My opinion

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Abstract
This article discussed the strength and limitations of the current US healthcare system and provided some preliminary reform proposals. The US health system spending is the highest around the world, yet its performance is disappointing. The issues of the US health system include ideological clash on health care right, the uninsured population that compromise the equity and responsiveness, the high health spending that made the government-sponsored programs unsustainable and put US business at competitive disadvantage, the disappointing quality of care and performance measures, as well as the political struggle to reform. A number of changes are proposed to establish a national health insurance program to provide basic health care for every citizen in this country. The policy level changes are proposed at systematic, programmatic, organizational, and instrumental levels. In addition to the ongoing health reform initiatives from the government, it is necessary to call for a more fundamental reform that would require ideological reform to recognize health care as a fundamental right, government reform to run and regulate the program, and economic reform to fund the program. The focus of the proposal will be on equity, government regulation, cost effectiveness/price control, and prevention/education.
Keywords: health system, equity, reform, balance, health spending, national health insurance system
Introduction
According to the definition of the World Health Organization (WHO) [1], health systems consist of all the people and action whose primary purpose is to improve health. Health systems serve three fundamental goals: improve health, enhance responsiveness to people’s expectations, and assure fair financial contribution [2] by performing four basic functions: namely financing, service provision, resource generation, and stewardship. There are approximately 200 countries and areas in the world, and each has its own health system to fund and provide health care to its people. The basic health system models include: the national health service model (Britain, Cuba), the social insurance model (Germany), the national health insurance model (Canada), and the out-of-pocket model (Cambordia, Burkina Faso) [3]. The features of the four health system models are presented in Illustration 1 and Attachment 1. The performance of health systems vary greatly among the different countries, which is measured by assessing the goal attainment with the available resources [2, 4]. The performance measurement helps to develop policies for improvement and to monitor the outcome of reforms in health systems [4].
The US health system has features of all the four basic models based on different population groups. While majority of people purchase private health insurance through their employers, the government finances the Veteran Health Administration for veterans, Medicare for senior citizens older than age of 65, Medicaid for low income citizens, and workers’ compensation for work-related disability. However, there are about 45 million, or 15%, citizens who do not have any health insurance, a phenomenon not seen in other industrialized countries. As Physicians for a National Health Program [3] stated, “When it comes to treating veterans, we’re Britain or Cuba. For Americans over the age of 65 on Medicare, we’re Canada. For working Americans who get insurance on the job, we’re Germany. For the 15 percent of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India …” (para. 3).
The US spend 15% of GDP on health care, or $6,714 per capita, which is the highest in the world (Illustration 3, Attachment 2). In addition, the health care spending is increasing fast, expecting to reach almost 20% of GDP by the year 2017, at a much faster rate than wages or inflation. Despite of abundant funding and advanced health care technology, the US health system is constantly under-perform, lagging behind major developed countries, such as the OECD countries (Illustration 3, Attachment 2) [5, 6]. The efficiency of US health system is barely above average worldwide [4]. The healthy life expectancy is lagging behind major OECD countries, and the health service and coverage are highly categorical, falling short the expectations of the public.
One wonder why the US, with such high GDP, sophisticated health care technology, and high health care spending, fails to do well in healthcare performance. What are the reasons? And how we can improve? This article gives an overview of the US health system as compared to other health system models, discusses the current issues the US health system faces, and makes a proposal for US health care reform.
Current Issues in the US Healthcare System
Ideological Clashes
In the US, there is no ideological foundation on health care. There are constant debates on whether health is a privilege or a right. The ideological difference resulted in lack of moral and cultural support of a public universal health system. Some people may fear the ideology of socialism in health care as rationing, while others think a mandatory insurance coverage is against the freedom of citizens. To get things worse, “Insurers, providers, business interests, and other opponents of reform loudly equate all such aggregate constraints with ‘rationing’, and the equation has dependably terrified public opinion” (p. 53) [5]. As a result, numerous reform attempts by governments met strong resistance and failed eventually.
Equity and Responsiveness
The health coverage in the US is highly categorical, as discussed previously. There are currently 15% or 46 million of citizens do not have any health insurance at all. A study showed that 62% of personal bankruptcies in the US are related to health expenditure in 2007, and meanwhile, average families have to pay additional $1000 each year in insurance premiums to cover the uninsured, which President Obama called “a hidden and growing tax” [7].
Increasing Financial Burden
Despite of the highest spending in the world, the US health care costs are increasing at a pace much faster than wage increase or inflation. The government sponsored health programs, such as the Medicare and Medicaid, are unsustainable without fundamental reforms. Influx of illegal immigrants further drained the government health budget. Prescription drugs are the most expensive per capita in the world, and there is no control on the monopoly price of patented drugs, which is a big financial burden to patients, insurance companies, and governments. On the other hand, the high costs of health insurance put US business at a competitive disadvantage. US small business becomes more and more reluctant to provide health insurance for their employees.
Unsatisfactory Health Care Performance
The US health care performance lagged behind many industrialized countries by many measurement gauges, including life expectancy, infant mortality rate, health system efficiency, years of potential life lost (Illustration 3, Attachment 2) [4, 8]. The WHO ranked the US 37th in overall performance and 72nd by overall level of health around the world.
Political Struggle on Health Reform
Though surveys show that majority of Americans support a universal health system, political reform on health care met strong resistance. Historically the US government and politicians have tried numerous times to make different forms of universal health programs. For example, Presidents F. D. Roosevelt, Truman, Johnson, and Nixon all attempted to established such programs, which were defeated by either political opposition or lobbying from health industry. Even today, the Republicans and Democrats are deeply split on major health care issues. No Republican supported the health reform bills proposed by President Obama. Each year, the lobbying groups from health care industry (drug companies, providers, and insurers) spend millions to billions of dollars to block health care reform initiatives in order to protect their special interests. Meanwhile, the health care industry in the US are much more profitable than any other country in the world.
Proposed Changes
Based on the discussions and readings learned from this course, I would like to propose to establish a national health insurance system in this country, which would cover the basic care for every citizen (and legal aliens) and would be provided free or with minimal co-pay at service. The reform would proceed at four policy levels at summarized in Illustration 2. The priority of reform would focus on cost effectiveness, preventive measures, and promote healthy lifestyle. It would also balance the finance for each component in the system, the different geographical areas, and the different specialties. It would encourage innovation and human resource development. However, due to the failures of previous reform attempts, it is necessary to initiate ideological, political, and economical reforms at the same time.
Ideological Reform
A fundamental health reform requires ideological reform on health care. If we think that 95% of human life is based on hardware, which is a physically and mentally healthy body, and only 5% of human life is based on built-on activities that we can make choices, such as professional, family, spiritual, and political activities. It would not be difficult for us to make a conclusion that health is a basic, and the ultimate, human right of all. Thus, health should not be treated as a commodity, and health coverage should not base on economic status. Every citizen in this country is entitled, at minimum, basic health care coverage. Universal health coverage reflects the core values of human right, dignity, community, equity, and solidarity. As Brown [5] stated, “Respect for human dignity demands that no one refrain from seeking medical care from fear of the consequences of doing so, and that no one suffer financial adversity as a result of having sought care” (p. 52). Some people in this country may fear the ideology of socialism in health care, actually respect of human dignity is the basic value of democracy and freedom. On the other hand, it is not right to treat health as a commodity and apply market principles to health care.
People, by perceptions, usually link public health care system to rationing, long wait lists, low health care quality, and high taxation. Experience in other countries indicated that they are not necessarily linked. For example, one study showed that health care quality in Canada, with a universal national health insurance system, is at least as good as that in the US, but at only half of the US health care spending per capita [9].
Government Reform
A good health system requires strong government regulation to ensure fairness and to be responsive to people’s expectations. Health coverage of its citizens is a responsibility of any government. The government will regulate taxation to ensure citizens pay the fair share to the health system, allocate the resources to ensure the system meet people’s needs, and control the prices for services and drugs, which is a key for cost containment, which has been demonstrated in countries with public health systems such as Canada [5].
The government should out-law the practice of lobbying of policy makers from special interest groups. Democracy should not be used as a tool for certain groups with social advantages or economic influence. These groups represent the special interest of their own, not that of the general public, thus lobbying is against the public interest and should be treated as a form of corruption.
The government policy will focus on the following issues: legislate health as a fundamental human right, reduce inequalities in contribution and coverage to ensure fairness, control service and drug prices and meanwhile encourage innovation, educate the public and promote preventive measures, establish strong primary care services and balance between different geographical areas, balance different health care specialties, crack down on abuse and fraud.
Economical Reform
The biggest question for any reform is the cost. Who is going to pay for a public health system with universal coverage? Do we have the capability to pay for it? This requires swift economical reforms. The government should fund the system with tax revenue, set ceiling on health care spending, control health care prices, control drug prices, regulate profit of health industry, allocate resources to improve efficiency. The government should oversight health service billing to avoid financial motivated wrong doings.
Health Education
The government should increase budget in public health education, promote healthy life style, and focus more on preventive measures. Studies have shown education is linked to health improvement, and it is a cost effective way of intervention. On the other hand, the government should encourage medical research and innovation in health care technologies, with the emphasize on cost efficiency.
Impact of Health Reforms
The proposed changes would have profound impact. President Obama enacted health reform bills to cover the uninsured population, protect patient rights, and cut health care spending. The proposed changes would go further than the Obama plan in the following areas: 1) it calls for ideological reconciliation on health care right; 2) the goal is to establish a national health insurance plan that cover every citizen and legal alien on uniform terms; 3) it requires strong government regulation on health care industry through financing, price/profit control, and planning; 4) it requires a nation-wide health information sharing to track patient health history; 5) The priority will focus on cost effectiveness, preventive measures, and good lifestyle.
Strong opposition to the proposed changes is predicted. Oppositions will come from the fear of higher taxation to support such a national health insurance program, long waiting list or health care rationing, decreased care quality, as well as lower salaries for health care providers. While to some extent the public health programs have such weakness, the proposed reforms will improve to attain goals on health, fairness, and responsiveness overall. That is why many industrialized countries with universal health care are constantly ranked higher than the US on many health measures. Of course, every health model in the world is facing challenges on old aging, worsening economy, insufficient funds, rising health costs, and increasing expectations. The governments should pro-actively seek opportunities for funding and better goal attainment with existing resources.

Conclusion

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This article gave a review of the issues in the current US healthcare system and made some reform proposals.  It calls for a fundamental health reform that would require ideological reform to recognize health care as a fundamental right, government reform to run and regulate the program, and economic reform to fund the program.  The focus of the proposal will be on equity, government regulation, cost effectiveness, price/profit control, and prevention/education.

Reference(s)

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1. World Health Organization.  The World Health Report 2000:  Health Systems:  Improving performance.  Geneva, Switzerland:  World Health Organization, 2000.
2. Murray, CJL, and Frenk, J.  A framework for assessing the performance of health systems.  Bulletin of the World Health Organization 2000; 78(6): 717 – 731.
3. Physicians for a National Health Program.  Health care systems – four basic models.  2010.  Retrieved from:  http://www.pnhp.org/resources/health-care-systems-four-basic-models
4. Evans, DB, Tandon, A, Murray CJL, and Lauer, JA.  Comparative efficiency of national health systems:  cross national econometric analysis.  British Medical Journal 2001; 323: 307 – 310.
5. Brown, LD.  Comparing health systems in four countries:  Lessons for the United States.  American Journal of Public Health 2003; 93(1): 52 – 56.
6. Light, DW.  Universal health care:  Lessons from the British experience.  American Journal of Public Health 2003; 93(1): 25 – 30.
7. The White House.  Remarks by the President to a joint session of Congress on health care.  2009, September 9; Retrieved from:  http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-Congress-o n-Health-Care/
8. Fried, BJ, and Gaydos, LM (Ed.).  World Health Systems:  Challenges and Perspectives.  Washington, D.C.:  AUPHA Press, 2002.
9. Guyatt, GH, Devereaux, PJ, Lexchin, J, and Stone, SB et al. Research: a systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine 2007; 1(1).  Retrieved from: http://www.openmedicine.ca/article/view/8/1
10.Frenk, J.  Dimensions of health system reform.  Health Policy 1994; 27: 19 – 34.
11.Mapelli, V.  Towards a taxonomy of health schemes and health care systems:  a user contribution.  Paris:  OECD, 2009.  Retrieved from:  http://www.oecd.org/dataoecd/16/58/42102169.pdf
12.USAID.  Key Health System Indicators by Country and Corresponding Peer Groups. 2010.  Country data retrieved from:  http://healthsystems2020.healthsystemsdatabase.org/datasets/CountryReports.aspx

Source(s) of Funding

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H.X. studies at A. T. Still University, Mesa, Arizona, U.S.A.; Y.Z. works at Chengdu No. 1 People's Hospital, Chengdu, Sichuan, China.

Competing Interests

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none

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