Medizinische Soziologie. Das Gesundheitssystem I: USA und UK

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1 Vorlesung WS 2011 / 2012 Medizinische Soziologie Das Gesundheitssystem I: USA und UK Thomas Kohlmann, Sandra Meyer-Moock & You-Shan Feng Institut für Community Medicine Universität Greifswald

2 Models of Health Systems Beveridge Model Bismarck Model National Health Insurance Out-of-pocket Medizinische Soziologie Vorlesung 2011/2012 2

3 General Characteristics Pop: 62,041,708 (2010 est) Size: 243,610 km 2 GDP: $35,720 (2009 Est) Parlimentary Pop: 310,872,000 (2010 est) Size: 9,826,675 km 2 GDP: $47,701 (2009 est) Federalist/Presidential Medizinische Soziologie Vorlesung 2011/2012 3

4 International Comparison of Spending on Health, Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP United States Norway Switzerland Canada Netherlands Germany France Denmark Australia Sweden United Kingdom New Zealand United States France Switzerland Germany Canada Netherlands New Zealand Denmark Sweden United Kingdom Norway Australia Figures from The Commonwealth Fund Website. Source Data: OECD Health Data 2010 (June 2010): Medizinische Soziologie Vorlesung 2011/2012 4

5 Mortality Amenable to Health Care * Countries age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S. Deaths per 100,000 population* France Australia Italy Japan Sweden Norway Netherlands Austria Finland Germany Greece Ireland New Zealand Denmark United Kingdom Source: Adapted from E. Nolte and M. McKee, Variations in Amenable Mortality Trends in 16 High Income Nations, Health Policy, published online Sept. 12, United States Medizinische Soziologie Vorlesung 2011/2012 5

6 Overview UK Health System Public System Equal access to the entire population living in the UK Centrally Regulated US Health System Hybrid System Market Based Disbursed Regulation Health and Social Care Act 2012 Patient Protection and Affordable Care Act (ACA, Obamacare ) Medizinische Soziologie Vorlesung 2011/2012 6

7 Brief History of the UK Health System Medizinische Soziologie Vorlesung 2011/2012 7

8 1911: Mixed Bag Trade Unions Friendly Societies Employers Etc. Private Insurances Providers 1948 (Post WWII): National Health Service Hospitals Budget Salary Specialists General Taxes Capitation GPs Gatekeeper Figures adapted from: Bodenheimer TS & Brumbach K. (2002). Understanding Health Policy: A Clinical Approach, Third Edition. The McGraw Hill Companies, Inc Medizinische Soziologie Vorlesung 2011/2012 8

9 1979, 1980s Conservatives: Introduces Internal Markets Strategic Health Authorities (SHA) Budget Buy Services Hospitals General Taxes Specialists Expanded Capitation GPs Buy Services Providers Purchasers Figures adapted from: Bodenheimer TS & Brumbach K. (2002). Understanding Health Policy: A Clinical Approach, Third Edition. The McGraw Hill Companies, Inc Medizinische Soziologie Vorlesung 2011/2012 9

10 1997, 2000s New Labour: Competition + Regulation Strategic Health Authorities (SHA) Hospitals General Taxes Expanded Capitation Negotiate Contract Specialists Contract: Private Providers Primary Care Trusts (PCT) Figures adapted from: Bodenheimer TS & Brumbach K. (2002). Understanding Health Policy: A Clinical Approach, Third Edition. The McGraw Hill Companies, Inc Medizinische Soziologie Vorlesung 2011/

11 Increasing Access and Patient Choice Figure taken from: Medizinische Soziologie Vorlesung 2011/

12 Inpatient waiting times, England, (months waited) Medizinische Soziologie Vorlesung 2011/

13 Health & Social Care Act 2012 the status quo is not an option Create an independent NHS Board, promote patient choice & to reduce NHS administration costs. 1.4 billion (Milliarden) Medizinische Soziologie Vorlesung 2012/

14 Health & Social Care Act 2012 Some Key Reforms any willing provider Abolish PCT and SHA & cut NHS management Clinical commissioning groups (GP consortiums) hold budget to buy care for their patients Public Health England responsible for publich health nationally HealthWatch groups funded by local authorities will monitor health care & service quality Monitor will be an economic regulator to oversee aspects of access and competition in the NHS Medizinische Soziologie Vorlesung 2012/

15 Medizinische Soziologie Vorlesung 2012/

16 Brief History of the US Health System(s) Medizinische Soziologie Vorlesung 2011/

17 Pre 1900s: Nearly no third party health plans Out of pocket Individual Provider Early 1900s: Private Insurance Health Plans Premium Reimbursement Individual Health Plan Provider Figures adapted from: Bodenheimer TS & Brumbach K. (2002). Understanding Health Policy: A Clinical Approach, Third Edition. The McGraw Hill Companies, Inc Medizinische Soziologie Vorlesung 2011/

18 World War II: Employer Sponsored Health Plans Premium Reimbursement Employee + Employer Health Plan Provider 1965 Medicare & Medicaid: Government Sponsored Health Plans Workers Individuals Taxes Enrollment (Premium) Public Plan Reimbursement Provider Figures adapted from: Bodenheimer TS & Brumbach K. (2002). Understanding Health Policy: A Clinical Approach, Third Edition. The McGraw Hill Companies, Inc Medizinische Soziologie Vorlesung 2011/

