Health Care Systems Essay

Abstract The primary objective of any health care system is to provide adequate and effective medical care to the population. Health care systems may vary due to political and other factors. Factors may include location, access to care, basic needs of the populations as well as economic status. However, the primary goal remains the same. Because of the ongoing need for government to allocate funds to the medical budget their involvement in health care cannot be discounted. This paper introduces two major health care systems. First that of the Netherlands and secondly, the United States. The pros and cons will be discussed, as well as the role and function of the government as it relates to health care. A compare and contrast of the differences and similarities of both systems will be made. Health Care Systems The Netherlands The health care system in the Netherlands is comprised of three distinct compartments and is mandatory for all residents and non-resident who pay Dutch income tax. They are required to purchase health insurance coverage, except for those with conscious objections and active members of the armed forces. Coverage is mandatory under the health insurance act provided by private insurance companies and regulated under private law. One percent of the Dutch population were uninsured in 2009 and approximately sixteen percent between the ages of twenty and thirty years. Those who failed to pay premiums for at least six months are also known as defaulters. (Westert & Klazinga, 2011, p. 1) Insurance companies are forbidden to perform â€Å"risk assessment† that deny coverage based on pre-existing conditions, risk factors based on age, gender, or health profile. Tax credits make the package affordable for those who have low income while those who have no income receive coverage as part of their social assistance package. (Daley & Gubb, 2011) The government provides health care allowances also known as premium subsidies for low-income families if their premium exceeds five percent of the household income. (Westert & Klazinga, 2011, p. 80) Individuals who do not sign up for health care coverage are subject to a tax fine of one hundred and thirty percent of the premium. (Daley & Gubb, 2011) The Exceptional Medical Expenses Act regulates the first compartment. (Daley & Gubb, 2011) Contributions were taken as a 12.55% salary deduction and further supplemented by a government grant. (Daley & Gubb, 2011) Basic insurance packages include General Practitioner, Hospital specialists, Midwives, as well as hospitalization, dental coverage up to the age of eighteen after which only specialist dental care is covered (dentures e.g); medical aides such as home health care and medical equipment pharmaceutical care, maternity, ambulance and patient transport services, paramedical care, mental health and limited lifestyle improvement (smoking cessation programs e.g.). In vetro fertilization is also covered for the first three attempts. (Westert & Klazinga, 2011, p. 1-2) The second compartment deals with basic and essential needs. These medical needs are first treated by a General Practitioner. Every resident and non-resident must be registered with a General Practitioner who oversees basic care including, physicals and common illnesses. In the event specialized care is needed, patients are referred to a Nurse Specialist who is responsible for giving medical treatment. This may include information pertaining to prevention, education, social and psychological support. (â€Å"Nursing,† n.d) For example if a patient is diagnosed with Diabetes Mellitus their first encounter is with the General Practitioner who makes the diagnosis, and puts together a team consisting of the Diabetic Nurse Specialist and an Endocrinologist. The Endocrinologist supervises the Nurse Specialist who in turn acts as a supervisor or consultant to the General Practitioner. Members of the team must meet on a regular basis to discuss the patient’s needs and progress. Based on the severity of the patient’s illness (which could be deemed as low, moderate or severe) determined by the patients’ test results one of the three care givers will in fact manage follow-up care. However, all three practitioners will continue to be involved. The Nurse Specialist acts a liaison between both the Practitioner and the Specialist. (â€Å"Nursing,† n.d) The third is an optional supplemental coverage and is paid for by the individual or as part of an employer/employee contract. Care can include, dental after the age of 18 years, physiotherapy and cosmetic procedures. The focus on overcoming disparities such as obesity and smoking cessation do not exist in the Netherlands, as it is believed that it is the responsibility of the individual to seek treatment, which is covered under the basic package. Before the 2006 Reform, there were long waiting lines to see the General Practitioner. There are forty Dutch health insurers across the country and individuals are free to choose the company of their choice based on their personal needs and preferences. At the time of annual open enrollment, patients are allowed to change their insurance company to one of their own choosing. (Westert & Klazinga, 2011, p. 84) Every insured individual age 18 and over must pay a deductible ranging from â‚ ¬170 to â‚ ¬ 670 referred to as cost sharing. General practitioner care and children health care are exempt from cost sharing. (Westert & Klazinga, 2011, p. 80) How is the health system financed? – The first â‚ ¬ 32,369 are taxed at a rate of 6.9 %. The employer is required to reimburse this contribution while the employee must pay taxes on the reimbursement. For those who do not have an employer or do not receive unemployment benefits the contribution is 4.8% while the self-employed is individually assessed by the Department of Revenue. (Westert & Klazinga, 2011, p. 80) Organization – The General Practitioner is the considered to be the gate- keeper. The General Practitioner must refer hospitalization or specialized health care and the only exception is for emergency care. The General Practitioner gets a capitation fee for each registered patient and is further compensated for after hours care on an hourly basis. Consultation fees including phone consults are also accrued and an additional amount is paid to the General Practitioner for managing the patients care without having to make a referral. Bundled payments are made for chronic diseases such as Diabetes Mellitus, Chronic Obstructive Pulmonary disease, Congestive Heart Failure etc. If the General Practitioner hires a private nurse to assist in his practice, the insurance company makes full reimbursement to the General Practitioner for nurses’ salary. The population of the Netherlands is 16.7 million people (â€Å"One World Nations Online†) of which only one percent is uninsured. The reason for this is not due to an inability to pay but rather a default for greater than six months. The health care system in the Netherlands is Universal and does not depend on employment status. (Westert & Klazinga, 2011, p. 78) Although the government mandates heath insurance, private insurance companies are allowed to provide coverage. With five insurance companies that dominate the market the government has created a market environment for healthy competition that also benefits the consumer. (Westert & Klazinga, 2011, p. 80) The triangle between the Insurer, the Provider and the Insured requires that quality and efficient care remains consistent. There are five non-governmental entities that regulate care. The Health Council advises the government on health care issues (e.g. public health); The Health Insurance Board (advises what should be included in the basic health insurance packet). The Medical Evaluation Board is responsible for efficiency, safety and quality are always taken into account; The Dutch Health Care sAuthority, which ensures that the market is functioning while the Dutch Competition Authority ensures there, is fair competition among insurers and providers. (Westert & Klazinga, 2011, p. 83) The United States In the United States government is heavily intertwined with health care at many different levels. Laws have been created by both the federal and state legislative bodies. Health care policies have been shaped through a combination of the arenas that make decisions at the local, state and federal levels. The United States health care system is comprised of two separate entities identified as the private and public sectors. First, the private sector is made up of private health insurance companies and employer sponsored insurance coverage. Beginning in 2014, the Affordable Care Act of 2010 will require employers who have fifty or more employees to provide health insurance coverage or pay a financial penalty to the federal government. Medicaid program will be expanding and will be required to cover those who fall above the level of poverty.. (Kaovner & Knicman, 2011, p. 36) This like the health care system in the Netherlands tries to cover a greater amount of the population The public s ector is made up of Medicaid and Medicare. Medicaid is a welfare initiative that is not a single national program, but a collection of fifty state-administered programs. (Kaovner & Knicman, 2011, p. 29) Medicaid is designed to cover low-income families. It is jointly funded by the state and federal government. The poorer the state the larger the federal contribution however, each state has specific eligibility rules, benefits and payment schedules. A little known fact about Medicaid is that it can be given free to those who cannot afford it, or it can be given at a low cost depending on one’s income. (Social Security†) Medicare on the other hand is a social as well as a federal insurance program designed to cover people aged 65 and older as well as the disabled regardless of age or income. There are four parts to Medicare. Part A also known as hospital insurance covers inpatient hospital stays, care in a skilled nursing facilities, hospice and some home health care. Part B also known as medical insurance covers certain doctor’s services, outpatient care, medical supplies and preventative services. Part C also known as the medical advantage plan is a type of medical health care plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits. Part D, also known as the prescription drug coverage, can be added onto the original Medicare plan. The aforementioned plans, are offered by insurance companies and other private companies approved by Medicare. (medicare.gov). The public sector is designed to cover the segment of the population that is not covered by employer-sponsored insurance. The United States highest annual health care spending per capita in terms of purchasing power parity is $7,538 is significantly higher than the Netherlands, which spends $4, 063 per capita. This trend has remained constant for the past forty years. (Kaovner & Knicman, 2011, p. 68) It is reported that the United States has the largest proportion of adults who have the hardest time seeing a specialist, however other countries have reported the same difficulties with low-income levels having a greater difficulty than those with higher income. (Kaovner & Knicman, 2011, p. 69) The life expectancy in the United States for male was 75.64 years while women was 80.78 years. In the Netherlands on the other hand, life expectancy for a male is 81.4 years and for female 85.3 years a significant difference and is believed to be due to the quality and access to health care. The quality of life in the Netherlands is assumed to be much better because of preventative care and education. Patient Protection and Affordable Care Act of 2010, children in the United States will now be covered up to the age of 26. (Kaovner & Knicman, 2011, p. 25) In the Netherlands children are only covered until the age of 18 at which time they are expected to be contributing members of society. Approximately 16% of the United States population is uninsured, which is a significant disparity between that of the Netherlands. Americans are uninsured primarily because of high out-of-pocket medical expenses and considerable amounts of medical debt. Most of those uninsured are families with full- or part-time jobs or those who are self-employed will not be able to afford or access health care. (Kaovner & Knicman, 2011, p. 32-33) Health care provisions are adequately satisfied in the Netherlands, which make provision for all Citizens while still leaving room for healthy competition among insurance carriers. Although guidelines are set up by the government to ensure universal health care it is the responsibility of insurance companies and non-governmental agencies to ensure that these guidelines are followed. On the other hand, while the United States supports those with low income and disabilities there remains the 17% of the population that contribute to the Medicaid and Medicare funds but are still unable to afford health insurance coverage. I believe it is to the detriment of the United States health care system to pull certain aspects from many different health care systems such as the Netherlands and Switzerland that do not always work to our benefit. (Kaovner & Knicman, 2011, p. 79) The absence of a body to oversee making checks and balances in the systems leaves the door open for fraud and fraudulent activities within the system. If these aspects were to be imported it must be modified and carefully monitored to ensure there is no conflict with existing programs that have been proven effective. If the average household income per year is $40,000 of which 30% is spent on heath care it leaves a family with insufficient funds to provide for basic needs. In effect, health care becomes the â€Å"basic need†, creating further health care needs due to the inability to cover food, clothing and shelter. In conclusion, it is my opinion that the health care system in the Netherlands is by far more advanced in terms of organization and effectiveness. The ability for all residents to access health care contributes to the longer life expectancy and overall quality of life which in together ensures that the people will be valuable contributors to society. References Daley, C., & Gubb, J. (2011). Health Care Systems: The Netherlands. Civitas. Retrieved from http://www.civitas.org.uk/nhs/download/netherlands.pdf Kaovner, A., & Knicman, J. (2011). Health Care Delivery in the United States (10th ed.). New Yor, NY: Springer Publishing Company LLC. Nursing in the Netherlands. (n.d). Retrieved from http://ec.europa.eu/internal_market/qualifications/docs/nurses/2000-study/nurses_nederland_en.pdf Westert, G., & Klazinga, N. (2011). International Profiles of Health Care Systems, 2011 [Entire issue]. The Common Wealth Fund. Retrieved from http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2011/Nov/1562_Squires_Intl_Profiles_2011_11_10.pdf