Healthcare system is one of the most important social institutions in every state. Its development and up-to-date technologies have a great impact on health of individuals and their well-being. The United States and Great Britain are two developed countries which good healthcare systems which allow the state to treat debases and support people in need. The main problems identified by researchers in Great Britain and the United States are financial budgeting and increased role of technology at expense of human relations and communication. One of the side effects of the preoccupation of the people with the capabilities of high-tech medicine has been the neglect of the role that individuals can and must play in the maintenance of their health through wholesome personal behavior and lifestyles. The potential contribution that expanded efforts at preventive medicine and health education can make to the nation’s health has also been neglected. Although there has been a marked decline in smoking and, to a lesser extent, the consumption of alcohol (largely among the better-educated, higher-income population), the nation has been plagued by increasing use of addictive drugs. Paying for healthcare services creates more uncertainty and doubt for American citizens while the UK society relies on state policies and government spending ensuring stable development and coverage of all social classes.
The United States
Most states report increasing financial difficulties stemming from their rising Medicaid outlays. The governors have noted repeatedly that escalating medical costs have left them with little or no scope to enlarge expenditures for urgent projects in other high-priority areas, such as education, highways, and prisons. Although the states have considerable discretion in determining the number of people to be covered by Medicaid and the range and depth of services that they provide, the program operates under federal statutes, which stipulate the categories of individuals for whom eligibility is mandatory and the minimum benefits that must be offered. Moreover, Congress has the authority to pass legislation mandating additional coverage with which the states must comply (Raffel and Barsikiewicz 2001). Since the mid-1980s, Congress has taken this route to broaden access to Medicaid services for low-income pregnant women and young children. Although the governors have requested at least a temporary halt to further federal mandates, Congress has been unsympathetic because it was concerned with the poor record of the United States in reducing its infant mortality rate, which far exceeds that of other advanced nations. The single largest non-governmental source of funding for the U.S. health care system is private health insurance, primarily through the health care benefits that employers provide employees (and their dependents) supplemented by coverage that individuals purchase for themselves. In 1993, private health insurance accounted for almost 32 percent of total health care outlays, making it an approximately equal partner with the federal government. The employer community has become increasingly concerned with its failure to control steeply rising costs for health care benefits despite a wide range of efforts, from self-insurance to pressuring their employees to join a managed-care plan (Naidoo and Wills 1997).
Such prepaid, capitated plans guarantee their members a wide range of benefits, provided by a selected pool of physicians whose discretion in the treatment of their patients is regulated by the plan, and promises potentially lower costs than traditional indemnity coverage. Many employers contend that their competitive position has been undermined as a result of their much higher health care costs compared to their foreign competitors, European or Japanese. But the issue of competitiveness aside, there is mounting evidence that growing numbers of employers–large, medium, and small–find the yearly increases in their health care benefit costs threatening to their continuing profitability (Naidoo and Wills 1997). The last major payment source is out-of-pocket expenditures by individuals for the health care services they obtain. Such payments cover just under a fifth of all health care costs, but only part of these outlays goes for physician or hospital care. Out-of-pocket spending is primarily for nursing home care, drugs, and dental care. Recently, the share of such payments has risen because of employer pressure on workers to assume a larger part of the costs of their health insurance coverage in the form of increased co-insurance and deductibles (Raffel and Barsikiewicz 2001).
It is something else if, having decided in favor of private insurance, a substantial and growing number of persons are unable to obtain or maintain coverage because of market strategies that the insurance companies pursue. Other perceived sources of weakness in the health care system are reflected in the patent public resentment of the relentless increases in health care costs. Blame is assigned to the inefficiency of the hospital industry, the avariciousness of the pharmaceutical manufacturers, the greed of the medical profession, excessive administrative expenses, the overtreatment of moribund patients, malpractice litigation with its inflated awards, misused expensive technology, and widespread fraud and abuse by providers (Naidoo and Wills 1997). Other things being equal, the odds favor continuation of the current system of health care financing and the delivery of services in the United States, surely within the constrained time frame of this decade (Raffel and Barsikiewicz 2001). Other things, however, are not equal, especially the total dollar amounts required to support the rising costs of the system and the disenchantment of growing numbers of the public with the future security and quality of their health insurance coverage.
