This research paper deals with comparison between health care systems of United States and India. I chose these two countries because of my familiarity with health care system in India and interest in the U.S health care system. While U.S. and India have few things in common, there are a lot of differences. The health care systems in these two countries are an ideal example of fundamental difference in health care system of an industrialized country and a developing country as well as two different approaches to health care. I will elaborate components of health care system, performance of health care system , health care expenditures, how government in involved, health care coverage and insurance system and a little about administration and payment system.
The health care system in United States can be categorized as public-private health care system while India has a universal health care system.
In US, Health care facilities are largely owned and operated by the private sector. Health insurance is primarily provided by the private sector, with the exception of programs such as Medicare, Medicaid, TRICARE, SCHIP (Children’s Health Insurance Program) and VA (Veterans Health Administration).
Universal health care system is built around the principle of providing universal coverage for all members of society, combining mechanisms for health financing and service provision.
Over the past few years, Indian health care system is in transition. With the growth of Indian economy, more and more money is pumped into nation’s health care system. This infusion of money has resulted in substantial gains in health care including increased life expectancy, reduced infant mortality and the eradication of several diseases; although these gains have been uneven across subpopulations.
A comparison between health care system of US and India can shed light on the challenges that are common to both and also highlight the unique challenges each faces.
What is Health Care System?
Health care system is made up of individuals and organizations that are involved in the delivery of health care to target population. Health care system can also be defined as the organization of people, institutions and resources to deliver health care services to meet the health needs of target populations.
Components of Health Care System
The health care system is made up of three interrelated components; providers, institutions and clients.
People who deliver health care services – the professionals and practitioners are health care providers. Health care providers are the ones that serve the clients and provide them treatments.
The systematic arrangements for delivering health care-the public and private agencies that organize, plan, regulate, finance and coordinate services are the institutions or organizations of the health care system. The institutional component includes hospitals, clinics and home-health agencies; the insurance companies and programs that pay for services like Blue Cross and Blue Shield, managed-care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs); and entitlement programs like Medicare and Medicaid.
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People in need of health care services are health care consumers or clients. Clients receive care from the healthcare provider. They also either pay the payers such as insurance companies who then pay the provider- or they pay the provider directly, or they have their bills paid on their behalf by the government. Providers receive payment from the payers.
Payers are those who finance the healthcare. Payers can include the family of the client, the clients themselves, the insurance companies, or the government.
Performance of health care system
Performance of health care system can be measured by examining which system performs better and its ability to distribute health care to the population. While comparing health care systems of US and India, I am not going to take into account the vast difference in resources available to each country; instead I will focus on the relative measure of total resources available and resources allocated to health care. We will use traditional measure of infant mortality, life expectancy and cancer survivability rate of the target population to compare health care systems of US and India.
Life expectancy at birth is the average number of years to be lived by a group of people born in the same year. This number can be used as measure of health of target population.
Life expectancy in US is 78.3 years.
Life expectancy in India is 64.7 years.
Infant mortality rate is the number of deaths of infants under one year old per 1,000 live births. This number is used as an indicator of the level of health care access and awareness in a country. The infant mortality rate of the world is 49.4 according to the United Nations and 42.09 according to the CIA World Fact book.
Infant mortality rate in US is 6.3.
Infant mortality rate in India is 55.
Cancer survival rate is the percentage of people who survive a certain type of cancer for a specific amount of time, usually measured for five years. This number is good indicator of richness of health care system.
In US, cancer screening tests like mammograms, Pap smear, PSA screening and colonoscopy are used more frequently. US have plenty of diagnostic equipments like Enhanced imaging equipments like LIFE (Lung Imaging Fluorescence Endoscopy), MRI machines and CT scanners. Abundance of these machines results in early screenings for cancer which in turn help in early treatment of cancer.
Cancer survival rate in US is 63% in men and 66% in men
Cancer survival rate in India is 30%.
Health care expenditure
U.S. spends more money on health care than any other nation in the world. In 2008, U.S. spent 16.2% of GDP on health care. This is around $2.3 trillion or $7681 per capita, of these 46% is financed by government.
Healthcare is one of India’s largest sectors in terms of revenue and employment and the sector is expanding rapidly. But it is nowhere near US health care sector in terms of size. During the 1990s, Indian health care grew at annual rate of 16%. Currently, the total value of the sector is more than $34 billion. This is around $34 per capita, or roughly 6% of GDP (private expenditure of 5.0% and public expenditure of 0.9%), of these 19% is financed by government.
Naturally, the overall standard of health care available to the majority of population is poor. The problems of care surrounding childbirth and maternal health, malnutrition in children, all kinds of infectious diseases and infestations are rampant mostly among rural and urban poor who constitute the majority of the population.
