healthcare is used in the United States to describe a group of activities ostensibly intended to reduce the cost of providing for profit health care and providing health insurance while improving the quality of that care. It has become the essentially exclusive system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
The healthcare reform in China refers to the previous and ongoing healthcare system transition in modern China. China's government, specifically the National Health and Family Planning Commission, plays a leading role in these reforms. Reforms focus on establishing public medical insurance systems and enhancing public healthcare providers, the main component in China's healthcare system. In urban and rural areas, three government medical insurance system, Urban Residents Basic Medical Insurance, Urban Employee Basic Medical Insurance and New Rural Co-operative Medical Scheme cover almost everyone. Various public healthcare facilities, including county or city hospitals, community health centers, township health centers, were founded to serve diverse needs. Current and future reforms are outlined in Healthy China 2030.
Healthcare in England is mainly provided by England's public health service, the National Health Service, that provides healthcare to all permanent residents of the United Kingdom that is free at the point of use and paid for from general taxation. Since health is a devolved matter, there are differences with the provisions for healthcare elsewhere in the United Kingdom. Though the public system dominates healthcare provision in England, private health care and a wide variety of alternative and complementary treatments are available for those willing to pay.
Healthcare in Taiwan is administered by the Ministry of Health and Welfare of the Executive Yuan. As with other developed economies, Taiwanese people are well-nourished but face such health problems as chronic obesity and heart disease. In 2002 Taiwan had nearly 1.6 physicians and 5.9 hospital beds per 1,000 population. In 2002, there were 36 hospitals and 2,601 clinics in the country. Per capita health expenditures totaled US$752 in 2000. Health expenditures constituted 5.8 percent of the gross domestic product (GDP) in 2001 ; 64.9 percent of the expenditures were from public funds. Overall life expectancy in 2009 was 78 years.
Healthcare in Georgia is provided by a universal health care system under which the state funds medical treatment in a mainly privatized system of medical facilities. In 2013, the enactment of a universal health care program triggered universal coverage of government-sponsored medical care of the population and improving access to health care services. Responsibility for purchasing publicly financed health services lies with the Social Service Agency (SSA).
Health care in Slovenia is organised primarily through the Health Insurance Institute of Slovenia.
An accountable care organization (ACO) is a healthcare organization that ties payments to quality metrics and the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of its services. According to the Centers for Medicare and Medicaid Services, an ACO is "an organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".
The nation of Austria has a two-tier health care system in which virtually all individuals receive publicly funded care, but they also have the option to purchase supplementary private health insurance. Care involving private insurance plans can include more flexible visiting hours and private rooms and doctors. Some individuals choose to completely pay for their care privately.
This article provides a brief overview of the health systems of the world, sorted by continent.
The Constitution of India makes healthcare in India the responsibility of the state governments, rather than the central federal government. It makes every state responsible for "raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties".
The Twelfth Five Year plan for health services in India covering 2012-2017 was formulated based on the recommendation of a High Level Experts Group (HLEG) and other stakeholder consultations. The long term objective of this strategy is to establish a system of Universal Health Coverage (UHC) in the country. Key points include: