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The answer requires quite a bit of education, information and foresight as every other 1st world country has had a proven Universal health care system for decades that is lower cost with better outcomes than the USA health care system.US Spends More on Health Care Than Other High-Income Nations But Has Lower Life Expectancy, Worse HealthPeople such as myself fight for the ACA because it is the only form of Universal health care available to USA citizens under age 65. All citizens including yourself are winners because of this as the Biggest Cause of Personal Bankruptcies? Medical Bills.You are a winner under this system in the long run because when the tax-exempt health sharing program kicks you out or when the tax-exempt health sharing program you are in becomes bankrupt you will have access to Universal health care.Your tax-exempt health sharing program is not large enough to be financially stable and is likely not available to all citizens especially those with pre existing conditions. we need to take care of all citizens.Universal health care is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship.[3]We need all healthcare model that covers all citizens not just the ones that happen to be fortunate and well off.The ACA (Patient Protection and Affordable Care Act - Wikipedia) is not the optimal solution as the best solution is likely a Single-payer healthcare which is a proven economic model practiced in many 1st world countries. It is probably the best proven method of providing economically efficient Universal health care.Here are the wikipages describing how Universal health care - Wikipedia works in all countries around the world. The ACA is a decent start although it is time to improve it not throw it out going back to the 3rd world stone ages.Even Trump may now realize this inescapable fact as Here’s why Trump is already waffling on Obamacare.Universal health care - WikipediaUniversal health care, sometimes referred to as universal health coverage, universal coverage, or universal care, usually refers to a health care system which provides health care and financial protection to all citizens of a particular country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes.[2]Universal health care is not one-size-fits-all and does not imply coverage for all people for everything. Universal health care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered.[2]It is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship.[3]The health policy framework is of central importance. Thus, in the development of universal health systems, it is appropriate to recognize "healthy public policy" (Health in All Policies) as the overarching policy framework, with public health, primary health care, and community services as the cross-cutting framework for all health and health-related services operating across the spectrum from primary prevention to long term care and end-stage conditions. Although that perspective is both logical and well grounded in the social ecological model, the reality is different in most settings, and there is room for improvement everywhere.[4]History[edit]The first move towards a national health insurance system was launched in Germany in 1883, with the Sickness Insurance Law. Industrial employers were mandated to provide injury and illness insurance for their low-wage workers, and the system was funded and administered by employees and employers through "sick funds", which were drawn from deductions in workers' wages and from employers' contributions. Other countries soon began to follow suit. In the United Kingdom, the National Insurance Act 1911 provided coverage for primary care (but not specialist or hospital care) for wage earners, covering about one third of the population. The Russian Empire established a similar system in 1912, and other industrialized countries began following suit. By the 1930s, similar systems existed in virtually all of Western and Central Europe. Japan introduced an employee health insurance law in 1927, expanding further upon it in 1935 and 1940. Following the Russian Revolution of 1917, the Soviet Union came close to a universal health care system. It established a fully public and centralized health care system in 1920.[5][6]However, it was not a truly universal system at that point, as rural residents were not http://covered.In New Zealand, a universal health care system was created in a series of steps, from 1939 to 1941.[7][8]In Australia, the state of Queensland introduced a free public hospital system in the 1940s.Following World War II, universal health care systems began to be set up around the world. On July 5, 1948, the United Kingdom launched its universal National Health Service. Universal health care was next introduced in the Nordic countries of Sweden (1955),[9]Iceland (1956),[10] Norway (1956),[11] Denmark (1961),[12] and Finland (1964).[13]Universal health insurance was then introduced in Japan (1961), and in Canada through stages, starting with the province of Saskatchewan in 1962, followed by the rest of Canada from 1968 to 1972.[7][14]The Soviet Union extended universal health care to its rural residents in 1969.[7][15]Italy introduced its Servizio Sanitario Nazionale (National Health Service) in 1978. Universal health insurance was implemented in Australia beginning with the Medibank system in 1975, which led to universal coverage under the Medicare system, established in 1984.From the 1970s to the 2000s, Southern and Western European countries began introducing universal coverage, most of them building upon previous health insurance programs to cover the whole population. For example, France built upon its 1928 national health insurance system, with subsequent legislation covering a larger and larger percentage of the population, until the remaining 1% of the population that was uninsured received coverage in 2000.[16][17]In addition, universal health coverage was introduced in some Asian countries, including South Korea (1989), Taiwan (1995), Israel (1995), and Thailand (2001).Following the collapse of the Soviet Union, Russia retained and reformed its universal health care system,[18] as did other former Soviet nations and Eastern bloc countries.Beyond the 1990s, many countries in Latin America, the Caribbean, Africa, and the Asia-Pacific region, including developing countries, took steps to bring their populations under universal health coverage, including China which has the largest universal health care system in the world.[19]A 2012 study examined progress being made by these countries, focusing on nine in particular: Ghana, Rwanda, Nigeria, Mali, Kenya, India, Indonesia, the Philippines, and Vietnam.[20][21]Funding models[edit]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 (by direct or optional insurance) for services beyond those covered by the public system.Almost all European systems are financed through a mix of public and private contributions.[22]Most universal health care systems are funded primarily by tax revenue (like in Portugal[22] Spain, Denmark, and Sweden). Some nations, such as Germany and France[23] and Japan[24] employ a multipayer system in which health care is funded by private and public contributions. However, much of the non-government funding is by contributions by employers and employees to regulated non-profit sickness funds. Contributions are compulsory and defined according to law.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. The progressivity of health care financing has limited implications for overall income inequality.[25]Compulsory insurance[edit]This is usually enforced via legislation requiring residents to purchase insurance, but sometimes the government provides the insurance. Sometimes, there may be a choice of multiple public and private funds providing a standard service (as in Germany) or sometimes just a single public fund (as in Canada). Healthcare in Switzerland and the US Patient Protection and Affordable Care Act are based on compulsory insurance.[26][27]In some European countries in which private insurance and universal health care coexist, such as Germany, Belgium, and the Netherlands, the problem of adverse selection is overcome by 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 they compete mainly on price and service. In some countries, the basic coverage level is set by the government and cannot be modified.[28]The Republic of Ireland at one time had a "community rating" system by VHI, effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. That 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 reintroduced community rating by a pooling arrangement and at least one main major insurance company, BUPA, then withdrew from the Irish market.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 or limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.[29][30]Single payer[edit]Single-payer health care is a system in which the government, rather than private insurers, pays for all health care costs.[31]Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or own and employ healthcare resources and personnel (as was the case in England before of the Health and Social Care Act). "Single-payer" thus describes only the funding mechanism and refers to health care financed by a single public body from a single fund and does not specify the type of delivery or for whom doctors work. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.Tax-based financing[edit]In tax-based financing, individuals contribute to the provision of health services through various taxes. These are typically pooled across the whole population, unless local governments raise and retain tax revenues. Some countries (notably the United Kingdom, Canada, Ireland, Australia, New Zealand, Italy, Spain, Portugal, Greece and the Nordic countries) choose to fund health care directly from taxation alone. 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.Social health insurance[edit]In social health insurance, contributions from workers, the self-employed, enterprises and government are pooled into a single or multiple funds on a compulsory basis. The funds typically contract with a mix of public and private providers for the provision of a specified benefit package. Preventive and public health care may be provided by these funds or responsibility kept solely by the Ministry of Health. Within social health insurance, a number of functions may be executed by parastatal or non-governmental sickness funds or in a few cases by private health insurance companies.Private insurance[edit]In private health insurance, premiums are paid directly from employers, associations, individuals and families to insurance companies, which pool risks across their membership base. Private insurance includes policies sold by commercial for profit firms, non-profit companies, and community health insurers. Generally, private insurance is voluntary in contrast to social insurance programs, which tend to be compulsory.[32]In some countries with universal coverage, private insurance often excludes many health conditions that are expensive and the state health care system can provide. For example, in the United Kingdom, one of the largest private health care providers is BUPA, which has a long list of general exclusions even in its highest coverage policy,[33] most of which are routinely provided by the National Health Service. In the United States, dialysis treatment for end stage renal failure is generally paid for by government, not by the insurance industry. Those with privatized Medicare (Medicare Advantage) are the exception and must get their dialysis paid through their insurance company, but those with end stage renal failure generally cannot buy Medicare Advantage plans.[34]The Planning Commission of India has also suggested that the country should embrace insurance to achieve universal health coverage.[35] General tax revenue is currently used to meet the essential health requirements of all people.Community-based health insurance[edit]A particular form of private health insurance that has often emerged if financial risk protection mechanisms have only a limited impact is community-based health insurance. Individual members of a specific community pay to a collective health fund, which they can draw from when they need of medical care. Contributions are not risk-related, and there is generally a high level of community involvement in the running of these plans.Implementation and comparisons[edit]Main article: Universal health coverage by countrySee also: Health care system and Health systems by countryHealth spending per capita, in US$ purchasing power parity-adjusted, among various OECD countriesUniversal health care systems vary according to the degree of government involvement in providing care and/or health insurance. In some countries, such as the UK, Spain, Italy, Australia 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, salary related mandatory contributions by employees and/or employers to regulated sickness funds, and by government taxes. These insurance based systems tend to reimburse private or public medical providers, 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, which are not allowed to make a profit from the mandatory element of insurance but can profit by selling supplemental insurance.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 United Kingdom 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 United States), and their relative costs and key health outcomes.[36]A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004.[37]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.Single-payer healthcareSingle-payer healthcare is a system in which the state, rather than private insurers, pays for all healthcare costs.[1]Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or may own and employ healthcare resources and personnel (as is the case in the United Kingdom).The term "single-payer" thus describes the funding mechanism, referring to healthcare financed by a single public body from a single fund, not the type of delivery or for whom physicians work. The British system is technically not single payer, as it consists of a number of financially and legally autonomous trusts.The actual funding of a "single payer" system comes from all or a portion of the covered population. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.Description[edit]Single-payer health insurance collects all medical fees and then pays for all services, by a single government (or government-related) source.[2]In wealthy nations, that kind of publicly managed insurance is typically extended to all citizens and legal residents. Examples include the United Kingdom's National Health Service, Australia's Medicare, Canada's Medicare, and Taiwan's National Health Insurance.The standard usage of the term "single-payer healthcare" refers to health insurance, as opposed to healthcare delivery, operating as a public service and offered to citizens and legal residents towards providing nearly universal or universal healthcare. The fund can be managed by the government directly or as a publicly owned and regulated agency.[2]Some writers describe publicly administered systems as "single-payer plans". Some writers have described any system of healthcare which intends to cover the entire population, such as voucher plans, as "single-payer plans",[3] but that is uncommon.Countries and regions[edit]Many nations worldwide have single-payer health insurance programs. These programs generally provide some form of universal healthcare, which are implemented in a variety of ways. In some cases doctors are employed, and hospitals run by, the government such as in the United Kingdom[4] or Spain.[5]Alternatively the government may purchase healthcare services from outside organizations, such as the approach taken in Canada.Australia[edit]Healthcare in Australia is provided by both private and government institutions. Medicare is the publicly funded universal health care venture in Australia. It was instituted in 1984 and coexists with a private health system. Medicare is funded partly by a 2% income taxlevy[6](with exceptions for low-income earners), but mostly out of general revenue. An additional levy of 1% is imposed on high-income earners without private health insurance. As well as Medicare, there is a separate Pharmaceutical Benefits Scheme that considerably subsidises a range of prescription medications. The Minister for Health, currently Sussan Ley, administers national health policy, elements of which (such as the operation of hospitals) are overseen by individual states.Canada[edit]See also: Canadian and American health care systems compared and Medicare (Canada)Healthcare in Canada is delivered through a publicly funded healthcare system, which is mostly free at the point of use and has most services provided by private entities.[7]It is guided by the provisions of the Canada Health Act of 1984.[8]The government assures the quality of care through federal standards. The government does not participate in day-to-day care or collect any information about an individual's health, which remains confidential between a person and his or her physician. Canada's provincially based Medicare systems are cost-effective partly because of their administrative simplicity. In each province each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses healthcare to be involved in billing and reclaim. Private insurance represents a minimal part of the overall system.Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes, except in British Columbia, the only province to impose a fixed monthly premium which is waived or reduced for those on low incomes.[9]There are no deductibles on basic health care and co-pays are extremely low or non-existent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). A health card is issued by the Provincial Ministry of Health to each individual who enrolls for the program and everyone receives the same level of care.[10]There is no need for a variety of plans because virtually all essential basic care is covered, including maternity and infertility problems. Depending on the province, dental and vision care may not be covered but are often insured by employers through private companies. In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered. These can be paid out-of-pocket or through private insurers. Health coverage is not affected by loss or change of jobs, as long as premiums are up to date, and there are no lifetime limits or exclusions for pre-existing conditions.Pharmaceutical medications are covered by public funds for the elderly or indigent,[11]or through employment-based private insurance. Drug prices are negotiated with suppliers by the federal government to control costs. Family physicians (often known as general practitioners or GPs in Canada) are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Canadians do wait for some treatments and diagnostic services. Survey data shows that the median wait time to see a special physician is a little over four weeks with 89.5% waiting less than three months. The median wait time for diagnostic services such as MRI and CAT scans[12] is two weeks, with 86.4% waiting less than three months.[13]The median wait time for surgery is four weeks, with 82.2% waiting less than three months.[14]Spain[edit]Building upon less structured foundations, in 1963 the existence of a single-payer healthcare system in Spain was established by the Spanish government.[15]The system was sustained by contributions from workers, and covered them and their dependents.[16]The universality of the system was established later in 1986. At the same time, management of public healthcare was delegated to the different autonomous communities in the country.[17]While previously this was not the case, in 1997 it was established that public authorities can delegate management of publicly funded healthcare to private companies.[18]Additionally, in parallel to the single-payer healthcare system there are private insurers, which provide coverage for some private doctors and hospitals. Employers will sometimes offer private health insurance as a benefit,[19] with 14.8% of the Spanish population being covered under private health insurance in 2013.[20]In 2000, the Spanish healthcare system was rated by the World Health Organization as the 7th best in the world.Taiwan[edit]Healthcare in Taiwan is administrated by the Department of Health 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.[21]In 2002 Taiwan had nearly 1.6 physicians and 5.9 hospital beds per 1,000 population.[21]In 2002, there were a total of 36 hospitals and 2,601 clinics in the country. Per capita health expenditures totaled US$752 in 2000.[21]Health expenditures constituted 5.8 percent of the gross domestic product (GDP) in 2001 (or $951 US in 2009[22]); 64.9 percent of the expenditures were from public funds.[21]Overall life expectancy in 2009 was 78 years.[23]The current healthcare 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 funds. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[24]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. Most health providers operate in the private sector and form a competitive market on the health delivery side. However, many healthcare providers took advantage of the system by offering unnecessary services to a larger number of patients and then billing the government. In the face of increasing loss and the need for cost containment, NHI changed the payment system from fee-for-service to a global budget, a kind of prospective payment system, in 2002.United Kingdom[edit]Healthcare in the United Kingdom is a devolved matter, meaning England, Northern Ireland, Scotland and Wales each have their own systems of private and publicly funded healthcare, generally referred to as the National Health Service (NHS). Each country having different policies and priorities has resulted in a variety of differences existing between the systems.[25][26]That said, each country provides public healthcare to all UK permanent residents that is free at the point of use, being paid for from general taxation. In addition, each also has a private sector which is considerably smaller than its public equivalent, with provision of private healthcare acquired by means of private health insurance, funded as part of an employer funded healthcare scheme or paid directly by the customer, though provision can be restricted for those with conditions such as AIDS/HIV.[27]The individual systems are:England: National Health ServiceNorthern Ireland: Health and Social Care in Northern Ireland (HSCNI)Scotland: NHS ScotlandWales: NHS WalesIn England, funding from general taxation is channeled through NHS England, which is responsible for commissioning mainly specialist services and primary care, and Clinical Commissioning Groups (CCGs), which hold 60% of the budget and are responsible for commissioning health services for their local populations.[28]These commissioning bodies do not provide services themselves directly, but procure these from NHS Trusts and Foundation Trusts, as well as private, voluntary and social enterprise sector providers.[29]United States[edit]A number of proposals have been made for a universal single-payer healthcare system in the United States, most recently the United States National Health Care Act, (popularly known as H.R. 676 or "Medicare for All") but none has achieved more than 20% congressional co-sponsorship.Advocates argue that preventive healthcare expenditures can save several hundreds of billions of dollars per year because publicly funded universal healthcare would benefit employers and consumers, that employers would benefit from a bigger pool of potential customers and that employers would likely pay less, would be spared administrative costs, and inequities between employers would be reduced. Advocates also argue that single payer could benefit from a more fluid economy with increasing economic growth, aggregate demand, corporate profit, and quality of life.[30][31][32]Also, for example, cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal.[33][34]Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventive health care,[35] although estimates from the Congressional Budget Office and The New England Journal of Medicine have found that preventive care is more expensive due to increased utilization.[36]Any national system would be paid for in part through taxes replacing insurance premiums, but advocates also believe savings would be realized through preventive care and the elimination of insurance company overhead and hospital billing costs.[37]An analysis of a single-payer bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year.[38]The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.[39]Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, are seen as possible routes to enacting single-payer on the federal level.[40][41]In December 2014, Vermont cancelled its plan for single payer healthcare.[42]National policies and proposals[edit]Medicare in the United States is a single-payer healthcare system, but is restricted to only senior citizens over the age of 65, people under 65 who have specific disabilities, and anyone with End-Stage Renal Disease.[43]Government is increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on individuals' medical care in 2004.[44]However, studies have shown that the publicly administered share of health spending in the U.S. may be closer to 60% as of 2002.[45]According to Princeton University health economist Uwe Reinhardt, U.S. Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) represent "forms of 'social insurance' coupled with a largely private health-care delivery system" rather than forms of "socialized medicine." In contrast, he describes the Veterans Administration healthcare system as a pure form of socialized medicine because it is "owned, operated and financed by government."[46]In a peer-reviewed paper published in the Annals of Internal Medicine, researchers of the RAND Corporation reported that the quality of care received by Veterans Administration patients scored significantly higher overall than did comparable metrics for patients currently using United States Medicare.[47]The United States National Health Care Act, is a perennial piece of legislation introduced in the United States House of Representatives by Representative John Conyers (D-MI) every year since 2002.[48]The act would establish a universal single-payer health care system in the United States, the rough equivalent of Canada's Medicare, the United Kingdom's National Health Service, and Taiwan's Bureau of National Health Insurance, among other examples. Under a single payer system, all medical care would be paid for by the Government of the United States, ending the need for private health insurance and premiums, and probably recasting private insurance companies as providing purely supplemental coverage, to be used when non-essential care is sought. The bill was first introduced in 2002,[48] and has been reintroduced in each Congress since. During the 2009 health care debates over the bill that became the Patient Protection and Affordable Care Act, H.R. 676 was expected to be debated and voted upon by the House in September 2009,[49] but was never debated.[50]The Congressional Budget Office and related government agencies scored the cost of a single payer health care system several times since 1991. The General Accounting Office published a report in 1991 noting that "[I]f the US were to shift to a system of universal coverage and a single payer, as in Canada, the savings in administrative costs [10 percent of health spending] would be more than enough to offset the expense of universal coverage.”[51]The CBO scored the cost in 1991, noting that "the population that is currently uninsured could be covered without dramatically increasing national spending on health" and that "all US residents might be covered by health insurance for roughly the current level of spending or even somewhat less, because of savings in administrative costs and lower payment rates for services used by the privately insured.[52]A CBO report in 1993 stated that "[t]he net cost of achieving universal insurance coverage under this single payer system would be negative" in part because "consumer payments for health would fall by $1,118 per capita, but taxes would have to increase by $1,261 per capita" in order to pay for the plan.[53]A July 1993 scoring also resulted in positive outcomes, with the CBO stating that, "[a]s the program was phased in, the administrative savings from switching to a single-payer system would offset much of the increased demand for health care services. Later, the cap on the growth of the national health budget would hold the rate of growth of spending below the baseline."[54]The CBO also scored Sen. Paul Wellstone's American Health and Security Act of 1993 in December 1993, finding that "by year five (and in subsequent years) the new system would cost less than baseline."[55]A 2014 study published in the journal BMC Medical Services Research by James Kahn, etal, found that the actual administrative burden of health care in the United States was 27.4% of all national health expenditures. The study examined both direct costs charged by insurers for profit, administration and marketing but also the indirect burden placed on health care providers like hospitals, nursing homes and doctors for costs they incurred in working with private health insurers including contract negotiations, financial and clinical record-keeping (variable and idiosyncratic for each payer). Kahn, et al. estimate that the added cost for the private insurer health system in the US was about $471 billion in 2012 compared to a single payer system like Canada's. This represents just over 20% of the total national healthcare expenditure in 2012. Kahn asserts that this excess administrative cost will increase under the Affordable Care Act with its reliance on the provision of health coverage through a multi-payer system.[56]State proposals[edit]Several single-payer state referendums and bills from state legislatures have been proposed, but, with the exception of Vermont,[57] all have failed. In December 2014, Vermont canceled its plan for single payer health care.[42]California[edit]California attempted passage of a single-payer bill as early as 1994,[58]and the first successful passages of legislation through the California State Legislature, SB 840 or "The California Universal Healthcare Act" (authored by Sheila Kuehl), occurred in 2006 and again in 2008.[59]Both times, Governor Arnold Schwarzenegger vetoed the bill.[60]State Senator Mark Leno has reintroduced the bill in each legislative session since.[61]Colorado[edit]Colorado Amendment 69, will have a ballot proposal in November 2016 to vote on a single payer healthcare system funded by a 10% payroll tax split 2:1 between employers and employees. This would replace the private health insurance premiums currently paid by employees and companies.[62]Hawaii[edit]In 2009, the Hawaii state legislature passed a single-payer healthcare bill that was vetoed by Republican Governor Linda Lingle. While the veto was overridden by the legislature, the bill was not implemented.[63]Illinois[edit]In 2007, the Health Care for All Illinois Act was introduced and the Illinois House of Representatives' Health Availability Access Committee passed the single-payer bill favorably out of committee by an 8–4 vote. The legislation was eventually referred back to the House rules committee and not taken up again during that session.[64]Massachusetts[edit]Massachusetts had passed a universal healthcare program in 1986, but budget constraints and partisan control of the legislature resulted in its repeal before the legislation could be enacted.[65]Question 4, a nonbinding referendum, was on the ballot in 14 state districts in November 2010, asking voters, "[S]hall the representative from this district be instructed to support legislation that would establish healthcare as a human right regardless of age, state of health or employment status, by creating a single payer health insurance system like Medicare that is comprehensive, cost effective, and publicly provided to all residents of Massachusetts?" The ballot question passed in all 14 districts that offered the question.[66][67]Minnesota[edit]The Minnesota Health Act, which would establish a statewide single payer health plan, has been presented to the Minnesota legislature regularly since 2009. The bill was passed out of both the Senate Health Housing and Family Security Committee[68] and the Senate Commerce and Consumer Protection Committee[69] in 2009, but the House version was ultimately tabled.[70]In 2010, the bill passed the Senate Judiciary Committee on a voice vote[71] as well as the House Health Care & Human Services Policy and Oversight Committee.[72]In 2011, the bill was introduced as a two-year bill in both the Senate[73] and House,[74] but did not progress. It has been introduced again in the 2013 session in both chambers.[75][76]Montana[edit]In September 2011, Governor Brian Schweitzer announced his intention to seek a waiver from the federal government allowing Montana to set up a single payer healthcare system.[77]Governor Schweitzer was unable to implement single-payer health care in Montana, but did make moves to open government-run clinics[78] and, in his final budget as governor, increased coverage for lower-income Montana residents.[79]New York[edit]New York State has been attempting passage of the New York Health Act, which would establish a statewide single-payer health plan, since 1992. The New York Health Act has passed the Assembly twice, once in 1992 and again in 2015, but has failed to advance through the Senate after referrals to the Health Committee. On both occasions, the legislation passed the Assembly by an almost two-to-one ratio of support.[80]Oregon[edit]The state of Oregon attempted to pass single payer healthcare via Oregon Ballot Measure 23 in 2002, and the measure was rejected by a significant majority.[81]Previous bills, including the Affordable Health Care for All Oregon Act, have been introduced in the legislature but have never left committee. The Affordable Health Care Act may be reintroduced in the 2013 session.[82]Pennsylvania[edit]The Family Business and Healthcare Security Act has been introduced in the Pennsylvania legislature numerous times, but has never been able to pass.[83][84][85]Vermont[edit]In December 2014, Vermont canceled its plan for single payer healthcare.[42]Vermont passed legislation in 2011 creating Green Mountain Care.[86]When Governor Peter Shumlin signed the bill into law, Vermont became the first state to functionally have a single payer health care system.[87]While the bill is considered a single-payer bill, private insurers can continue to operate in the state indefinitely, meaning it does not fit the strict definition of single-payer. Representative Mark Larson, the initial sponsor of the bill, has described Green Mountain Care's provisions "as close as we can get [to single-payer] at the state level."[88][89]Vermont abandoned the plan in 2014, citing costs and tax increases as too high to implement.[90]Public opinion[edit]Advocates for single payer point to support in polls, although the polling is mixed depending on how the question is asked.[91]Polls from Harvard University in 1988,[92] the Los Angeles Times in 1990,[93] and the Wall Street Journal in 1991[94] all showed strong support for a health care system comparable to the system in Canada. More recently, however, polling support has declined.[91][95]A 2007 Yahoo/AP poll showed a majority of respondents considered themselves supporters of "single-payer health care,"[96] and a plurality of respondents in a 2009 poll for Time Magazine showed support for "a national single-payer plan similar to Medicare for all."[97]Polls by Rasmussen Reports in 2011[98] and 2012[99] showed pluralities opposed to single payer health care.A 2001 article in the public health journal Health Affairs studied fifty years of American public opinion of various health care plans and concluded that, while there appears to be general support of a "national health care plan," poll respondents "remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan."[95]Politifact rated a statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care." According to Politifact, responses on these polls largely depend on the wording. For example, people respond more favorably when they are asked if they want a system "like Medicare."[91]Advocacy groups[edit]This section needs to be updated. Please update this article to reflect recent events or newly available information. (February 2014)Physicians for a National Health Program[100] the American Medical Student Association[101] and the California Nurses Association[102] are among advocacy groups that have called for the introduction of a single payer healthcare program in the United States. A study published in the Annals of Internal Medicine found that 59% of physicians "supported legislation to establish national health insurance" while 9% were neutral on the topic, and 32% opposed it.[103]Universal health coverage by countryFrom Wikipedia, the free encyclopediaSee also: Health systems by country 58 countries with universal health care in 2009.[1]58 countries with legislation mandating universal health care, along with >90% health insurance coverage, and >90% skilled birth attendance.Main article: Universal health careUniversal health coverage 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.[2]A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004[3]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.The UN has adopted a resolution on universal health care. It may be the next stage after the Millennium Development Goals.[4]Africa[edit]Algeria[edit]Algeria operates a public healthcare system. A network of hospitals, clinics, and dispensaries provide treatment to the population, with the Social Security system funding health services, although many people must still cover part of their costs due to the rates paid by the Social Security system unchanged since 1987. The poor are generally entitled to health services free of charge, while the wealthy pay for treatment according to a sliding scale.[5][6]Botswana[edit]Botswana operates a system of public medical centers, with 98% of health facilities in the country run by the government. All citizens are entitled to be treated in public facilities free of charge, though a nominal fee of $70 is typically charged for public health services except for sexual reproductive health services and antiretroviral therapy services, which are free.[7]Burkina Faso[edit]Burkina Faso operates a scheme called Universal Health Insurance (AMU) which provides universal healthcare to citizens. It is administered by two separate bodies, one for civilians and the other for the armed forces.[8]Egypt[edit]Egypt operates a system of public hospitals and clinics through the Ministry of Health. Egyptian citizens can receive treatment at these facilities free of charge. However, those Egyptians who can afford it prefer to pay out of pocket for private healthcare.[9]Ghana[edit]Ghana operates the National Health Insurance Scheme to provide citizens with health insurance. The level of premiums citizens must pay varies according to their level of income. Most medical facilities are run directly by the Ministry of Health or Ghana Health Service.[10]Mauritius[edit]The Government of Mauritius operates a system of medical facilities that provide treatment to citizens free of charge.[11]Morocco[edit]Morocco operates a public health sector run by the government that operates 85% of the country's hospital beds. It deals mainly with the poor and rural populations, who cannot afford private healthcare. In addition, there is a non-profit health sector operated by the National Social Security Fund which covers 16% of the population. There is also a private sector for those who can afford it.[12]Rwanda[edit]Rwanda operates a system of universal health insurance through the Ministry of Health called Mutuelle de Santé (Mutual Health), a system of community-based insurance where people pay premiums based on their income level into local health insurance funds, with the wealthiest paying the highest premiums and required to cover a small percentage of their medical expenses, while those at the lowest income levels are exempt from paying premiums and can still utilize the services of their local health fund. In 2012, this system insured all but 4% of the population.[13]South Africa[edit]South Africa has a public healthcare system that provides services to the vast majority of the population, though it is chronically underfunded and understaffed, and a private system that is far better equipped, which covers the wealthier sectors of society.[14]Tunisia[edit]Tunisia operates a public healthcare system under the National Health Insurance Fund (Caisse Nationale d'Assurance Maladie). All Tunisian citizens and residents can receive treatment in state-run hospitals and clinics free of charge.[15]Asia[edit]Countries that provide public healthcare in Asia include Bhutan,[16]Bahrain,[17]China, Hong Kong, India, Iran,[18]Israel[19](see below), Jordan,[20]Kazakhstan,[21]Macau (see below), Malaysia,[22]Mongolia,[23]Oman,[24][25]Singapore, Sri Lanka,[26]Syria,[27]Taiwan (R.O.C.)[28](see below), Tajikistan,[29]Thailand (see below), Turkey,[30]and Turkmenistan[31]have universal health care.Bhutan[edit]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.[32]Hong Kong[edit]Hong Kong has early health education, professional health services, and well-developed health care and medication system. The life expectancy is 84 for females and 78 for males,[33]which is the second highest in the world, and 2.94 infant mortality rate, the fourth lowest in the world.[34][35]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 an adult to adult live donor liver transplant in 1993.[36]India[edit]India's healthcare system is dominated by the private sector, although there are various public healthcare systems like Rajiv Gandhi Jeevandayee Arogya Yojana in Maharashtra that provides free healthcare to those below the poverty line.[37][38]Currently, the majority of Indian citizens do not have health insurance, and must pay out of pocket for treatment. There are government hospitals that provide treatment at taxpayer expense. Some essential drugs are offered free of charge in these hospitals.An outpatient card at AIIMS costs a one-time fee of 10 rupees (around 20 cents U.S.) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on the financial condition of the patient and the facilities utilized, but are usually much less than the private sector. For instance, a patient is waived treatment costs if their income is below the poverty line. However, getting treatment at high quality government hospitals is very tough due to the high number of people needing healthcare and the lack of sufficient facilities.Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These hospitals provide treatment free of cost, but only if they are functional. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses.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).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.The government-run healthcare suffers from a lack of hygiene; the rich avoid the government hospitals and go to private hospitals. With the advent of privatized healthcare, this situation has changed. India now has medical tourism for people from other countries while its own poor find high-quality healthcare either inaccessible or unaffordable.The current Indian government is planning to unveil a national universal healthcare system called the National Health Assurance Mission, which will provide all Indian citizens with insurance coverage for serious illnesses, and free drugs and diagnostic treatments.[39]Israel[edit]Health care in Israel as a percentage of GDPIsrael has a system of universal healthcare as set out by the 1995 National Health Insurance Law. The state is responsible for providing health services to all residents of the country, who can register with one of the four national health service funds. To be eligible, a citizen must pay a health insurance tax. Coverage includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, preventive dental care for children, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.[40]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 headed by Shoshana Netanyahu which examined restructuring the health care system in Israel in the late 1980s. Prior to the law's passage over 90% of the population was already covered by voluntarily belonging to one of four nationwide, not-for-profit sickness funds which operated some of their own medical facilities and were funded in part by employers and the government and in part by the insured by levies which varied according to income. However, there were three problems associated with this arrangement. First, membership in the largest fund, 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 funds restricted entry to new members based on age, pre-existing conditions or other factors. Second, different funds 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 funds 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 sickness funds based on their membership and its demographic makeup. This ensured that all citizens would now have health coverage. While membership in one of the funds now became compulsory for all, free choice was introduced into movement of members between funds (a change is allowed once every six months), effectively making the various sickness funds 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 funds 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 fund 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 funds 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 began offering additional "supplementary" insurance to cover certain additional services not included in the basket. However, since this insurance is optional (though usually very modestly priced, costing the equivalent of about US$10 to $20 a month), 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.Macau[edit]Macau offers universally accessible single-payer system funded by taxes. Health care is provided by the Bureau for Health.People's Republic of China[edit]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.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 coverage 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.[41]On January 21, 2009, the Chinese government announced that a total of 850 billion yuan (US$127.5 billion) will be provided between 2009 and 2011 in order to improve the existing health care system.[42]At the end of 2008, the government published its reform plan clarifying government's responsibility by saying that it would play a dominant role in providing public health and basic medical service. It declared "Both central and local governments should increase health funding. The percentage of government's input in total health expenditure should be increased gradually so that the financial burden of individuals can be reduced," The plan listed public health, rural areas, city community health services and basic medical insurance as four key areas for government investment. It also promised to tighten government control over medical fees in public hospitals and to set up a "basic medicine system" to quell public complaints of rising drug costs.[43]The plan was passed by the Chinese Cabinet in January 2009. The long-awaited medical reform plan promised to spend 850 billion yuan by 2011 to provide universal medical service and that measures would be taken to provide basic medical security to all Chinese.[44]Singapore[edit]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.[45]Singapore currently has the second lowest infant mortality rate in the world and among the highest life expectancies from birth, according to the World Health Organization.[46]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.[47]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.[47]Taiwan[edit]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.[48]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.[49]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, dentalservices, Chinese medicine, home nurse visits and many more. 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.[50]Thailand[edit]Thailand introduced universal coverage reforms in 2001, becoming one of only a handful of lower-middle income countries to do so at the time. 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.[45]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.[51][52][53]Europe[edit]Virtually all of Europe has either publicly sponsored and regulated universal health care or publicly provided universal healthcare. The public plans in some countries provide basic or "sick" coverage only, with their citizens being able to purchase supplemental insurance for additional coverage. Countries with universal health care include Austria, Belarus,[54]Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Malta, Moldova,[55]the Netherlands, Norway, Portugal,[56]Romania, Russia, Serbia, Spain, Sweden, Switzerland, Ukraine,[57]and the United Kingdom.[58]Austria[edit]Healthcare in Austria is universal for residents of Austria as well as those from other EU countries.[59]Austria has a two-tier health care system in which many individuals receive publicly funded care; they also have the option to purchase supplementary private health insurance.Croatia[edit]Croatia has a universal health care system that provides high quality medical services and is coordinated by the Ministry of Health. The population is covered by a basic health insurance plan provided by statute and optional insurance and administered by the Croatian Health Insurance Fund. In 2012, annual compulsory healthcare related expenditures reached 21.0 billion kunas (c. 2.8 billion euro). There are hundreds of healthcare institutions in Croatia, including 79 hospitals and clinics with 25,285 beds, caring for more than 760 thousand patients per year, 5,792 private practice offices and 79 emergency medical service units.Czech Republic[edit]Czech Republic has a universal public health system paid largely from taxation. Private health care systems do co-exist freely alongside public ones, sometimes offering better quality or faster service. Almost all medical services are covered by health insurance and insurance companies, though certain services such as prescription drugs or vision and dental care are only covered partially.Denmark[edit]Denmark has a universal public health system paid largely from taxation with local municipalities delivering health care services in the same way as other Scandinavian countries. Primary care is provided by a general practitioner service run by private doctors contracting with the local municipalities with payment on a mixed per capita and fee for service basis. Most hospitals are run by the municipalities (only 1% of hospital beds are in the private sector).Finland[edit]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.[60]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%.[61]Finnish health care expenditures are below the European average.[62]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.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.Finland has a highly decentralized three-level public system of health care and alongside this, a much smaller private health-care system.[63]Overall, the municipalities (funded by taxation, local and national) meet about two thirds of all medical-care costs, with the remaining one third paid by the national insurance system (nationally funded), and by private finance (either employer-funded or met by patients themselves).[63]Private inpatient care forms about 3–4% of all inpatient care.[63]In 1999 only 17 per cent of total funding for health care came from insurance, comprising 14.9% statutory (government) insurance and 2.1% private health insurance. Spectacles are not publicly subsidized at all, although dentistry is available as a municipal service or can be obtained privately with partial reimbursement from the state.[63]The government announced in 2009 that Kela would re-imburse the cost of private dental-hygiene work, starting in 2010.[64]The percentage of total health expenditure financed by taxation in Finland (78%)[65]is above the OECD average and similar to the levels seen in Germany (77%) and France (80%) but below the level seen in the UK (87%). The quality of service in Finnish health care, as measured by patient satisfaction, is excellent. According to a survey published by the European Commission in 2000, Finland has one of the highest ratings of patient satisfaction with their hospital care system in the EU: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[66]There are caps on total medical expenses that are met out-of-pocket for drugs and hospital treatments. The National Insurance system pays all necessary costs over these caps. Public spending on health care in 2006 was 13.6 billion euros (equivalent to US$338 per person per month). The increase over 2005 at 8.2 per cent was below the OECD average of 9 percent. Household budgets directly met 18.7 per cent of all health-care costs.[67]France[edit]France has a system of universal health care largely financed by government through a system of national health insurance. It is consistently ranked as one of the best in the world.[68]Germany[edit]Germany has the world's oldest national social health insurance system,[69][70][71]with origins dating back to Otto von Bismarck's Sickness Insurance Law of 1883.[72][73]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.[74]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, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries.[75]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.[76]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).[77][78]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).[79]Greece[edit]The Greek healthcare system provides high quality medical services to insured citizens and is coordinated by the Ministry for Health and Social Solidarity. Public health services are provided by the National Healthcare Service, or ESY (Greek: Εθνικό Σύστημα Υγείας, ΕΣΥ). In 2010 there were 35,000 hospital beds and 131 hospitals in the country.The Greek healthcare system has received high rankings by the World Health Organization, ranked 14th in the overall assessment and 11th in quality of service in a 2000 report by the WHO.Guernsey / Jersey[edit]The medical care system in the Channel Islands is very similar to that of the UK in that many of the doctors and nurses have been trained from the UK health perspective. There is universal health care for residents of the islands.[80]Iceland[edit]Iceland has a universal public health system paid largely from taxation with local municipalities delivering health care services in the same way as other Scandinavian countries. Iceland's entire population has equal access to health care services.Ireland[edit]The public health care system of the Republic of Ireland is governed by the Health Act 2004,[81]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 January 1, 2005; however the new structures are currently in the process of being established as the reform program continues. In addition to the public-sector, there is also a large private health care market.Isle of Man[edit]The Isle of Man provides universal public health coverage to its residents.[82]Italy[edit]Italy has a public health care service for all the residents called "Servizio Sanitario Nazionale" or SSN (National Health Service) which is similar to the UK National Health Service. It is publicly run and funded mostly from taxation: some services requires small co-pays, while other services (like the emergency medicine and the general doctor) are completely free of charge. Like the UK, there is a small parallel private health care system, especially in the field of Dental Medicine.Luxembourg[edit]Luxembourg provides universal health care coverage to all residents (Luxembourgers and foreigners) by the National Health Insurance (CNS - Caisse nationale de santé (French) or National Gesondheetskeess (Luxembourgish)) which is funded by mandatory contributions of employers and the workforce and by government subsidies for insuring jobseekers, the poor and for financing medical infrastructure. It exists as well a mandatory public long-term care insurance.[83][84]Netherlands[edit]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.[45]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 not 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. There is a fixed yearly threshold of €375 for each adult person, excluding first visits for diagnosis to general physicians.Norway[edit]Norway has a universal public health system paid largely from taxation in the same way as other Scandinavian countries. Norway's entire population has equal access to health care services. The Norwegian health care system is government-funded and heavily decentralized. The health care system in Norway is financed primarily through taxes levied by county councils and municipalities. Dental care is included for children until 18 years old, and is covered for adults for some ailments.[85]Norway regularly comes top or close to the top of worldwide healthcare rankings.Portugal[edit]Portugal's National Healthcare Service, known nationally as Serviço Nacional de Saúde (SNS), is a universal and free healthcare service, provided nationwide since 1979, and is available to both Portuguese and foreigner residents. In 2014, Portugal SNS ranked 13th best healthcare service in Europe.[86]The National Medical Emergency Institute (INEM) is the main emergency medical serviced and can be activated by calling 112.Romania[edit]According to Article 34 of the Constitution of Romania, the state is obliged "to guarantee the protection of healthcare". Romania has a fully universal health care system, which covers up medical check-ups, any surgical interventions, and any post-operator medical care, as well as free or subsidized medicine for a range of diseases. The state is also obliged to fund public hospitals and clinics. Dental care is not funded by the state, although there are public dental clinics in some hospitals, which treat patients free of charge. However, due to inadequate funding and corruption, it is estimated that a third of medical expenses are, in some cases, supported by the patient.[87][clarification needed]Furthermore, Romania spends, per capita, less than any other EU state on medical care.Russia and Soviet Union[edit]In the Soviet Union, the preferred term was "socialist medicine"; the Russian language has no term to distinguish between "socialist" and "socialized" (other than "public", Rus: obshchestvenniy/общественный, sometimes "collectivized" or "nationalized", Rus: obobshchestvlenniy/обобществленный).[88][89]Russia in Soviet times (between 1917 and the early 1990s) had a totally socialist model of health care with a centralised, integrated, hierarchically organised with the government providing free health care to all citizens. Initially successful at combating infectious diseases, the effectiveness of the socialized model declined with underinvestment. Despite a doubling in the number of hospital beds and doctors per capita between 1950 and 1980, the quality of care began to decline by the early 1980s and medical care and health outcomes were below western standards.The new mixed economy Russia has switched to a mixed model of health care with private financing and provision running alongside state financing and provision. The OECD reported that unfortunately, none of this has worked out as planned and the reforms have in many respects made the system worse.[90]The population's health has deteriorated on virtually every measure. The resulting system is overly complex and very inefficient. It has little in common with the model envisaged by the reformers. Although there are more than 300 private insurers and numerous public ones in the market, real competition for patients is rare leaving most patients with little or no effective choice of insurer, and in many places, no choice of health care provider either. The insurance companies have failed to develop as active, informed purchasers of health care services. Most are passive intermediaries, making money by simply channelling funds from regional OMS funds to healthcare providers.Article 41 of the Constitution of the Russian Federation confirms a citizen's right to state healthcare and medical assistance free of charge.[91]This is achieved through state compulsory medical insurance (OMS) which is free to Russian citizens, funded by obligatory medical insurance payments made by companies and government subsidies.[92][93]Introduction in 1993 reform of new free market providers in addition to the state-run institutions intended to promote both efficiency and patient choice. A purchaser-provider split help facilitate the restructuring of care, as resources would migrate to where there was greatest demand, reduce the excess capacity in the hospital sector and stimulate the development of primary care. Russian Prime Minister Vladimir Putin announced a new 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.[94]He also said that obligatory medical insurance tax paid by companies will increase from current 3.1% to 5.1% starting from 2011.[94]Serbia[edit]The Constitution of the Republic of Serbia states that it is a right of every citizen to seek medical assistance free of charge.[95]This is achieved by mutual contribution to the Compulsory Social Healthcare Fund of RZZO (Republički Zavod za Zdravstveno Osiguranje or National Health Insurance Institution). The amount of contribution depends on the amount of money the person is making. During the 1990s, Serbia's healthcare system has been of a poor quality due to severe underfunding. In the recent years, however, that has changed and the Serbian government has invested heavily in new medical infrastructure, completely remodeling existing hospitals and building two new hospitals in Novi Sad and Kragujevac.Sweden[edit]Sweden has a universal public health system paid largely from taxation in the same way as other Scandinavian countries. Sweden's entire population has equal access to health care services. The Swedish public health system is funded through taxes levied by the county councils, but partly run by private companies. Government-paid dental care for children under 21 years old is included in the system, and dental care for adults is somewhat subsidised by it.Sweden also has a smaller private health care sector, mainly in larger cities or as centers for preventive health care financed by employers.Sweden regularly comes in top in worldwide healthcare rankings.[96]Switzerland[edit]Healthcare in Switzerland is universal and is regulated by the Federal Health Insurance Act of 1994. Basic health insurance is mandatory for all persons residing in Switzerland (within three months of taking up residence or being born in the country). Insurers are required to offer insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans.[97]United Kingdom[edit]Each of the Countries of the United Kingdom has a National Health Service that provides public healthcare to all UK permanent residents that was originally designed to be free at the point of need and paid for from general taxation; but changes included introducing charging for prescription medicines and dentistry (those below 16 and those on certain benefits may still get free treatment). However, since Health is now a devolved matter, considerable differences are developing between the systems in each of the countries as for example Scotland abolished prescription charges.[98]Private healthcare companies are free to operate alongside the public one.England[edit]Norfolk and Norwich University Hospital, a National Health Service hospital.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.[99]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. Waiting times are low, with most people able to see their primary care doctor on the same day or the following day.[100]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 the like (e.g., child birth).[101]One of the main goals of care management is to ensure that patients do not experience a delay of more than 18 weeks from initial hospital referral to final treatment, inclusive of time for all associated investigative tests and consultations.102]At present, two-thirds of patients are treated in under 12 weeks.[103]Although centrally funded, the NHS is not managed by a large central bureaucracy. 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, certain students in full-time education, the elderly, the unemployed and those on low incomes). Around 89 pc of NHS prescriptions are obtained free of charge, mostly for children, pensioners, and pregnant women. Others pay a flat rate of £8.20,[104]and others may cap their annual charges by purchasing an NHS Prescription Prepayment Certificate. 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.[105]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.[106]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[107]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 (in the short term) increasing the public sector borrowing requirement, because long-term contractually obligated PFI spending commitments are not counted as government liabilities.Northern Ireland[edit]Health and Social Care in Northern Ireland is the designation of the national public health service in Northern Ireland.Scotland[edit]The Royal Aberdeen Children's Hospitalis a specialist children's hospital within NHS Scotland.NHS Scotland, created by the National Health Service (Scotland) Act 1947, was also launched on 5 July 1948, although it has always been a separate organization. Since devolution, NHS Scotland has followed the policies and priorities of the Scottish Government, including the phasing out of all prescription charges by 2011.[citation needed]Wales[edit]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,[108]in turn being transferred under devolution to what is now the Welsh Government.North America[edit]The Bahamas,Barbados, Canada, Costa Rica, Cuba, Mexico, Panama, and Trinidad and Tobago all provide some level of universal health coverage.The Bahamas[edit]The Bahamas approved the National Health Insurance Act in August 2016. The legislation allows for the establishment of a universal health coverage system that will begin with universal coverage of primary health care services and later expand to include a wide set of benefits including all specialized care. The system will all for universal coverage of a basic benefit package and for voluntary insurance to be purchased as a top up policy to cover services or amenities that are not included in the government plan.[109]Canada[edit]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."[110]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.[111]About 29% of Canadians' health care is paid for by the private sector or individuals.[112]This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and vision care.[113]Many Canadians have private health insurance, often through their employers, that cover these expenses.[114]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.[115][116]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.Costa Rica[edit]Universal healthcare and pensions are run by the Caja Costarricense de Seguro Social (CCSS). In 1941, Costa Rica established Caja Costarricense de Seguro Social (CCSS), a social security insurance system for wage-earning workers. In 1961, coverage was expanded to include workers’ dependents and from 1961 to 1975, a series of expansions extended coverage for primary care and outpatient and inpatient specialized services to people in rural areas, the low-income population, and certain vulnerable populations. Further expansions during the late 1970s extended insurance coverage to farmers, peasants, and independent contract workers. Additionally, CCSS mandates free health service provision to mothers, children, indigenous people, the elderly, and people living with disabilities, regardless of insurance coverage. By 2000, 82 percent of the population was eligible for CCSS, which has continued to expand in the ensuing period. By covering all population groups through the same system, Costa Rica has avoided social insurance stratification and inequity common in many other countries in the region.[117]CCSS is funded by a 15 percent payroll tax, as well as payments from retiree pensions [6]. Taxes on luxury goods, alcohol, soda, and imported products also help to cover poor households who do otherwise pay into the system. All CCSS funds are merged into a single pool, which is managed by the central financial administration of CCSS. In 1973, the Ministry of Health decided to move away from direct service provision and adopt a steering role. Responsibility for the provision of most care was transferred to the CCSS, although the Ministry retained responsibility for disease control, food and drug regulation, environmental sanitation, child nutrition, and primary care for the poor. Through the CCSS, health care is now essentially free to nearly all Costa Ricans. Private health care is also widely available and INS offers private health insurance plans to supplement CCSS insurance.[118]Cuba[edit]The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of all its citizens. There are no private hospitals or clinics as all health services are government-run. The present Minister for Public Health is Roberto Morales Ojeda. However, although the coverage is wide, the system is underfunded and recently also understaffed. The government organized medical missions in other countries has taken a very significant amount of doctors and other personal. In 2005 there were 25000 Cuban doctors only in Venezuela.Mexico[edit]Public health care delivery is accomplished via an elaborate provisioning and delivery system instituted by the Mexican Federal Government. Public health care is provided to all Mexican citizens as guaranteed via Article 4 of the Constitution. Public care is either fully or partially subsidized by the federal government, depending on the person's (Spanish: derechohabiente's) employment status. All Mexican citizens are eligible for subsidized health care regardless of their work status via a system of health care facilities operating under the federal Secretariat of Health (formerly the Secretaria de Salubridad y Asistencia, or SSA) agency. Employed citizens and their dependents, however, are further eligible to use the health care program administered and operated by the Instituto Mexicano del Seguro Social (IMSS) (English: Mexican Social Security Institute). The IMSS health care program is a tripartite system funded equally by the employee, its private employer, and the federal government. The IMSS does not provide service to employees of the public sector. Employees in the public sector are serviced by the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) (English: Institute for Social Security and Services for State Workers), which attends to the health and social care needs of government employees. This includes local, state, and federal government employees. The government of the states in Mexico also provide health services independently of those services provided by the federal government programs. In most states, the state government has established free or subsidized healthcare to all their citizens.On December 1, 2006, the Mexican government created the Health Insurance for a New Generation also known as "life insurance for babies".[119][120][121]On May 16, 2009, Mexico to Achieve Universal Health Coverage by 2011.[122]On May 28, 2009, Mexico announced Universal Care Coverage for Pregnant Women.[123]On August 2012 Mexico installed a universal healthcare system.[124]Trinidad and Tobago[edit]Main article: Healthcare in Trinidad and TobagoA 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[edit]Main article: Patient Protection and Affordable Care ActSee also: Health care reform in the United States and Health care in the United StatesThe United States does not have a universal health care system. However, the Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act of 2010, seeks to have expanded insurance coverage to legal residents by 2014. It provides for federally mandated health insurance to be implemented in the United States during the 2010–2019 decade with the Federal government subsidizing legal resident households with income up to 400% of the Federal poverty level.[125]This threshold varies according to State and household size, but for an average family of four, subsidies would be available for families whose income was about $88,000 or lower.[126]In June 2010 adults with pre-existing conditions became eligible to join a temporary high-risk pool.[127]In 2014, applicants of the same age began to be able to obtain health insurance at the same published rate regardless of health status — the first time in U.S. history that insurers no longer had the right to load the premium or deny coverage prior to contract, or cancel a policy after contractdue to an adverse health condition, or test result indicating that one may be imminent. The law prohibits insurers from capping their liability for a person's health care needs, a move which is expected to rectify medically induced bankruptcy. As of April 13, 2015, the U.S. uninsured rate fell to 11.9% from the 17.1% recorded at the end of the fourth quarter of 2013. This is the lowest quarterly average recorded since Gallup and Healthwaysbegan tracking the percentage of uninsured Americans in 2008. Gallup attributed this sharp decline to the Affordable Care Act's requirements for most Americans to have healthcare in the beginning of the first quarter of 2014.[128]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,[129]partly from the elimination of insurance company overhead costs.[130]In 2009, a universal health care proposal was pending in Congress, the United States National Health Care Act (H.R. 676, formerly the "Medicare for All Act").The Congressional Budget Office (CBO) estimated that the bill would reduce the number of nonelderly people who are uninsured by about 32 million, leaving about 23 million nonelderly residents uninsured (about one-third of whom would be illegal immigrants). Under the legislation, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent in 2010 to about 94 percent by 2019.[131]In May 2011, the state of Vermont became the first state to pass legislation establishing a single-payer health care system. The legislation, known as Act 48, establishes health care in the state as a "human right" and lays the responsibility on the state to provide a health care system which best meets the needs of the citizens of Vermont. The proposal was shelved not long after the main provisions of the law took effect in 2014.[132]A revised estimate in July 2012 by the CBO stated 30 million people would gain access to health insurance under the law.[133]Discussion in the United States commonly uses the term socialized medicine to impart a pejorative meaning to the idea of universal health care.South America[edit]Argentina, Brazil, Chile, Colombia, Peru, Uruguay, and Venezuela all have public universal health care provided.Argentina[edit]Health care is provided through a combination of employer and labor union-sponsored plans (Obras Sociales), government insurance plans, public hospitals and clinics and through private health insurance plans. It costs almost 10% of GDP and is available to anyone regardless of ideology, beliefs, race or nationality.Brazil[edit]The universal health care system was adopted in Brazil in 1988 after the end of the military regime's rule. However, universalized/socialized health care was available many years before, in some cities, once the 27th amendment to the 1969 Constitution imposed the duty of applying 6% of their income in healthcare on the municipalities.[134]Chile[edit]Health care in Chile is provided by the government (via Fonasa) and by private insurers (via Isapre). All workers and pensioners are mandated to pay 7% of their income for health care insurance (the poorest pensioners are exempt from this payment). Workers who choose not to join an Isapre, are automatically covered by Fonasa. Fonasa also covers unemployed people receiving unemployment benefits, uninsured pregnant women, insured worker's dependant family, people with mental or physical disabilities and people who are considered poor or indigent.Fonasa costs vary depending on income, disability or age. Attention at public health facilities via Fonasa is free for low-income earners, people with mental or physical disabilities and people over the age of 60. Others pay 10% or 20% of the costs, depending on income and number of dependants. Fonasa beneficiaries may also seek attention in the private sector, for a designated fee.Additionally, there are a number of high-mortality illnesses (currently 69) that have special attention guarantees for both Isapre and Fonasa affiliates, in relation to access to treatment, waiting times, maximum costs and quality of service.Colombia[edit]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.Peru[edit]On April 10, 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).[135][136]On April 2, 2010, President Alan Garcia Perez on Friday signed a supreme ordinance approving the regulations for the framework law on the Universal Health Insurance, which seeks to provide access to quality health care for all Peruvian citizens.Peru's Universal Health Insurance law aims to increase access to timely and quality health care services, emphasizes maternal and child health promotion, and provides the poor with protection from financial ruin due to illness.[137]The regulation states that membership of the Universal Health Insurance (AUS for its Spanish acronym) is compulsory for the entire population living in the country. To that end, the Ministry of Health will approve, by supreme ordinance, the mechanisms leading to compulsory membership, as well as escalation and implementation.[138]Oceania[edit]Australia and New Zealand have universal health care.Australia[edit]In Australia, Medibank — as it was then known — was introduced, by the Whitlam Labor government on July 1, 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.[139]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.[140]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.[45]New Zealand[edit]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%.[45]

Traditionally, Indians are consumerists. Every Indian female and male, regardless of age and income, is preoccupied with acquisition of consumer goods- both durable and consumable.Statistics from various Indian and foreign sources revealed, India’s consumer spending stood at whopping Rs.17.05 billion during third quarter of financial year 2017-2018.In a country of 1.3 billion citizens, where 21.9 percent live below poverty line, this large consumer spend is quite high.Casualty countCommercials on TV, newspapers, radio, street-side hoardings, special offers at stores, discounts given by restaurants, boom in online shopping are leading to surge in spending and decline in saving patterns of Indians.According to figures for fiscal year 2015-2016, provided by the Ministry of Statistics Programs and Information, savings by households fell to 31.6 percent from the 32.3 percent in the previous year.This clearly indicates, saving money is the main casualty of India’s rising consumerism and that’s the reason you should save money India.Reality checkBy the above statement, we do not blame consumers or their spending patterns. Consumerism is healthy for Indians since it helps them improve lifestyle. It keeps companies in business and helps them expand, generating more jobs.However, there are some excellent ways and means to save money in India. Below, we take a look at some of these :Ways to Save Money for StudentsAs student, there is not much to worry about. All your expenses will be met by mom and dad or your guardian. Also as student, you are not required to look deep into family finances or savings and investment related issues. However, here are some ways you can save money for your parents;1. Back-To-School salesGenerally, Back-To-School sales are held twice a year by large stores selling student requirements such as schoolbags, stationery and books. You can avail discounts while buying the stuff during sales for a savings of between 10 percent and 20 percent on actual price.2. Cooperative storesCooperative stores in villages, towns and cities sell notebooks and stationery at cheaper rates at the beginning of school seasons. You can save between five and 10 percent of expenses you would otherwise incur on buying elsewhere.3. Free books & stationeryCharity organizations in India give away free notebooks, stationery and sometimes, schoolbags to students. You can avail of these freebies and save money.4. ScholarshipsStudy well for a great future, excel in your class and get scholarships offered by your school or some external source. They help your parents save on fees and other expenses.5. TravelAs student, you can avail discounted travel on government run bus services, Indian Railways, state-owned and private airlines. Buy a bus or train pass for your daily commute to save as high as 50 percent to 75 percent of your transportation costs.6. Used text booksOpt for used text books sold by students who graduate to a higher class. However, ensure they are relevant and conform fully to the syllabus. You can save between 50 percent and 70 percent of the cost you would incur on new text books.7. Packed breakfast and lunchTaking the ubiquitous ‘Tiffin’ box to your school or college containing breakfast and lunch from home will save you unnecessary expenses of eating at a canteen or restaurant. Homemade food is any day healthier than stuff from canteens and restaurants.8. Save money through Midday mealsShould you be studying at a school that offers free midday meals, avail the facility. Regardless of whether you eat or not, the supplier charges the state government for your food. Hence, there is no point in letting go what your parents have paid for, through taxes.9. Junior bank accountsMost banks encourage saving habits among students by offering special banking products. You can open such an account to save part of your pocket money. Having such an account also helps you learn basic ropes of banking.10. Health & fitnessKeep yourself healthy and fit by engaging in outdoor sports and other physical activity rather than becoming a couch potato watching TV, glued to smart phone or computer. While enjoying great health, you will also help save expenses on medical treatment required to treat ailments triggered by sedentary lifestyle.Save money ideas for TeenagersUnderstandably, teenage is the best part of life, when you want to enjoy. Money should not be a constraint. You can still use some technique that help school students save money like buying travel pass, opening bank account, health and fitness and availing scholarships. Yet, here are some more ideas to help you save money.11. Save money by shopping onlineRemember, online stores offer everything you need, from cosmetics to garments, smart phones to electronic gadgets. Invariably, these cost 10 percent to 25 percent lesser than at stores. Look for online sales too, for more savings.12. Save money with Group travelAs teenager, you will be tempted to travel around with friends and classmates. Booking airline, bus and rail tickets for student groups helps you save as much as 50 percent fare.13. Youth hostelsAs teenager, you are entitled to membership of various international organizations including Hostelling International, Young Men’s Christian Association (YMCA) and Young Women’s Christian Association (YWCA). Now, YMCA and YWCA are not religious organizations, so your faith does not matter. Memberships of these organizations will help you stay cheap while away from home, in a group or alone.14. Share vehiclesOne way of fostering friendship is to share rides with friends. You can either ride on a friend’s motorbike or car or simply take them on yours. Sharing fuel costs is a great way to save money.15. No addictionsResearch worldwide proves, teenagers are most likely to develop addictions to drugs, alcohol, tobacco as well as movies, social media, gambling and sex. These will take a heavy toll on your pocket money and leave you craving for more. Staying off these addictions is beneficial to your physical, mental and financial wellbeing.16. Personal hygieneOne of the main causes of pimples, acne and other skin problems during teenage is poor body hygiene. Rather than spend heavily on expensive crèmes and lotions that have dubious results, maintain high level of personal hygiene. It is advisable for females to use sanitary pads rather than suffer from infection that requires expensive treatment.17. Choose cosmeticsAll cosmetics, beauty and skincare product manufacturers target teenagers as customers. Choose your cosmetics wisely by ensuring they suit your skin type. Rapid hormonal changes impact your skin too.Hence, crème or lotion that suits you today may prove useless a few days later. You can buy smaller packs. This way, you will save money that would be otherwise spent on useless cosmetics.18. Effective time managementAs teenager, you want to do a dozen things in a few hours. Hence, the tendency to rush between places by hopping on cabs and rickshaws. With effective time management and proper schedules, you can save a lot of money otherwise spent on taxis while using public transport.19. Learn to bargainBargaining is a vital skill you need to learn as teenager, while buying anything in the market. Remember, most vendors, especially those operating on sidewalks, add a premium when they quote a price. Bargaining will help you get the stuff at the right price while saving money. It is also an essential life skill.20. Budget your pocket moneyMake a monthly budget about how you intend to spend your pocket money. There are several free mobile apps available that help you set limits on how much you spend and where. These apps will also indicate where you can curb expenses to save money.How can housewives/ working women can save moneyWhether you are full-time housewife or working, there are several avenues where you can save a lot of money. Housewives generally manage most critical functions like shopping for food and cooking as well as planning the family budget. Here are some tips to help save money.21. Sales & special offersMajor stores frequently hold a sale offering regular groceries at prices that are five to 10 percent below the market average. You can buy such discounted stuff from one or more stores to save money. Also, look for special offers and new launches.Special offers such as Buy-1-Get-1 free and the likes helps save money provided you are cautious enough to check production and expiry dates of the product. Newly launched products are sold much cheaper than their well established counterparts.22. Save money with loyalty programsSubscribe to every loyalty program offered by stores where you shop and banks where you hold an account. You get loyalty points for money you spend at the store. These can be redeemed for groceries and other stuff.Loyalty points from banks helps you buy things for the house. Online shopping for groceries and other household essentials is a great way to save money, provided they give free home delivery. Cooperative stores also offer stuff at prices slightly lower than others.23. Save money through bulk shoppingInvite your neighbors, relatives and friends to form a group and buy your household needs in bulk from wholesalers. You can save as much as five to 20 percent on your purchases.Additionally, you will also save transportation costs since the wholesaler will deliver your stuff home.24. Electricity billsEnsure all appliances, electronics and lights in your house are switched off, while not in use. Also, have power guzzling electric bulbs replaced with low energy consuming fluorescent tubes and bulbs. Adjust proper temperature of your refrigerator, since they account for high electricity usage.25. Pay bills immediatelyAll utilities and service providers charge a penalty for paying bills after the due date. This can vary from Rs.10 to Rs. 250, depending upon the service and its provider. Paying immediately helps avoid this penalty, gives you a better credit score with the provider and avoids undue disconnection and reconnection charges.However, if there is a dispute, bring it to the notice of the service provider immediately. Instant action will save you considerable money at times.26. Delegate choresHiring a domestic helper to do household chores such as cleaning the home, washing utensils and doing laundry is fine. However, domestic helpers cost anything between Rs.3, 000 to Rs. 5,000 per month for an hour’s work daily. Instead, delegate such chores to your spouse and kids. The money saved can be better utilized for the family. Doing household task together also develops team spirit.27. Avoid food wastageIndia has the dubious distinction of wasting more food than the entire population of UK consumes. This too at a time when about 13 percent of the world’s population is starving while millions remain undernourished. Food wastage is the biggest contributor that causes families to save less.You can effectively save thousands of Rupees every year by planning every meal. Cook prudently, ensuring that nothing gets leftover. Freeze leftovers immediately and consume them at the first available opportunity.28. Family travelBook family travel tickets well in advance. Airlines offer very low rates to early birds who book tickets for any route. Prices rise as the date of travel nears. Long distance trains get booked quickly and you may have to pay more for tickets under the ‘Tatkal’ scheme of the Indian Railways. Bus operators follow the same system as airlines. Buying in advance, once your family finalizes dates, helps you save thousands of Rupees on your holiday.29. Keep pests awayRodents tend to damage expensive furniture and electronics, while insects can spread disease. Their presence is disgusting and speaks ill about your housekeeping skills to visitors. Nowadays, pest control is available at fairly economical rates, especially if you sign an annual maintenance contract. This expense will help you save a lot of money that would otherwise be spent on replacing or repairing furniture and appliances or medical treatment.30. Subscribe to saving schemesAn old axiom says: Income minus Savings equals Expenses. Therefore, subscribe to a saving schemes few that will force you to keep money aside. You can apply this to your personal income as well as that of the entire family. We do not imply you live a miserly life or cut corners on reasonable expenses, for the sake of savings.Astute budgeting, control over expenses will help you chart a savings plan for the family. Pigmy banks, whose representatives come home to collect a daily amount, are an excellent option, provided the service is provided by a reputed, Public Sector Undertaking (PSU) bank.Save money ideas for working menSingle men who work generally have cavalier approach towards money. Au contraire, married men are considered as head of the family and hence, have lots of obligations, including financial ones, towards spouse and kids. Whatever your civil status, here are some tips that can help you save some money or stretch your Rupee a little longer.31. Travel passes/ vehicle poolUnless you are fortunate to have a company vehicle or fuel allowance from the employer to afford driving a car to work, dependence upon public transport will be heavy. You can save costs on public transport by buying bus and railway passes of longer durations such as three months. They offer a savings of at least 20 percent to 25 percent over monthly passes. Vehicle pooling is another great way to save transportation costs.32. Office mealsAgain, few are lucky to have canteens offering subsidized meals at workplace. However, working men in large and small cities can avail of ‘Tiffin’ meals available from various providers to suit your palate. These meals are fairly reasonably priced when compared to dining at restaurants. It also saves the hassle of carrying a lunch box whose contents may get spoilt by the time you reach office causing food wastage.33. Home maintenanceAs head of the household, you can save lots of money by paying some attention every week to electrical, plumbing and structural condition of your home. Having any defects or problems repaired immediately will help you save money. Putting them off for later means allowing the problem to worsen, leading to expensive repairs.34. Mobile plans for familyNowadays, all major mobile service providers offer special family plans. Meaning, every member of your family enjoys discounted or free calls and Internet services on mobile for a fixed monthly fee. You can save a lot on mobile and Internet bills by subscribing to a family plan.35. Family health insuranceMedical inflation in India has risen by almost 30 percent over the last decade. Though your family enjoys great health, it is prudent to buy a family health insurance plan. Several Public Sector Undertaking (PSU) banks offer health insurance schemes for individuals and families at throwaway prices. Avail of these to prevent sudden expenses on any unforeseen medical emergency.36. Minor creditMinor credit availed from tea and coffee suppliers at workplace, cigarette and tobacco vendors often cause you to spend more than you intend. Firstly, these sellers do not keep proper records of your actual consumption and charge you based on their estimates. Secondly, minor credit tempts us to consume more regardless of the impact such stuff has on health. Avoiding minor credit is a great way to save cash in India.37. IroningThis is a sphere where all men can save lots of money. Having your family’s clothes ironed at a laundry may not be quite expensive. However, you can save this expense by performing the task yourself once a week. The few hundred Rupees you save can be better utilized elsewhere for investment.38. Home tutoringFor married men with kids, home tutoring is a task they can easily perform. Here, we talk of children who are school students and not enrolled for higher education that requires specialized coaching. As father, you can help your kids revise lessons and conduct occasional tests. This way, you can save a lot on expensive coaching classes, where children of working parents are compelled to go nowadays.39. Bill monitoringEvery household receives a plethora of bills every month. As head of the household, you can check these bills for any errors and mistakes that have caused you to be charged more. It is fairly common for electricity, piped gas, mobile services and landline providers to charge more due to flaws in their billing system or wrong readings. Checking your monthly bills before payment will help you to save money.40. Clearing liabilitiesSometimes, we are forced to take one or more liabilities on board, in form of loans and credit for home, vehicle or other purposes. Get rid of these liabilities at the earliest by stepping up installments, if possible.This will help you get debt free faster and get a high credit score. Further, you can also negotiate a lower interest rate with the lender for stepping up payments, thus saving you several thousands of Rupees you would have spent over years.Best ways to save money for everyoneHere are some more useful tips that can save you money. Further, you can also make this saved money to work for you in the stock market, saving schemes or other hedged investments.41. Avoid credit cardsA credit card attracts something called annual membership fee which can be anything from Rs.200 to Rs.2, 000 per annum. Some banks waive the first year membership to entire subscribers. Buying on credit cards is fine but pay entire amount. You can pay about 10 percent of the spent amount ever month.However, the unpaid amount attracts interests that can go as high as 28 to 30 percent per annum every year. The interest charged by the credit card issuer this month also attracts additional interest the next month and so on.Meaning, you may end up paying more interest than the credit amount. Credit cards are notorious for sending perfectly sane people on shopping binges.42. Dispose junkEvery household has junk in the form of old newspapers and clothes, damaged furniture, irreparable appliances, metal scrap and whatever more. Dispose off your junk regularly. It will get you a few Rupees. You can give it away free or dump in some trashcan. Keeping junk at homes can prove expensive.It provides ideal breeding ground for insects, rodents and disease causing microbes while robbing the home of its clean and aesthetic looks. You will also prevent expenses on inadvertent injuries and other health issues caused by household junk.43. Socialize wiselySelect the circle of friends you and your family wish to socialize with. Trying to get friendly with the wealthy can force you to spend more to appear as their peer. On the other hand, poor people will try and borrow money from you they can never repay. In both situations, you lose money. Remember, adult women and men are equally susceptible to fall prey to addictions, should you have the misfortune of socializing with the wrong people.44. Discount vouchers/ Cash backOnline retailers as well as physical stores offer discount vouchers for spending a particular amount. You can find these coupons & deals on CouponWaale.in. OR any other websites. Avail these discount vouchers and cash-back coupons to use for future shopping. They can help you save as much as 50 percent of the bill, the next time you shop.45. Cash withdrawalsConsidering you already hold a bank account, here are some tips for saving money. Acquaint yourself with the bank’s policy for use of debit cards at Point-Of-Sale machines, online purchases and ATM machines of other banks.Better learn about their overall policy regarding cash withdrawal. Some banks permit only five withdrawals per month, regardless whether you spend at POS, online or withdraw from ATMs of other banks or make a cheque payment.Others allow five free withdrawals from other bank ATMs while future ones are charged. Some banks also charge for more than five withdrawals at their own ATMs. The charge can vary between Rs 18 and Rs.25 per transaction.46. Ensure minimum balanceNowadays, banks are rather rigid about the minimum balance required to be maintained in your account. If this amount goes below the minimum required for any reason, including service charges levied by the bank itself- you will be charged a penalty.Of course, the bank sends you an SMS alert or email, if you have subscribed to the facility. Otherwise, you can lose anything from Rs.10 per day to Rs.75 per month, depending upon the bank, should your minimum balance drop. Ensure that you retain the minimum balance and save money.47. Tax savingsThe India government offers a variety of schemes that helps people save on Income Tax. These include investing in postal savings schemes, insurance policies and lots more.Check with an experienced Chartered Accountant about which schemes you can avail of to save money that would otherwise be paid as tax. Generally, these tax-saving investments fetch you reasonable interest.48. Shopping listIt is a good idea to ask every member of your family whether they require anything specific before going to shop. Also, take stock of all the essentials and household requirements you have and make a list based upon anticipated usage. This saves you vital money that would otherwise be spent on random shopping based on guesswork.49. Vehicle maintenanceA critical area where you can save lots of money is maintenance of your two-wheeler or four-wheeler. Ensure you change the engine oil and filter at intervals stipulated by the manufacturer.Also, keep tires inflated to the right pressure. This helps save fuel. Maintain brakes, gears and steering since they can prevent any accidents.50. Bars & restaurantsOf course, you should occasionally enjoy with family and friends at a bar or restaurant. However, a lot of bars and restaurants do not mention taxes they intend to charge on the final bill.The situation has worsened after implementation of Goods and Services Tax (GST) by the Central government and its localized versions by state government. A lot of issues related to GST levy by restaurants are still unclear.Before dining out, find out how much taxes and service charges the bar or restaurant levies. There are instances when taxes and service charges have been almost 30 percent of the total cost of food and drink.Ways to Save money for Retired/ Senior CitizensFor those lucky to draw pensions, saving money after retirement or as senior citizens may sound weird. However, saving money is equally important for retirees and the elderly, regardless of the wealth they have accumulated, pensions and income from other sources.To save money as retiree or senior citizen, avail of all discounts and rebates in taxes that are currently prevailing in India.51. Buy health insuranceThe best time to buy health insurance is while working. This way, you have a policy that covers any sudden illnesses typical with ill-health. The reason we recommend buying medical or health insurance prior to retirement is, most insurers do not provide the facility to people above a specific age group.Every insurer has a different age after which they do not issue health policies. Further, to cover a broader range of illnesses, your policy needs to be taken at least three years or more.The good news is, nowadays lots of insurers are also offering medical insurance policies for senior citizens. Cashless health insurance shields you against spending your hard earned cash or digging into lifetime savings.52. Never relocateMillions of people believe that retiring to native village or town will help them save expenses while providing a relaxed retired life. This is a pure myth. Firstly, relocating from the city or town where you have worked involves buying a house.Even if you own a house or ancestral property, relocation costs can prove high. Secondly, relocation means bidding adieu to old friends, colleagues and relatives.Making new friends and acquaintances takes time and also involves expenses. You also become susceptible to crimes against senior citizens in such places and may end up being defrauded of cash and valuables.53. Buy Holiday Savings PlanObviously, as retiree, you would wish to travel and explore various destinations in the abundant spare time. Holidays cost a lot of money. In recent years, a lot of banks and travel agents are offering holiday savings schemes.This means, you put invest book a holiday package and pay for it over a period of six to 12 months. Upon payment of the last installment, you can utilize the holiday package and travel.Your investment in these plans attracts an interest. Hence you actually pay much lesser for that dream holiday.54. Post Office Saving SchemesIndia Post offers two excellent saving plans for retirees: Senior Citizens Saving Scheme(SCSS) and Monthly Income Scheme (MIS). While SCSS has a lock-in period of five years, it offers you a great rate of 8.3 percent compounded interest per annum.This means, the money you receive as retirement benefits from your employer, works for you. Another safe way to make your lifetime savings or retirement benefits work for you is by investing in India Post’s Monthly Income Scheme (MIS), which holds immense benefits.A single investor, you can deposit a maximum of Rs.450,000 in the scheme or Rs.900,000 if you include your spouse or kids in the account.At a rate of 7.5 percent per annum, you get a monthly income from the post office, paid directly into your savings account. Alternatively, you can invest the same in a Recurring Deposit account through direct debit order.55. Avail Senior Citizen benefitsAlmost every Indian state offers a host of benefits to senior citizens. This ranges from discounted travel on state-transport buses and those operated by municipal bodies. Additionally, you get great discounts on airline and railway tickets, medical expenses at government hospitals and lots more.Some states like Goa offer a monthly pension of Rs.2,000 for women aged 58 years and above and men of 60 years or more. However, these benefits are available only if you register as senior citizen with the concerned department of the state government and procure the Senior Citizen Card which is issued free of cost.Indian government’s helpThe good news however is, the Indian government has launched two portals for Indian citizens, where consumers can lodge grievances against any service provider or company. One is for public grievances and another for consumer complaints. Acquaint yourself with consumer protection laws to save money in your daily living.Source : MainI hope you got your answer…

The six major government health care programs—Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program—provide health care services to about one-third of Americans. The federal government has a responsibility to ensure that the more than $500 billion invested annually in these programs is used wisely to reduce the burden of illness, injury, and disability and to improve the health and functioning of the population. It is imperative that the federal government exercise strong leadership in addressing serious shortcomings in the safety and quality of health care in the United States.RECOMMENDATION 1: The federal government should assume a strong leadership position in driving the health care sector to improve the safety and quality of health care services provided to the approximately 100 million beneficiaries of the six major government health care programs. Given the leverage of the federal government, this leadership will result in improvements in the safety and quality of health care provided to all Americans.Suggested Citation:"2 Overview of the Government Health Care Programs." Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press. doi: 10.17226/10537.The six major government health care programs serve older persons, persons with disabilities, low-income mothers and children, veterans, active-duty military personnel and their dependents, and Native Americans. Three of these programs—Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP)—were devised for groups for whom the health care market has historically failed to work because of their high health care needs and low socioeconomic status. The remaining three programs—DOD TRICARE, VHA, and IHS—serve particular populations with whom the federal government has a special relationship, respectively, military personnel and their dependents, veterans, and Native Americans.Many millions of Americans receive services through multiple government programs simultaneously. Low-income Medicare beneficiaries who qualify for both Medicare and Medicaid account for 17 percent of the Medicare population and 19 percent of the Medicaid population (Gluck and Hanson, 2001; Health Care Financing Administration, 2000). These “dual eligibles” account for a total of 28 percent of Medicare expenditures and 35 percent of Medicaid expenditures. Native Americans eligible to receive services through IHS may also qualify for Medicaid if they satisfy income and other eligibility requirements, and those aged 65 and older may qualify for Medicare. Nearly 45 percent of veterans are 65 years and older and also qualify for Medicare (Van Diepen, 2001b). In addition, many Americans eligible for these programs have private supplemental insurance as well. Thus, patients and clinicians would surely benefit from greater consistency in quality enhancement requirements, measures, and processes across public and private insurance programs.Table 2-1 provides a capsule summary of the six government health care programs. A more detailed description of the programs is provided in the following section. The broad trends affecting the needs and expectations of the programs’ beneficiaries are then reviewed. The final section examines some key features of the programs beyond their quality enhancement processes.MEDICARE1Medicare provides health insurance to all individuals eligible for social security who are aged 65 and over, those eligible for social security because of a disability, and those suffering from end-stage renal disease (ESRD)—a total of about 40 million beneficiaries and growing. While chronic condition and 63 percent have two or more (Anderson, 2002). The over 30 percent of the Medicare population that has a physical and/or cognitive impairment accounts for about 60 percent of expenditures (see Figure 2-1). Medicare beneficiaries with three or more chronic conditions account for the bulk of program expenditures (see Figure 2-2). The most prevalent diagnoses in persons aged 65 and over—high blood pressure, osteoporosis, chronic obstructive pulmonary disease, asthma, diabetes, heart disease, and stroke—are all chronic illnesses requiring medical management over extended time periods and multiple settings (Medical Ex-Suggested Citation:"2 Overview of the Government Health Care Programs." Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press. doi: 10.17226/10537.FIGURE 2-1 Medicare beneficiaries with cognitive and/or physical limitations as a percentage of beneficiary population and total Medicare expenditures, 1997. NOTE: A person with cognitive impairment has difficulty using the telephone or paying bills, or has Alzheimer’s disease, mental retardation, or various other mental disorders. A person with physical impairment is someone reporting difficulty performing three or more activities of daily living.SOURCE: Reprinted with permission from Moon and Storeygard, 2001.penditure Panel Survey, 1998). The fastest-growing sectors in Medicare in terms of spending (though not the largest proportion of total program spending) have been home health, skilled nursing facilities, and hospice care, reflecting a shift in demand toward more chronic care.MEDICAID2Medicaid serves about 42 million people who are poor and who require health care services to achieve healthy growth and development goals or meet special health care needs. The program covers low-income people who meet its eligibility criteria, such as children, pregnant women, certain low-income parents, disabled adults, federal Supplemental Security Income (SSI) recipients (low-income children and adults with severe disability), and the medically needy (non-poor individuals with extraordinary medical expenditures who meet spend-down requirements generally for long-term care). There is a good deal of variability across states in the maximum income for eligibility.Unless otherwise indicated, data in this section are based on Centers for Medicare and Medicaid Services, 2000a.Suggested Citation:"2 Overview of the Government Health Care Programs." Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press. doi: 10.17226/10537.FIGURE 2-2 Medicare beneficiaries with five or more chronic conditions account for two-thirds of Medicare spending.SOURCE: Centers for Medicare and Medicaid Services, 1999.Medicaid is administered and financed jointly by the federal government and the states, although the federal government pays for over 50 percent of aggregate program expenditures (U.S. Government Printing Office, 2002). There is a good deal of variability in methods of health care delivery and financing across states. Medicaid programs rely extensively on private-sector health care providers, managed care plans, and community health centers to deliver services and, to a lesser degree, state, county, or other publicly owned facilities or programs. Nationwide, over half of the total Medicaid population is enrolled in Medicaid managed care arrangements. Institutionalized, disabled, dually eligible, and elderly beneficiaries are most likely to receive services through FFS payment arrangements.The majority of Medicaid beneficiaries are children (54 percent), most under the age of 6 (see Figure 2-3). Each year, over one-third of all births in the United States are covered by Medicaid. While a minority of the program in terms of population (26 percent), the aged/blind/disabled account for 71 percent of program expenditures. Over half of Medicaid expenditures are for long-term care services, with the majority going to institutional long-term care providers (Centers for Medicare and Medicaid Services, 2000a).While coordinated collection of Medicaid data from the states is lacking, other data sources indicate a substantial prevalence of chronic condi-Suggested Citation:"2 Overview of the Government Health Care Programs." Institute of Medicine. 2003. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press. doi: 10.17226/10537.FIGURE 2-3 Distribution of persons served through Medicaid and payments by basis of eligibility, fiscal year 1998.NOTE: Disabled children are included in the aged, blind and disabled category.SOURCE: Centers for Medicare and Medicaid Services, 2000a.tions in the program. These conditions include asthma, diabetes, neurological disorders, high blood pressure, mental illness, substance abuse, and HIV/AIDS (Centers for Medicare and Medicaid Services, 2001c; Medical Expenditure Panel Survey, 1996; Westmoreland, 1999).STATE CHILDREN’S HEALTH INSURANCE PROGRAM3Designed as a joint federal-state program, SCHIP was created in 1997 to provide health insurance to poor and near-poor children through age 18 without another source of insurance. Approximately 4.6 million children were enrolled in SCHIP as of fiscal year 2001 (Centers for Medicare and Medicaid Services, 2000b). SCHIP is targeted to children with incomes that exceed Medicaid eligibility requirements but remain under 200 percent of the federal poverty level (FPL) (Rosenbach et al., 2001). Some states recognized American Indian and Alaska Native tribes. IHS currently provides health services to approximately 1.4 million American Indians and Alaska Natives belonging to more than 557 federally recognized tribes in 35 states.The provision of these health services is based on treaties, judicial determinations, and acts of Congress that result in a unique government-to-government relationship between the tribes and the federal government. IHS, the principal health care provider, is organized as 12 area offices located throughout the United States. These 12 areas contain 550 health care delivery facilities operated by IHS and tribes, including: 49 hospitals; 214 health centers; and 280 health stations, satellite clinics, and Alaska village clinics. Almost 44 percent of the $2.6 billion IHS budget is transferred to the tribes to manage their own health care programs.Poverty and low education levels strongly affect the health status of the Indian people. Approximately 26 percent of American Indians and Alaska Natives live below the poverty level, and more than one-third of Indians over age 25 who reside in reservation areas have not graduated from high school. Common inpatient diagnoses include diabetes, unintentional injuries, alcoholism, and substance abuse.BROAD TRENDS AFFECTING THE NEEDS AND EXPECTATIONS OF BENEFICIARIESIn identifying ways to improve the quality enhancement processes of government health care programs, it is important to understand both the needs and expectations of today’s beneficiaries and the trends likely to affect these needs and expectations in the future. As beneficiaries’ needs and expectations evolve over time, so, too, must the government health care programs. This section highlights two important trends: the increase in chronic care needs and expectations for patient-centered care.Chronic Care NeedsTrends in the epidemiology of health and disease and in medical science and technology have profound implications for health care delivery. Chronic conditions (defined as never resolved conditions, with continuing impairments that reduce the functioning of individuals) are now the leading cause of illness, disability, and death in the United States and affect almost half the U.S. population (Hoffman et al., 1996). Most older people have at least one chronic condition, and many have more than one (Administration on Aging, 2001). Fully 30 percent of those aged 65–74, and over 50 percent of those aged 75 and older report a limitation caused by a chronic condition (Administration on Aging, 2001). The proportion of children and adolescents with limitation of activity due to a chronic health condition more than tripled from 2 percent in 1960 to over 7 percent in the late 1990s (Newacheck and Halfon, 1998).Thus, the majority of U.S. health care resources is now devoted to the treatment of chronic disease (Anderson and Knickman, 2001). This trend is strongly reflected in the government health care programs. In the Medicare and VHA programs, most of the beneficiaries have multiple chronic conditions. Diseases such as asthma, diabetes, hypertension, cancer, congestive heart failure, and mental health and cognitive disorders are important clinical concerns for all or nearly all of the programs.The increasing prevalence of chronic illness challenges systems of care designed for episodic contact on an acute basis (Wagner et al., 1996). Hospitals and ambulatory settings are generally designed to provide acute care services, with limited communication among providers, and communication between providers and patients is often limited to periodic visits or hospitalizations for acute episodes. Serious chronic conditions, however, require ongoing and active medical management, with emphasis on secondary and tertiary prevention. The same patient may receive care in multiple settings, so that there is frequently a need to coordinate services across a variety of venues, including home, outpatient office or clinic setting, hospital, skilled nursing facility, and when appropriate, hospice.There is mounting evidence that care for chronic conditions is seriously deficient. Fewer than half of U.S. patients with hypertension, depression, diabetes, and asthma are receiving appropriate preventive, acute, and chronic disease management services (Clark, 2000; Joint National Committee on Prevention, 1997; Legorreta et al., 2000; Wagner et al., 2001; Young et al., 2001). Health care is typically delivered by a mix of providers having separate, unrelated management systems, information systems, payment structures, financial incentives, and quality oversight for each segment of care, with disincentives for proactive, continuous care interventions (Bringewatt, 2001). For individuals with multiple chronic conditions, coordination of care and communication among providers are major problems that require immediate attention.There are many efforts under way to develop new models of care capable of meeting the needs of the chronically ill. For example, Healthy Future Partnership for Quality, an initiative in Maine now in its fifth year, enrolls insured individuals (from leading health plans and the state Medicaid program) and uninsured individuals (covered by a 10 percent surcharge on the fee for each insured participant and paid by insurance companies) with chronic illness in an intensive care management program that provides patient education, improved access to primary care and preventive services, and disease management (Healthy Futures Partnership for Quality Project, 2002). The diabetes telemedicine collaborative in New York State (IDEATel, 2002) is a randomized controlled trial supported by CMS and others. It involves 1,500 patients, half of whom participate in home monitoring (using devices that read blood sugar, take pictures of skin and feet, and check blood pressure), intensive education on diabetes, and reminders and instructions on how to manage their disease.The changing clinical needs of patients have important implications for government quality enhancement processes. These processes and the health care providers they monitor should be capable of assessing how well patients with chronic conditions are being managed across settings and time. This capability necessitates consolidation of all clinical and service use information for a patient across providers and sites, a most challenging task in a health care system that is highly decentralized and relies largely on paper medical records.Patient-Centered CarePatient-centered care is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values and circumstances guide all clinical decisions (Institute of Medicine, 2001). Informed patients participating actively in decisions about their own care appear to have better outcomes, lower costs, and higher functional status than those who take more passive roles (Gifford et al., 1998; Lorig et al., 1993, 1999; Stewert, 1995; Superio-Cabuslay et al., 1996; Van Korff et al., 1998). Most patients want to be involved in treatment decisions and to know about available alternatives (Guadagnoli and Ward, 1998); (Deber et al., 1996; Degner and Russell, 1988; Mazur and Hickam, 1997). Yet many physicians underestimate the extent to which patients want information about their care (Strull et al., 1984), and patients rarely receive adequate information for informed decision making (Braddock et al., 1999).Patient-centered care is not a new concept, rather one that has been shaping the clinician and patient relationship for several decades. Authoritarian models of care have gradually been replaced by approaches that encourage greater patient access to information and input into decision making (Emanuel and Emanuel, 1992), though only to the extent that the patient desires such a role. Some patients may choose to delegate decision making to clinicians, while patients with cognitive impairments may not be capable of participating in decision making and may be without a close family member to serve as a proxy. Patients may also confront serious constraints in terms of covered benefits, copayments, and ability to pay (discussed below under benefits and copayments)American Society of Internal Medicine (ACP-ASIM) Foundation, and the European Federation of Internal Medicine embodies three fundamental principles to guide the medical profession, including:Principle of Patient Autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demand for inappropriate care (American Board of Internal Medicine et al., 2002, p. 244).The current focus on making the health care system more patient-centered stems at least in part from the growth in chronic care needs discussed above. Effective care of a person with a chronic condition is a collaborative process, involving extensive communication between the patient and the multidisciplinary team (Wagner et al., 2001). Patients and their families or other lay caregivers deliver much if not most of the care. Patients must have the confidence and skills to manage their condition, and they must understand their care plan (e.g., drug regimens and test schedules) to ensure proper and safe implementation. For many chronic diseases, such as asthma, diabetes, obesity, heart disease, and arthritis, effective ongoing management involves changes in diet, increased exercise, stress reduction, smoking cessation, and other aspects of lifestyle (Fox and Gruman, 1999; Lorig et al., 1999; Von Korff et al., 1997).Pressures to make the care system more respectful of and responsive to the needs, preferences, and values of individual patients also stem from the increasing ethnic and cultural diversity that characterizes much of the United States. Although minority populations constitute less than 30 percent of the national population, in some states, such as California, they already constitute about 50 percent of the population (Institute for the Future, 2000). A culturally diverse population poses challenges that go beyond simple language competency and include the need to understand the effects of lifestyle and cultural differences on health status and health-related behaviors; the need to adapt treatment plans and modes of delivery to different lifestyles and familial patterns; the implications of a diverse genetic endowment among the population; and the prominence of nontraditional providers as well as family caregivers.Although there has been a virtual explosion in Web-based health and health care information that might help patients and clinicians make more informed decisions, the information provided is of highly variable quality (Berland et al., 2001; Biermann et al., 1999; Landro, 2001). Some sites provide valid and reliable information. These include the National Library of Medicine’s Medline Plus sites (Lindberg and Humphreys, 1999); the National Diabetes Education Program, launched by the Centers for Disease Control and Prevention and the National Institutes of Health (U.S. Government Printing Office, 2001); and the National Health Council’s public education campaign. There are also notable efforts to provide consumers with comparative quality information on providers and health plans. Examples are the health plan report cards produced by the National Committee for Quality Assurance and by the Consumers Union/California HealthCare Foundation Partnership and nursing home quality reports produced by CMS (Centers for Medicare and Medicaid Services, 2001a; Consumers Union/California Healthcare Foundation Partnership, 2002; National Committee for Quality Assurance, 2002). These efforts are discussed further in Chapter 5. There is little doubt, however, that we are embarking on a long journey to determine how best to make valid and reliable information available to diverse audiences with different cultural and linguistic capabilities (Foote and Etheredge, 2002).In general, communication with consumers is enhanced through the use of common terminology, standardized performance measures, and reporting formats that follow common conventions. At the program level, the predilection of each government program to design and operate its health care quality enhancement processes independently is a serious problem.KEY PROGRAM FEATURESAlthough the focus of this report is on quality enhancement processes, the committee believes it important to acknowledge other important program features—such as benefits, payment approaches, and program design and administration—that influence quality. Just as the quality enhancement processes of the government programs are being assessed in this report, these other aspects of program design must be evaluated in the future for alignment with the objectives of those processes.Benefits and CopaymentsHealth insurance was established in the United States in the 1930s and 1940s as a way to help the average person cope with the high costs of hospital care (Stevens, 1989). Today hospital care, although still very expensive, consumes about one-third of the health care dollar, and other facets of health care, such as prescription medications (9 percent with a growth rate of 13.8 percent) have grown in importance (Centers for Medicare and Medicaid Services, 2002c; Strunk et al., 2002). Increased demand for these other facets of care reflects the growth in chronic care needs discussed earlier as well as new treatment options stemming from the extraordinary advances made in medical knowledge and technology, including minimally invasive surgery.The benefit package of an insurance program has a direct effect on the likelihood of patients receiving needed health care services (Federman et al., 2001). Although there are frequent changes in the benefit packages of the various government health care programs, these modifications have not always kept pace with the needs, especially the chronic care needs, of the populations being served (Bringewatt, 2001).When one assesses the extent to which the government health care programs provide coverage for benefits important to persons with chronic conditions, the results are mixed (see Table 2-2). The basic Medicare package, for example, generally does not cover outpatient prescription drugs or personal care, and coverage is very limited for preventive services, nursing home services, family counseling, and dietitian–nutritionist services. Medicare payment mechanisms are designed for acute care, often by a single provider; there is no Medicare payment mechanism that recognizes care delivered by a team of providers to an individual with multiple chronic conditions or that rewards prevention efforts such as extensive patient education for self-care.Other government programs offer important benefits in specific areas. VHA provides extensive mental health outpatient and inpatient services, especially for veterans with service-related disabilities. Medicaid provides residential care to the disabled and mentally retarded and long-term care for the elderly as a major part of program spending. Its benefit package is very comprehensive, including complex therapies for chronic conditions and congenital neurological disorders, such as cerebral palsy and Down syndrome, although states vary substantially in the scope of such benefits. Both Medicaid and SCHIP programs cover outpatient prescription medications. Note that IHS is not included in Table 2-2 because it is not an entitlement program or an insurance plan; therefore, it has no established benefit package (Indian Health Service, 2001). It is estimatedCost-sharing provisions are also important. Persons with chronic conditions are the heaviest users of health care services. Deductibles and especially copayments can be sizable for these individuals. Some government health care programs, such as VHA, have minimal cost-sharing provisions, while others, especially Medicare, make more extensive use of such provisions.Also important is how the different programs interpret “medical necessity.” Even when a service is covered, payment for that service to a particular patient can be denied because of failure to meet a medical necessity criterion. In some instances, the quantity and duration of certain repetitive services may be limited unless the person shows functional improvement, not just stability or a slowing of decline (Anderson et al., 1998).The committee believes that each of the six government health care programs should review its benefit package and medical necessity criteria to identify enhancements in coverage or cost sharing that would facilitate the provision of more appropriate care to today’s beneficiaries. Such analyses should be conducted under alternative financial scenarios, including budget neutrality and varying levels of growth in expenditures. Efforts should also be made to understand how well the benefit packages of various government health care programs meet the needs of vulnerable populations and how well these packages fit together for those who are dual- or triple-eligible.Payment ApproachesEfforts to improve quality of care will be far more effective if implemented in an environment that encourages and rewards excellence. Unfortunately, current methods of payment to health plans and providers have the unintended consequence of working against quality objectives. This is true for both capitated and FFS payment methods.Capitation is a payment arrangement in which health plans are paid a fixed amount for each enrollee under their care, regardless of the level of services needed by and actually provided to the person. Some health plans also pay physicians on a capitated basis for certain outpatient care, putting them at some degree of financial risk.Capitated payment rates are usually based on the average cost per enrollee of the enrolled group, often with adjustments for demographic characteristics (e.g., age and sex). Capitation rates are usually not adjusted for the health status of the enrolled population. Therefore, health plans and providers receive the same payment for someone who is less healthy and more likely to use a large number of services, such as a person with a chronic condition, as they do for someone who is healthier and likely to use no or fewer services during the year.Health plans or clinicians that develop exemplary care programs for persons with chronic conditions may, as a result, attract a disproportionate share of these individuals. Under capitated payment systems, this situation has a highly negative financial impact on the health plan and providers (Luft, 1995; Maguire et al., 1998). Persons with chronic conditions are more likely both to use services and to use a greater number of services during the year than those without chronic conditions. In 1996, for example, mean health care expenditures for a person with one or more chronic conditions were nearly 4 times the overall average ($3,546 versus $821) (Partnerships for Solutions, forthcoming). The average number of inpatient days per year is 0.2 for persons with no chronic conditions compared to 4.6 for those with five or more such conditions.Risk adjustment is a mechanism designed to ensure that payments to health plans and other capitated providers more accurately reflect the expected cost of providing health care services to the population enrolled. Capitated plans and providers caring for a population that includes less healthy, higher-cost enrollees should receive higher payments. As more states require their entire Medicaid populations, including those who are disabled and have high health care needs, to enroll in managed care, adjustment of payments becomes even more necessary to ensure quality of care for enrollees (Maguire et al., 1998). Some states have addressed this issue. Michigan, for example, has created a separately funded capitated option for children with special health care needs (Department of Health and Human Services, 2000).Numerous options exist for risk-adjusting payments, but their application in government health care programs has been limited (Ellis et al., 1996; Hornbrook and Goodman, 1996; Newhouse et al., 1997; Starfield et al., 1991). The Medicare+Choice program has initiated demonstration projects to pilot the application of capitated payments adjusted for health status (Centers for Medicare and Medicaid Services, 2000d).Regardless of whether the beneficiary is enrolled in an indemnity or capitated plan, the physicians on the front line of care delivery in the private sector are generally compensated under FFS payment methods (Center for Studying Health System Change, 2001; Institute of Medicine, 2001). FFS is the most common method of payment to physicians under Medicare, Medicaid, and SCHIP.Under FFS payment, physicians have strong financial incentives to increase their volume of billable services (e.g., visits and office-based procedures and tests). Sometimes the incentives of FFS or other physician payment methods are attenuated by incentives (e.g., bonuses) tied to performance (e.g., measures of safety, clinical quality, service), but this is not the norm. In a 1998–1999 survey of a nationally representative sample of physicians, fewer than 30 percent indicated that their compensation was affected by performance-based incentives, a result similar to findings from a survey conducted in 1996–1997 (Stoddard et al., 2002). When they are used, performance-based incentives are more likely to be tied to patient satisfaction (24 percent) and quality measures (19 percent) than to measures that may restrain care, such as profiling (14 percent).The principal “reimbursable event” under FFS is a face-to-face encounter between a physician and patient, which may or may not trigger other reimbursable events, such as diagnostic tests and minor office procedures. Services such as e-mail communications, telephone consultations, patient education classes, and care coordination are important for the ongoing management of chronic conditions, but they are not reimbursable events. Moreover, physicians who communicate with patients through e-mail or telephone to emphasize patient education, self-management of chronic conditions, and to coordinate care may experience a reduction in overall revenues if these uncompensated services have the effect of reducing patient demand for or time available to devote to reimbursable face-to-face encounters.There is no perfect payment method; all methods have advantages and disadvantages. FFS contributes to overuse of billable services (e.g., face-to-face encounters, ancillary tests, procedures) and underuse of preventive services, counseling, medications, and other services often not covered under indemnity insurance programs. Overuse, especially the provision of services that expose patients to more potential harm than good, is a serious quality-of-care and cost concern. On the other hand, capitated payments may contribute to underuse—the failure to provide services from which patients would likely benefit. This is especially true when there is a good deal of turnover among plan enrollees so that the long-term cost consequences of underuse tend to be borne by another insurer. Although particular payment methods may contain a bias towards underuse or overuse, it is important to note that the quality-of-care literature contains ample evidence of both phenomena occurring in both FFS and capitated payment systems, reinforcing the notion that payment is but one, albeit an important, factor influencing care (Chassin and Galvin, 1998).The committee believes enhancements can be made in both capitated and FFS payment approaches to encourage the provision of quality health care. It should also be noted that there are some promising efforts under way to design alternative payment approaches and evaluate their impact on quality. The National Health Care Purchasing Institute, a nonprofit research institute supported by The Robert Wood Johnson Foundation, has identified various incentive models that might be effective in motivation.The Buyers Health Care Action Group, an employer coalition in Minnesota, provides gold ($100,000) and silver ($50,000) awards to care systems for performance on quality improvement projects (Bailit Health Purchasing, 2002a)PacifiCare in California has developed a quality index that profiles providers on the basis of measures of clinical quality, patient safety, service quality, and efficiency. This information is used to reward providers on the basis of their performance, as well as to construct a tiered system of premiums, copayments, and coinsurance rates for enrollees that vary inversely with provider performance in terms of quality and efficiency (Ho, 2002)The Employers’ Coalition on Health in Rockford, Illinois, makes incentive payments to provider groups based on whether the group completes care flowsheets on 95 percent of its diabetic encounters and maintains hemoglobin A1c levels below 7.5 for the majority of patients. Incentive payments to medical groups have been approximately $28,000 per year ($3.60 per member per year) (Bailit Health Purchasing, 2002a)Blue Shield of California has introduced a variable cost-sharing model under which patients pay either an additional $200 copayment or 10 percent of the hospital’s fee each time they are admitted to a hospital that is not on Blue Shield’s preferred list. Blue Shield rates hospitals on the basis of measures of quality, safety, patient satisfaction, and efficiency (Freudenheim, 2002)General Motors’ value-based purchasing approach rates health plans according to their performance on various clinical quality measures, patient satisfaction measures, NCQA accreditation results, and cost-effectiveness measures, and adjusts employee out-of-pocket contributions so that those choosing the best-ranked plans have the lowest contributions (Salber and Bradley, 2001).It may be hoped that much more will be known about the impact of various financial and non-financial incentive models in the near future. The Robert Wood Johnson Foundation (National Health Care Purchasing Institute, 2002) has recently announced an initiative entitled “Rewarding Results,” which will provide support for payment demonstrations that reward improvements in quality. This initiative is being evaluated under an Agency for Healthcare Research and Quality contract.Program Design and AdministrationBenefits coverage and payment methods are among the most important design features of the six government health care programs reviewed in this report, but they are not the only ones that influence the likelihood of patients receiving high-quality care. Other important features include delivery system and provider choices, fluctuations in eligibility and delivery system options, and administrative efficiency.In some government health care programs, consumers have multiple options in terms of delivery system and choice of providers, while in others the options are more limited. Under Medicare, 87 percent of beneficiaries have chosen to enroll in FFS arrangements, which provide extensive choice of clinicians and hospitals. Most Medicare beneficiaries who live in metropolitan areas also have the option of enrolling in Medicare+Choice plans, enrollment that historically has been associated with enhanced benefits for little or no additional out-of-pocket expense. Enrollment in managed care is mandatory for the majority of the Medicaid population in most states, and in some instances, there is little or no choice of plan. DOD TRICARE, the VHA, and IHS programs are all structured to encourage, and in some cases require, use of their own health care delivery systems, which are similar to group or staff-model health plans.Studies of the clinical quality (in terms of both medical care processes and patient outcomes) in managed care and indemnity settings consistently find little or no difference between the two (Chassin and Galvin, 1998; Miller and Luft, 1993; Schuster et al., 1998). But it is clear that some consumers have strong preferences for one delivery system over another, and that most prefer to have choice (Gawande et al., 1998; Ullman et al., 1997). Limited choice of health plans may or may not seriously constrain the choice of clinicians and hospitals, since plan networks vary greatly in size and structure (Lake and Gold, 1999). In the private sector, there has been a pronounced trend in recent years toward larger networks of providers in response to consumer demand for more extensive choice (Draper et al., 2002; Lesser and Ginsburg, 2000). In the absence of comparative quality information on providers, consumers apparently equate choice with quality.The design and financing of some government health care programs result in frequent changes in eligibility and delivery system options that disrupt patterns of care delivery. Since the implementation of changes in Medicare payment policies stemming from enactment of the Balanced Budget Act of 1997, there has been a steady erosion of health plans participating in the Medicare+Choice program. Since 1998, 2.2 million Medicare beneficiaries have been involuntarily disenrolled from Medicare+Choice plans, affecting approximately 5 percent of beneficiaries in 2002. Of the health plans that remain, the proportion offering prescription drug coverage during the period 1999 through 2002 dropped from 73 to 66 percent, and the proportion charging zero premiums to beneficiaries from 62 to 39 percent (Gold and McCoy, 2002). Under Medicaid, beneficiaries move in and out of the program as their eligibility changes in accordance with minor fluctuations in income, causing beneficiaries to lose contact with providers and further complicating the tracking of care. For many eligible children and women, the re-enrollment process is initiated only when they present themselves at a hospital or physician’s office seeking service for an illness; this process results in adverse selection in capitated plans.Lastly, efforts must be made to reduce administrative burden. In recent years, there has been a steady growth in regulatory requirements in most if not all of the government health care programs. The Secretary’s Advisory Committee on Regulatory Reform estimates that about two regulations are published each week, resulting in the promulgation of more than 120 regulations in each of the last two years (Wood, 2002). The American Hospital Association (2002) has identified 100 new or revised regulations pertaining to hospitals that have been issued by federal agencies since 1997, of which 57 are significant. Some of these regulations relate to quality enhancement processes and data requirements, while others relate to such areas as payment, patient confidentiality and privacy, and fraud and abuse.The current practice of promulgating separate regulations for each type of provider (e.g., hospital, home health agency, nursing home, ambulatory care provider) has produced excessive burdens and barriers to the provision of coordinated care. Unnecessary regulations frustrate clinicians and reduce the time available to devote to patient care. They can also interfere with the movement of individuals across settings, thus hampering the transition from hospital to nursing home to home health agency, for example.Regulatory burden must also be fair. For example, the quality measurement and reporting requirements applied to Medicare+Choice plans should be applied to FFS Medicare institutional and individual providers. These issues are addressed further in Chapters 3 and 4.In summary, while technically comprising separate areas of analysis, the issues of benefits, payment, program design, and administration are inextricably linked to achieving consistent levels of high-quality care.