The public health care system is meant to help those with financial problems (be they related to age, disability or other causes). Actually the system does not work properly because to be properly cured it seems you have to be poor or rich in the U.S.. More precisely, Americans have Medicare which is a federal social insurance program run by the United States government, providing health insurance coverage to people who are 65 or over and disabled. This program/service is divided in three categories: Medicare part A which covers hospital bills, Medicare Part B which covers medical insurance, and Medicare Part D which covers prescriptions for drugs, (Medicare Part C is a mix between A and B). Then, in the U.S. they have Medicaid. It is another service (single-state administered) available for some, but not all of the poor. Indeed, the main criterion for Medicaid eligibility is limited income. There are other Medicaid eligibility categories related to age, pregnancy, disability, blindness, income and resources. Medicaid services can be assigned to private health insurance companies or just payed by the state. Madicaid includes dental services which should at least provide pain relief and restoration of teeth. Centers for Medicare and Medicaid Services (CMS) control the state-run programs and determines requirements for service quality and eligibility. Some states operate a program known as the Health Insurance Premium Payment Program (HIPP). This program allows a Medicaid Recipient to have private health insurance paid by Medicaid. Often this gives the recipient a better coverage, and more doctors available to them. This option is the best one can get but what you can get strongly depends on the State you live in. Another minimum public service is EPSDT (Early and Periodic Screening, Diagnostic and Treatment) whereby individuals below the age of 21 are not to be limited emergency services. EPSDT is compulsory for children. Then, there is a special program: the State Children's Health Insurance Program which covers children of low-income families. once again it seems that you must be poor to be cured. As a matter of fact the public 'heal-care-system people' do not consider that a middle-class family can get poor because of the medical treatments they have to face privately; it is a vicious circle. Despite this, the government does not forget his sons. Indeed in the U.S. they also have the Veterans Health Administration which deals with U.S. veterans through a nationwide system of hospitals, stop being continuously at war would be a more effective treatment though, but this solution is not contemplated in the program. There is even an Indian Health Service (IHS), for the relationship with natives is really different than once now. The IHS is supported by other government agencies such as the National Institutes of Health (NIH) together with the National Institute on Drug Abuse (NIDA) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).

Privare healthcare (Nicola Canton)

As far as the private healthcare is concerned, for medium-income-citizens, the cost of medicines is frequently not covered by insurance, and U.S. citizens sometimes go to Canada and Mexico for drug purchases, as we can see in Michael Moore's movie "Sicko". Basically, you might receive state financial helps but they cannot be enough for covering all the costs. Some States are trying to help more those people with financial problems. (see Minnesota and Massachusetts with their recent 2006 Health Reform Statute). However, employer-benefit -based health insurance is still the more common with bigger companies. Workers injured on the job are covered by government mandated worker compensation insurance and wage replacement benefits. These benefits (which cover only a percentage of your weekly wage) are different according to the state considered and risky jobs are linked to higher insurance costs than other safe jobs, that is not that democratic, because usually risky jobs are those which are paid less but maybe 'they' did not realize it, running health care programs is difficult indeed. While, Workers' Compensation is an insurance paid by your employer and provides cash benefits and medical care if you become disabled because of an injury or illness related to your job. All employees are covered by the Workers' Compensation Law. Relatives can receive the benefit of one's insurance in case of death. The insurance carrier for New York State is the State Insurance Fund (SIF). In order to pay wage replacement benefits, the S.I.F. needs an accident report from your employer and a medical report from a doctor indicating your disability is a job-related injury. It is a government mandated requirement that every business carry this type of insurance in almost every state. There are different types of workers compensation insurance programs available. For an employee who has been working in a company for a long time, it generally means that the company takes care of his needs and provides excellent benefits. If the employer is not able to afford to cover their employee, the employee can sue them for negligence. But besides these kind of insurances, the US market-based care system counts primarily on private resources. Private companies such as United Health Care study you a lot before deciding about your eligibility. That is when problems arise. Private healthcare companies do not want people that are surely going to get ill. That is all. A Company runs a business but your health is not a product. That is why a private health care system produces numbers of social and moral problems. A positive thing, however, is that at the end of the year, when you have to declare your income for tax paying, you can receive a little discount calculated on your health care expenses, it is not much but it is something, if you are still alive.

The issue of a Universal Health Care in the USA. (Elena Sottil)

There is no way to measure objectively which health care is the best in the world. Universal health care refers to the idea that every American should have access to affordable, high-quality health care. America does not measure well against other countries on many health indicators. Whatever one may think about the US health care there are some numbers which cannot be denied:^[1]

the United States ranks

- 23rd in infant mortality, down from 12th in 1960 and 21st in 1990

- 20th in life expectancy for women down from 1st in 1945 and 13th in 1960

- 21st in life expectancy for men down from 1st in 1945 and 17th in 1960.

Overall U.S.A. is 67th, right behind Botswana. Outcome studies on a variety of diseases, such as coronary artery disease, and renal failure show that the United States' position is below Canada and a wide variety of industrialized nations. On one hand all of these performances are really strange especially given that America spend almost twice as much per capita on healthcare than any other country. On the other hand it is true that the United States offer some of the best care in the world, for those who can afford it.

The most controversial idea is that Universal Health Care would be too expensive but the United States spends on health care more than any other industrialized country with universal health care. Some politician make reference to Canada as a clear example of a universal care system with problems but the costs of health care in this nation is not so high as in the United States, despite the US economy is much stronger. In Canada the health care is known as a single payer system where basic services are provided by private doctors, but the entire fee is paid by the government at the same time. Most all family doctors receive a fee per visit. These rates are negotiated between the provincial governments and the province's medical associations.^[2]

Then, it is to be considered that, after all, the US, denies access to health care to those who can not afford it. Another key point is that in the US you can not chose who you want to be cured by, it depends on your insurance. With a universal health care system there would be free choice of health care providers. In addiction, with a universal Health Care, taxes, fees and benefits would be decided by the insurer. It would not be a government controlled system, although the government would have to approve the taxes. The system would be run by a public trust, not the government.

The level of satisfaction with the US health care is the lowest of any industrialized nation. 80% of citizens and 71% of doctors believe that this Health Care has caused quality of care to be compromised. Managed health care can not solve the US health care problems because health care is not a commodity one can buy, and quality of care must always be compromised when the motivating factor for corporations is to save money through denial of care and decreasing provider costs. Hence in America health is trated as an economic good and not as a social or public good. As the world-famous Princeton health economist Uwe Reinhardt pointed out: "The issue of universal coverage is not a matter of economics. Little more than 1% of GDP^[3] assigned to health could cover all. It is a matter of soul."^[4]

Sistema Sanitario Nazionale (Leah)

Assistenza a regime pubblico:

In Italia, l' assistenza a regime pubblico è il SSN, il Servizio Sanitario Nazionale. Il concetto di SSN nasce dopo la Seconda Guerra Mondiale perche’ si voleva dare a tutta le gente una efficente e uniforme assistenza sanitaria. Cosi in 1978 fu fondato il SSN che rappresenta un grande passo in avanti per la Civilta’ Democratica perche’ viene garantita l’assistanza sanitaria a tutta la popolazione senza nessuna discriminazione di sesso, eta’ o fascia economica, ed in piu’ viene garantita l’assistenza medica a tutto i turisti o cittadini al di fuori della EU in caso di emergenza. Un altro traguardo importante e’ stato raggiunto nel 1998 quando il SSN fu separato dall’INPS e fu prevista nell' IRAP (Imposta Regionale Sulle Attivita` Produttive) una tassa per garantire il SSN a se stessi e agli altri membri della famiglia, come per esempio i bambini sotto i 16 anni. Se un cittadino non rietra all’interno di queste categorie deve fare ricorso al Servizio Sanitario Privato. Il SSN e’ gestito a livello Regionale da aziende come ASL e USL ( Azienda di Sanita’ Locale e Unita’ Sanitaria Locale) che favoriscono l’efficenza.^[5] Il SSN provede a dare alle persone che ne hanno bisogno esami, cure mediche, trapianti; visite specialistiche come ad esempio visite pediatriche (con scelta gratuita del proprio dottore) o ostetriche. Per altri servizi, come test in laboratorio o il servizio di ambulanza, le vaccinazioni o iservizi sociali come il consultorio hanno dei costi relativamente bassi. Il ricovero ospedaliero e’ completamente gratuito. ^[6]

Assistenza a regime privato:

In Italia c’e’ un processo di trasformazione dello Stato nel senso che si sta compiendo negli ultimi anni un fatto federale che ha un portato profondo mutamento nella sanità italiana per garantire a tutti il diritto di curarsi in maniera democratica; si può quindi scegliere tra il Servizio Sanitario Nazionale e le cure private, con l’obbligo, però, di una assicurazione privata. Per tutti c’è l’obbligo di seguire una delle due strade di assicurazione contro le malattie. Con un servizio sanitario con assicurazione non si metterebbe in crisi il SSN ma semplicemente quest'ultimo non avrebbe piu’ il monopolio assoluto e quindi ci sarebbero delle condizioni di mercato e di concorrenza tra le strutture pubbliche e quelle private. Bisogna dire che in Italia c’e’ una grande interconnessione tra le strutture private e quelle pubbliche e le private si distinguono principalmente in due categorie: piccole strutture che offrono prestazioni di bassa specialita’ come per esempio strutture riabilitative, lungodegenza e psichiatriche, oppure strutture di grandi dimensioni fortemente orientate all’alta specialità, , impegnate nella ricerca e coinvolte nella rete dell’emergenza-urgenza. L’intensificarsi delle relazioni tra le strutture private e le strutture pubbliche fa si che tutto il sistema migliori in modo tale che venga garantito a tutta la popolazione un trattamento sanitario completo, efficace ed efficente. ^[7]

A comparison between the US and the Italian health care system (Davide Pozzato)

ITALY

The extension of universal health care coverage to the whole population is a key characteristic of the Italian health care system. This system was replaced in 1978 by the institution of the Italian National Health Service (NHS), Servizio Sanitario Nazionale. The NHS was created to achieve the objective in article 32 of the Italian Constitution, which declares that the Italian state has the responsibility of safeguarding the health of each citizen as an individual asset and a community interest. Moreover, article 32 affirms that the Italian state guarantees free care to the indigent.

The Italian NHS is decentralized, because of a recent strong policy of devolution, which shifts power to the regions. National legislation from 1992 to 1993 and subsequent reforms in 1997 and 2000 have radically transformed the NHS, giving the 20 regions political, administrative, and financial responsibility regarding the provision of health care.

The Italian state retains limited supervisory control and continues to have overall responsibility for the NHS to assure uniform and essential levels of health services across the country.

Universal coverage entitles all citizens, regardless of their social status, to equal access to essential health care services, services that are necessary and appropriate to promoting, maintaining, and restoring health in the population.

Essential health services are provided free of charge, or at a minimal charge, and include general medical and pediatric services; essential drugs and those for chronic diseases; treatments administered during hospitalization; rehabilitation and long-term postacute inpatient care; instrument and laboratory diagnostics, as well as other specialized services for early diagnosis and prevention.

Finally, the NHS guarantees that the system is subject to popular democratic control at the national, regional, and local level. The Italian NHS is structured into three different levels

of public authority: the central government, the regions, and the local health care agencies (LHAs)—Agenzie Sanitarie Locali.

The central Governement

As the main organization of the NHS, the Ministry of Health is responsible for national health planning, including general aims and annual financial resources to be spent on health, and rules the commercialization of drugs and medical equipment in accordance

with the European Union regulations. In addition, the Ministry of Health is responsible for monitoring and taking measures to improve the health status of the population and assure a uniform level of services, care, and assistance to the population.

