Health care reform is for the most part governmental policy that affects health care delivery in a given place. Health care reform typically attempts to:
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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).
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.
This article's factual accuracy may be compromised due to out-of-date information. (January 2012)
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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 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.
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. 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 OECD none of 1991-93 reforms worked out as planned and the reforms had in many respects made the system worse. Russia has more physicians, hospitals, and 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
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
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.