Government Involvement in health care
In the U.S., direct government funds health care through Medicare, Medicaid that covers senior citizens over 65, poor and disabled, nursing home care and women with low income and State Children’s Health Insurance Program which covers children in families below 200% of poverty level. The federal government also runs the Veterans Administration, which provides medical care to veterans, their families and survivors.
Some 59% of U.S. residents have employer health care coverage although this figure is decreasing Workers contribution varies widely in this coverage. People who are self employed or unemployed have to purchase their own insurance.
U.S. federal and state governments is more and more involved in U.S. health care spending regardless of large private business. In 2004, governments spent 45% of the $2.2 trillion spent on medical care in 2004. The U.S. government spends more on health care than on Social Security and national defense combined.
Beyond direct spending, the U.S. government is also involved in health care through regulation. For example, the 1973 HMO Act provides for HMO by giving grants and loans.
“The health care system in India is characterized by multiple systems of medicine, mixed ownership patterns and different kinds of delivery structures. Public sector ownership is divided between central and state governments, municipal and Panchayat local governments. Public health facilities include teaching hospitals, secondary level hospitals, first-level referral hospitals (CHCs or rural hospitals), dispensaries; primary health centers (PHCs), sub-centers and health posts. Also included are public facilities for selected occupational groups like organized work force (ESI), defense, government employees, (CGHS), railways, post and telegraph and mines among others”.
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Health care in India is universal health care system run by the constituent states and territories of India. The private sector is the dominant sector in India. In India, already 80% of the curative care is being sought by people from the private sector. Hospitals are run by government, charitable trusts and private organizations. The government hospitals in rural areas are called Primary Health Center. These provide basic health care. If there are patients such as snake bite or heart attack, such patients are given basic drug treatment and then sent to a hospital nearby. Hospitals are located in major cities. Along with modern system of medicine, traditional and indigenous medicinal systems like Ayurvedic and Homeopathy systems are in practice throughout the country.
Indian health care system is run by the state governments. Government hospitals provide preliminary treatment at the expense of taxpayers. Primary care is focused on immunization, malnutrition prevention, pre and postnatal care and treatment of common ailments. Necessary drugs are offered for free in government hospitals. In these hospitals, charges for basic in-hospital check-up and treatment are much less compared to the private sector. But the private sector also is not expensive when compared to western countries. The cost for these subsidies comes from central and state governments.
But government hospitals are not financed enough and have less staff. Since they do not face competition, government hospitals do not maintain basic standards of treatment. Because of these factors, many people are either forced to or prefer to visit private medical practitioners.
The majority of the Indian population is unable to access high quality healthcare provided by private entities as a result of high costs. Many are now looking towards insurance companies for providing alternative financing options so that they too can afford better quality healthcare. 75% of expenditure on healthcare in India is still being met by ‘out-of-pocket’ consumers. Only 10% of the Indian population today has health insurance coverage. The opportunity remains huge for insurance providers entering into the Indian healthcare market since Health insurance has a way of increasing accessibility to quality healthcare delivery for private healthcare providers for whom high cost remains a barrier.
Health Care Coverage and Access
About 16% of US population is uninsured. Also, about 24% of the U.S. population was under-insured and have insurance that barely covers their medical needs. This leaves them unprepared for major medical expenses. According to some studies, about 40% of U.S. citizens do not have sufficient health insurance to cover their health needs. 59% of U.S. citizens have health insurance related to employment, 27% have government-provided health-insurance while nearly 9% purchase health insurance directly (there is some overlap in these figures). Medical debt is the one of the major cause of bankruptcy in the United States. Thus, the cost of health care not the availability of resources is major impedance to health care access in US.
The US federal government does not offer universal health care to all its citizens. But there are some publicly funded health care programs to help elderly, disabled, poor and children. “The Emergency Medical Treatment and Active Labor Act or EMTALA ensures public access to emergency services. The EMTALA law forces emergency health care providers to stabilize an emergency health crisis and cannot withhold treatment for lack of evidence of insurance coverage or other evidence of the ability to pay.” But person receiving health care under EMTALA still has to pay the hospital. Hospital can pursue any defaulter for the cost of emergency services they provided.
When it comes to healthcare, there are two faces of India: a country that provides high-quality medical care to middle-class Indians and medical tourists and a country whose residents have limited or no access to quality health care. Today only 25% of the Indian population has access to Western (allopathic) medicine, which is practiced mainly in urban areas, where two-thirds of India’s hospitals and health centers are located. Many of the rural poor must rely on alternative forms of treatment, such as Ayurvedic and Homeopathy.
A widespread lack of health insurance compounds the healthcare challenges India is facing. Although some form of health protection is provided by government and major private employers, health insurance schemes available to the Indian public are generally basic and inaccessible to most people. Only 11% of the population has any form of health insurance coverage. For the small percentage of Indians who do have some insurance, the main providers are all government run insurance companies. Only 1% of the population was covered by private health insurance in 2004-05.
