care system. One of your patients is not following his health care regime. You wonder what thought processes this patient is using to justify continuing an activity that presents risk to his health.
How can you best assist the patient in your health care system and community? What kinds of structures, processes, and outcomes will your system want to develop to improve care to this patient and the population of patients that your system serves? How could you work in the community to enhance the population's choices for diet, exercise, or lifestyle?
State Regulation of Health Insurance
Three key pieces of federal legislation set forth national standards that the individual states use to regulate health insurance. First, the Employee Retirement Income Security Act (ERISA) of 1974 provides a framework for states to regulate health insurers. Second, the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 ensures that employees who resigned, were laid off, were terminated, or lost their jobs due to family‐related reasons, can retain their health insurance coverage for up to 18 months and, in some cases, up to a maximum of 36 months if they are deemed qualified and pay the full premiums. A third piece of legislation, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, imposed restrictions on limitations and exclusions of insurance coverage for those with preexisting conditions and restricted other attempts to exclude employees from insurance coverage. It also provides protection of insurance coverage as employees change employers, and it provides tax exclusions for medical savings accounts.
International Perspective
To the extent that the United States is similar economically and socio‐politically to countries such as France, Canada, and Japan, an examination of the health systems in those countries is useful. The differences in health care spending in the United States as compared to other countries as a percent of GDP are graphically displayed in Figure 2.7 (Table 2.3).
Source: Tikkanen, R. (2018). Multinational Comparisons of Health Systems Data, 2018. Retrieved October 6, 2019, from https://www.commonwealthfund.org/sites/default/files/2018‐12/Multinational Comparisons of Health Systems Data 2018_RTikkanen_final.pdf.. (Commonwealth, 2017)
Table 2.3 HIPAA Privacy Regulations
| Allows patient to review and request amendments to their medical recordsGives consumers control over how their personal health information is used and limits the release of information without a patient's consentRestricts the amount of patient information shared between physicians and other caregivers to the minimum necessaryRequires privacy‐conscious business practices, such as hiring a privacy officer and training employees about patient confidentialityRequires that paper records and oral communications be protected from privacy breaches. |
Source: Compiled with information from U.S. Department of Health & Human Services. (1996). Summary of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, available at www.hhs.gov/ocr/privacy
The UK is rated as number one (and spends 9.6% of its GDP on health care), followed respectively by Australia (10.3%), the Netherlands (10.1%), New Zealand (9.0%), Norway (10.4%), Sweden (10.9%), Switzerland (12.3%), Germany (11.3%), Canada (10.4%), France (11.3%), and trailing at 11th with 17.2% of the GDP spent on health care, the United States Papanicolas (2018). The U.S. ranks last overall on health care outcomes. Compared to other countries, the U.S. comes in last on infant mortality, life expectancy at age 60, and deaths that were potentially preventable with timely access to effective health care Papanicolas (2018).
France
France, ranked as having the tenth best health care system in the world, spends 11.3% of its GDP on health care Papanicolas, (2018). This is almost one‐half of what the United States spends on health care per person. Comprehensive health care is guaranteed for all citizens and legal residents in France. Similar to the United States, health care in France is provided through private and government insurance. Unlike Canada and Britain, there are no lengthy wait times in France. Unlike the United States, everyone is insured in France, and there are no additional patient charges for health insurance plan deductibles (Shapiro, 2008). Employed residents are covered by a national health insurance plan, referred to as Sécurité sociale, which includes spouses and children. Another plan, couverture maladie universelle (CMU), provides coverage for those people who do not qualify for the sécurité sociale program, and is free to some people whose income is below a certain level. The national health insurance plan is funded through private and public means, with employees paying up to 21% of their incomes to the national health care system and employers making similar contributions. By comparison, Americans pay fewer taxes but pay more for health care (e.g., through paying health insurance premiums and other out‐of‐pocket expenses not covered by their insurance plans). In France, costs are dependent upon the type of provider seen; for example, a general practitioner is less expensive than a specialist. Likewise, it is more expensive to seek treatment at night, on the weekend, or on public holidays. Hospital care is reimbursed through the national health plan, and a percentage of the cost of prescription drugs is also reimbursed to the patient. Essentially, the sicker a person is, the more coverage is allowed, including for expensive drugs and experimental cancer treatments. Reducing cost and improving efficiency are the challenges for this system. Waste, such as doctor shopping, whereby a patient seeks treatment from more than one health care provider for the same ailment, and overuse of prescription drugs, are partly responsible for high health care costs in France (National Coalition on Health Care (NCHC), 2008; Shapiro, 2008).
Canada
Annually, the Canadian government spends 10% of its GDP on its national health care system Papanicolas, (2018). The Canadian health care system is administered by each Canadian provincial or territorial government. Seventy percent of health spending is publicly funded through federal and provincial taxation of individuals and corporations, and the remaining 30% is paid through private and out‐of‐pocket sources for additional services such as prescription medications or dental and vision care (Canadian Institute for Health Information (CIHI), 2006). All Canadians have equal access to the same quality and quantity of health care. Under the Canada Health Act of 1984, comprehensive health care is publicly administered, portable between provinces, and accessible to all. Primary care is provided by physicians and nurse practitioners, who may work in private clinics or public institutions. These health care providers are reimbursed on a fee‐for‐service basis, which allows them to be reimbursed by each provincial or territorial health plan for each health care service rendered to a patient.
Unlike the privatized health care system in the United States, extra billing, deductibles, and copayments are not allowed. The health care provider bills the provincial or territorial health plan and is reimbursed with an agreed‐upon amount for each health service given. No additional charges or costs can be billed to or recovered from the patient. With only one insurance payer, referred to as a single‐payer system, many of the problems embedded within the American health care system are eliminated. The problem currently facing the Canadian health care system is the lengthy wait times to access family practitioners, specialists, emergency room services, diagnostic tests,