19 Health Insurance Coverage in the U.S., 2008 SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2009 CPS; figure from the Kaiser Family Foundation Website. Uninsured 15% Employer- Sponsored Insurance 52% Medicaid/ Other Public 13% 1974: ERISA 1985: COBRA 1996: HIPPA Total = million Medicare 14% Private Non- Group 5% Medizinische Soziologie Vorlesung 2011/

20 Brief Overview of Health Maintenance Organizations Medizinische Soziologie Vorlesung 2011/

21 HMOs IPA-Model HMOs Health Plan Physicians Hospitals Health Plan Hospitals Pharmacies Physicians Pharmacies Figures adapted from: Bodenheimer TS & Brumbach K. (2002). Understanding Health Policy: A Clinical Approach, Third Edition. The McGraw Hill Companies, Inc Medizinische Soziologie Vorlesung 2011/

22 Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Family Coverage, * Estimate is statistically different from estimate for the previous year shown (p<.05). Source: Kaiser/HRET Survey of Employer Sponsored Health Benefits, Figure from Kaiser Family Foundation Website 1999 $5,791 $1,543 $4,247 Worker Contribution 2000 $1,619 $4,819* $6,438* Employer Contribution 2001 $1,787* $5,269* $7,061* 2002 $2,137* $5,866* $8,003* 2003 $2,412* $6,657* $9,068* 2004 $2,661* $7,289* $9,950* 2005 $2,713 $8,167* $10,880* 2006 $2,973* $8,508* $11,480* 2007 $3,281* $8,824 $12,106* 2008 $3,354 $9,325* $12,680* 2009 $3,515 $9,860* $13,375* 2010 $3,997* $9,773 $13,770* $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14, Medizinische Soziologie Vorlesung 2011/

23 Decline in Employer Sponsored Health Insurance Medizinische Soziologie Vorlesung 2011/

24 Health Insurance Coverage in the U.S., 2008 SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2009 CPS; figure from the Kaiser Family Foundation Website. Uninsured 15% Employer- Sponsored Insurance 52% Medicaid/ Other Public 13% Total = million Medicare 14% Private Non- Group 5% Medizinische Soziologie Vorlesung 2011/

25 Public Plans Medicare (1965) Federal Level for >65 years old and eligible for social security, those with severe disabilities and those with chronic renal disease Part A hospital insurance Part B supplementary medical services Part C (1997) option to join plans structured as PPOs and HMOs Part D (2003) prescription drug coverage Medicaid (1965) State Level Low income and disabled SCHIP (1997, reauthorized 2009) State Level Children in low income families Military/Veteran s Association (1930) Military and former military personnel Medizinische Soziologie Vorlesung 2011/

26 Chart 4.6: Aggregate Hospital Payment-to-cost Ratios for Private Payers, Medicare, and Medicaid, Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2008, for community hospitals. (1) Includes Medicaid Disproportionate Share payments. Figure from American Hospital Association s Trendwatch Chartbook Medizinische Soziologie Vorlesung 2011/

27 Children s Eligibility for Medicaid/CHIP by Income, December 2009 WA VT NH ME OR CA NV ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS NY MI PA OH IN WV VA KY NC TN SC AL GA DE CT NJ MD DC MA RI TX LA AK FL HI < 200% FPL (4 states) % FPL (23 states) 250% or higher FPL (24 states, including DC) *The federal poverty line (FPL) for a family of three in 2009 is $18,310 per year. **IL uses state funds to cover children above 200% FPL. MA uses state funds to 400% FPL. SOURCE: Based on a national survey conducted by KCMU with the Center on Budget and Policy Priorities, Medizinische Soziologie Vorlesung 2011/

28 Health Insurance Coverage in the U.S., 2008 SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2009 CPS; figure from the Kaiser Family Foundation Website. Uninsured 15% Employer- Sponsored Insurance 52% Medicaid/ Other Public 13% Total = million Medicare 14% Private Non- Group 5% Medizinische Soziologie Vorlesung 2011/

29 Total Number of Uninsured, Note: Figures for are U.S. residents without hospital insurance. Data: National Health Interview Survey, Current Population Survey, The Lewin Group. Figure Taken from Commonwealth Fund Website Millions uninsured Medizinische Soziologie Vorlesung 2011/

30 Medizinische Soziologie Vorlesung 2011/

31 Patient Protection and Affordable Care Act 2010 (111th congress) March 23, 2010: President Obama signed the bill into law Insure 32 million americans in the next 10 years $940 billion (Milliarden) Medizinische Soziologie Vorlesung 2011/

32 Protection Affordable Mandated health insurance for all residents Large employers must provide insurance for employees Expand Medicaid and CHIP Temporary high-risk pool (now to 2014) New private insurance regulations Provide premiums for low income families Provide funds for health insurance for small businesses Create state-based Exchanges "Health Reform Hits Main Street Video: Ilc5xK2_E Text Summary: Implementation Timeline: Medizinische Soziologie Vorlesung 2011/

33 Subsequent Actions "Repealing the Job-Killing Health Care Law Act" (H.R.2): June 8, 2012: Supreme court upholds all but one provision of the ACA Medizinische Soziologie Vorlesung 2012/

34 From: From Kaiser Family Foundation: Medizinische Soziologie Vorlesung 2012/

35 Some additional resources Informative, entertaining and free radio segments about the American health care system (created for lay audiences). Comparative Health Politics: The United States and the United Kingdom Journal of Health Politics, Policy and Law (Duke University Press) Special issue in Feb Medizinische Soziologie Vorlesung 2011/

36 Thank you for your attention! Medizinische Soziologie Vorlesung 2011/

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