Because so little insurance is available to the population of India, out-of-pocket payments for medical care amounted to 98.4% of total health expenditures by households, as of the most recent (2001-02) census. Without insurance, the poor must resort to taking on debt or selling assets to meet the costs of health care. It is estimated that 20 million people in India fall below the poverty line each year because of indebtedness due to healthcare needs.
Availability of health care resources
There is a greater availability of health care equipments and facilities for tests such as mammograms and PAP smears (for women), PSA screenings (for men) and colonoscopies in US. Consequently, the use of these tests is more frequent in the U.S. – for example, 86 percent of U.S. women ages 40 to 69 have had a mammogram. The U.S. also is endowed with many MRI machines and CT scanners per capita. Higher levels of screening and equipment helps in early detection and treatment of diseases like cancer.
While no such statistics is available for India, low cancer survivability rate can be attributed to scarcity of diagnostic facilities in India.
“In the United States, access to health care is primarily determined by whether a person can pay for the treatment, by the availability of services in the area and by willingness of the provider to deliver service at the price set by the insurer”.
Waiting time determines how fast a patient is able to get medical attention. Waiting time illustrates efficiency of health care system. In US, the average wait time was 17 days for an appointment with an orthopedic surgeon. One of my friend had to wait 27 days to see a female surgeon.
In India, according to one survey, waiting time is a chronic problem affecting hospitals run by Indian government. 44% patients wait in the hospital for more than two weeks before seeing doctor for preliminary diagnosis. They cannot start treatment before knowing cause of their illness. Although this is not the case in private hospitals.
In some government hospitals, patient has to wait for couple of weeks for X-ray or USG exams. Waiting time for surgery could stretch up to 2 months.
In India, it is not mandatory to reach a government hospital in times of emergency. You can go to your physicians’ private hospital or a multi-facility hospital run by a panel of doctors.
Also you have an easy access to your Primary care physician in case you need to talk to him. This does not happen in U.S. You have to communicate with the nursing staff before talking to your physician.
India faces a huge need gap in terms of availability of number of hospital beds per 1000 population. India stands just a little over 0.7 hospital beds per 1000 population whereas U.S. has 2.5 beds per 1000 population.
Administration accounts for 31% of health care spending in the United States. Some of that money goes to doctors, nurses and other medical professionals.
Private insurance in US has administrative overhead of about 12%, Medicare has administrative overhead of about 4% while Medicaid has administrative overhead of about 7%.
United States have a program to provide prescription drugs to the poor but it is limited. The introduction of Medicare Part D in US has extended partial coverage for drugs to Medicare recipients.
Most important difference between health care systems of US and India is the much higher cost of prescription drugs in the United States. It is very expensive to get a treatment in United States as compared to India.
For instance: cost of normal delivery in Indian private hospitals is approximately Rs 6,000 ($120). It is free of charge in government hospitals for everyone. Caesarean section costs about Rs 20,000 ($400) inclusive of anesthesia charges and drug expense but you pay everything out of pocket. In U.S. cost of normal delivery is approximately $20,000. Insurance plan covers most of the cost but depending on the plan, patients usually receive separate bills for anesthesiology and other expenses.
U.S. disallows Medicare or Medicaid from negotiating drug prices. Therefore, they cannot buy medicines in bulk and lower prices.
In US, the cost of malpractice lawsuits is 0.46% of health care spending which comes to $16 per person each year for the total cost of settlements, legal fees, and insurance. “The total cost of defending and settling malpractice lawsuits in the U.S. in 2001 was approximately $6.5 billion, or 0.46% of total health spending. According to some, defensive medicine consumes up to 9% of American healthcare expenses”.
India has fewer doctors per capita than the United States. US have 2.3 doctors per 1,000 people in 2005 while India has 0.6 doctors per 1000 people. Physicians are paid fee for service. Now multi-facility clinics have a panel of doctors who work as hospital employees.
There are a number of additional costs that are significantly higher in the U.S. Government orders on keeping the records of insured people which results in greater administrative effort. Higher marketing costs by insurance companies and health care providers contribute to higher health care costs.
Overall health care system in India and U.S has their own drawback and benefits. U.S. health care system is better in terms of cost coverage and quality health care but it is more expensive than that in India and lack of universal care affect the poor people in U.S.
Patient Protection and Affordable Care Act passed on 23rd March, 2010 mandates universal coverage for all. This will certainly benefit the poor. “So, by expanding resources and making health care more affordable and accessible to many Americans through premium tax credits, individual mandates, the expansion of Medicaid, new employer benefits and responsibilities, and state-based Exchanges, the United States has taken a step in the right direction. Health care reform will absolutely grant many millions of Americans with what we feel is a basic human right: access to health care”.
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