In contrast to the USA, healthcare system in United Kingdom is funded by general taxation and all residents receive It is important to note that even under the centrally controlled National Health Service in Great Britain, approximately 30 percent of all elective surgery is performed outside the governmental system. In most other countries of Western Europe as well, payments originating outside government and insurance–that is, out-of-pocket contributions of households–often comprise 20 to 25 percent of total health care expenditures (Komaromy 2006). Some years ago, the government enacted legislation prohibiting the purchase of supplemental private insurance, but within a few years the unpopular measure was rescinded. In the United States, a country characterized by variations in income levels and a historic commitment to individual freedom of choice and decision making, it would be difficult to conceive of a reform effort that aimed to impose a cap on all expenditures for health care, including the use of personal funds by individuals who wish to obtain one or another type of approved medical treatment (Naidoo and Wills 1997).
The Great Britain experience and our own suggest that when consumers are forced to rely on out-of-pocket disbursements to pay in whole or in part for a variety of products and services, low-cost as well as luxury items, the demand for these items declines. In the arena of health care, obvious examples are the virtual disappearance of private accommodations in hospitals (the few single rooms that remain are reserved for physician-prescribed situations) and similarly, private duty nursing, the low frequency of cosmetic surgery and the underutilization of dental care (Moran, 1999). This eases to some degree the pressure on governmental and insurance payments. In general, health care analysts believe that individuals should continue to be responsible for selected payments, partial or full, for the medical services and products that they need or desire. There is, however, disagreement on the role that out-of-pocket payments should play in determining the demand for health care services. Given the difficulties of designing and implementing an effective mechanism for budgetary constraint in the health care sector, it would appear judicious to allow households to supplement the funds provided by government and insurance Komaromy 2006).
Problems and Difficulties in the USA and Great Britain
In the USA, the opinion polls suggest that a growing majority of Americans favor early action to provide insurance coverage for the entire population, although they express considerable ambivalence about assuming any significant additional tax liabilities to pay for it (Williams and Torrens 2001). The elderly and the population approaching retirement are concerned that Medicare does not offer extended nursing home coverage. If either universal coverage or long-term care, or both, we’re easy to finance and implement, their enactment along with a program aimed at moderating total health care expenditures would elicit broad public support. However, the relative indifference of the public thus far to the remorseless increase in health care expenditures, the erosion in benefits that many will face as part of a major reform effort, and the difficult choices that will have to be made among alternative methods to restrain total outlay suggest that it may be preferable, at least for the time being, to defer the issue of long-term care (Raffel and Barsikiewicz 2001).
Competition in the internal market is introduced by separating those who purchase or commission health care from those who provide it. In England and Wales, DHAs, FHSAs, and GP fundholders are primarily responsible for commissioning health care. By contrast, health care is provided by NHS Trust hospitals, the small number of hospitals under the supervision of DHAs, and FHSAs. Momentum is achieved in the market by enabling GP fund-holders to compete on quality by using their funds in the ways they consider most appropriate in the interests of their patients. Similarly, NHS Trust hospitals are obliged to attract custom by providing a high-quality, low-cost service to patients (Moran, 1999). Contracts between commissioners and providers are negotiated at local level and, subject to national policy constraints, the assessment of health needs will be dominated by local influences Komaromy 2006). This incentive to attract more customers has no doubt enabled some hospitals to do more work than others. It has not, however, entirely resolved the problem of the efficiency trap. One would expect the major part of a hospital’s revenue to arise from block contracts, in which a lump sum payment is agreed by a DHA purchaser for a category of work. In this case, even the most efficient hospitals with the greatest income will face the prospect of exhausting their revenue before the end of the financial year because the money available to purchasers remains limited (Williams and Torrens 2001).
In the current UK system it is more accurate to say that purchasers of health care decide how and when to spend resources, and therefore that the patient follows the money. Research so far suggests that the internal market for health has not significantly expanded the choices available to patients and doctors. Inevitably, with significant purchasing power in the hands of general practices, there has been a power shift away from consultants and toward fund-holders (Komaromy 2006). Waiting times for treatment are reduced, for example, because a consultant has spent a day a week in the fundholder’s clinic, or the provider has extended its facilities. In addition, laboratory testing has improved by competition from private services, and GPs have generally been able to exercise more influence over hospital services( Moran, 1999).
The main problem for the Great Britain healthcare system is that its only strategy is to increase short-term efficiency and value for money. On one analysis, the closure of a hospital ward, indeed the closure of the entire hospital, may represent the finest example of market forces in action. If the cost of its procedures is higher than those of other hospitals, its income will decline as GPs and DHAs purchase less expensively elsewhere. Patients, however, may hold that the same hospital in the highest regard (Moran, 1999). To them, its closure might be considered a disaster. A ‘pure market’ cannot take into account, as Tomlinson recommended, how and when the adjustments should occur. For this reason, the effects of the market in health care must be regulated to preserve continuity and standards, and to implement strategy. Additional funding is needed to plan the adjustments which market forces introduce. To maintain consistency and reliability, funds must always be reserved to allow services to be phased in or out over a reasonable period of time (Williams and Torrens 2001).
In terms of the health care system, the nation has never faced up to the issue of providing all members of the society with insurance coverage that would ensure them access, or at least remove the financial barriers in seeking access, to essential health care. Although the issue has gained increasing visibility, the United States has been slow to undertake such a commitment. There is, however, another side to the coin: Americans have at the same time refrained from decisions that would explicitly impose rationing, such as prevails in many other advanced countries, where age and similar criteria arbitrarily limit the availability of high-cost medical interventions (Komaromy 2006). Arguably, such avoidance is a failure, not an achievement, since distributive justice and equity might be better served by a formal system of rationing. However, many patients who would have been refused critical services under a formal rationing system have benefited from life-prolonging treatment under the more haphazard arrangements that continue to prevail in the United States (Moran, 1999).
A description of the management structure of the NHS is a very limited way of analysing accountability. After all, the NHS is financed from general taxation and provides a public service. It ought also to be sensitive to matters which concern those whom it serves and who pay for it. One such concern is about proper standards of public life. Quite apart from the funds generated from NHS contracts with health authorities and GP fund-holders, hospitals in the NHS may raise revenue from (i) private patients and (ii) NHS patients. As a general rule services provided to patients in the NHS ‘shall be free of charge except in so far as the making and receiving of charges is expressly provided for by or under any enactment. However, private fee paying care may be provided in NHS hospitals. Similarly, under arrangements made with medical or dental practitioners, a health authority may allow accommodation and services to be made available for the treatment of private patients of the practitioner. In the USA, since Medicare was designed as an entitlement program and Medicaid as a quasi-entitlement program, federal and state governments have had little alternative but to meet the steeply rising bills presented to them. Private employers have also exercised all due deliberation in seeking to modify the health care benefits they provide their employees. Like government, most employers have felt committed to paying the health care costs incurred by their employees. The other side of the coin reflects the mounting claims for payment, submitted primarily by physicians and hospitals, that have operated under few market or other constraints to control the volume of services that they provide even while continuously striving to improve the quality of care that they offer. Looking at the dynamics of the health care market in retrospect, the wonder is not that total health care outlays increased fourfold since the mid-1960s but that, in the absence of governmental and market controls, the increases were not even greater. Relatively few Americans have any awareness of the implications of continuing health care spending at its present rate with an approximate doubling of the absolute dollar outlay and a 50 percent increase in the share of GDP between now and the decade’s end. There has been even less recognition of or debate over the implications of potential governmental action to arrest this explosive trend. Corrective action is indicated in at least four areas to adjust for the disproportionate benefits that now accrue to those at the upper end of the income distribution. In contrast to Great Britain, relatively little attention has been paid to expansion of the biomedical R&D enterprise in the United States, supported with federal funds and conducted through informal, highly productive relations with the leading academic health centers on the one hand and with private, profit-seeking pharmaceutical and medical equipment manufacturing companies on the other.
Komaromy, C. (2006). Dilemmas in UK Health Care (Health and Disease). Open University Press; 3rd edition.
Moran, M. (1999), Governing the Health Care State: A Comparative Study of the United Kingdom, the United States and Germany. Manchester: Manchester UP.
Naidoo, J. & Wills, J. (1997). Health Promotion: Foundations for Practice. London: Baillière Tindall.
Raffel, M. W. Barsikiewicz, C. (2001), The US Health System: Origins and Functions 5th Edition. Delmar Cengage Learning.
Williams, S., Torrens, R. R. (2001), Introduction To Health Services. Delmar Cengage Learning; 6 edition.