The Regions

Recent national legislation has transferred several important administrative and organizational responsibilities and authority from the central government to the 20 regions. These measures, the results of which are still unclear, aim to make the regions more sensitive to the need for controlling expenditures and promoting efficiency, quality, and citizen satisfaction. The 20 regions define a regional plan in accordance with central government guidelines. Regional activities must be covered by regional laws approved by Parliament, although these laws may vary from one region to another. The regions have significant autonomy on the revenue side of the regional health budget, and are required to fund any deficit that might occur from their own resources, beginning with the 1992–1993 reforms. The regions organize services that are designed to meet the needs of their specific populations, define ways to allocate financial resources to all the LHAs within their territories, monitor LHAs’ health care services and activities, and assess their performance.

In addition, the regions are responsible for selecting and accrediting public and private health services providers and issuing regional guidelines to assure a set of essential health

care services in accordance with national laws.

The Local Health Agencies

The LHAs form the basic elements of the Italian NHS. In 1998, there were 196 LHAs in Italy providing health care services to the population. Each LHA is financed from its region under a global budget with a weighted capitation system. In addition, in 2000, there were 98 public hospitals qualified as “hospital trusts”. Hospital trusts work as independent providers of health services and have the same level of administrative responsibility as LHA. Based on criteria of efficiency and cost – quality, the LHAs might provide care either directly, through their own facilities (directly managed hospitals and territorial services), or by paying for the services delivered by providers accredited by the regions, such as independent public structures (hospital agencies and university-managed hospitals) and private structures (hospitals, nursing homes, and laboratories under contract to

the NHS).

Patients can freely choose among the public or accredited private providers. They can also choose to be treated either in the LHA in the area where they reside or in another LHA; if they choose the latter, the cost of care will be paid by the other LHA. Therefore, LHAs operate simultaneously as a payer and a supplier of services, and patients’ choices of providers might indirectly affect the services delivered. Indeed, by law, the LHAs must guarantee the quality of all services directly delivered or externally acquired, as well as control the overall expense, so that it does not exceed the budget.

Health Care Services

The Italian NHS is a huge organization with almost 650,000 employees, over 1,000 hospitals, and 16,000 ambulatory facilities. It also relies on private accredited health structures and different types of health professionals under contract with the NHS. The Italian NHS provides free primary care, hospital care and community health and hygiene, including diagnosis, treatment, and rehabilitation, as well as prevention, health promotion and educational activities.

Primary health care is provided mainly by general practitioners (GPs) and pediatricians, and on-call physicians (Guardia Medica) for afterhours medical care and services. All of these professionals work within the LHA districts, which also include home care and pharmacies. In addition to providing primary care, GPs and pediatricians act as “gatekeepers” for the system, assessing the needs of citizens, prescribing pharmaceuticals, ordering diagnostic procedures, and referring patients to specialists and hospitals.

There are 3,036 Guardia Medica stations employing about 18,000 doctors in Italy. On-call physicians are available during holidays, nights and weekends, providing after-hours medical care and services when GPs and pediatricians are not available.

Hospitals provide inpatient care for conditions that cannot be effectively treated on an outpatient basis. Hospital services are free or at nominal charges at the point of use, and four basic services — general medicine, surgery, pediatrics, and gynecology— are available in most general hospitals. Physicians working for NHS hospitals are paid by salary. However, there are some adjunct specialists for inpatient and outpatient services under contract within the NHS that are paid by fee schedule established by the regions.

Pharmacies have the monopoly of drugs sales, but are subject to numerous clauses. There are 16,000 pharmacies distributed across the country. In general, pharmacies are privately owned by pharmacists, who act as independent contractors under the NHS.8 There are only 1,129 public pharmacies, owned mainly by municipalities and managed by

pharmacists employed by municipalities and paid by salary. By law, both private and public pharmacies are licensed to sell commercial products and, on behalf of the NHS, pharmaceuticals, which include medication drugs and dietary goods. Consumers

can only purchase pharmaceuticals if they have prescriptions from their general practitioners. Since the creation of the NHS, drug co-pay rates have been introduced as a

cost-containment policy. Prices for pharmaceuticals in classes, which are covered by the NHS, are fixed centrally through a complex mechanism that takes into account the average European prices of the equivalents of Italian products.

USA

The American health care system represents a paradox because if it is true that US has the best health care system in the world, we can not forget that there are about 40 million people who are currently without health insurance. It is obvious that this mechanism is not working for everyone, and also, there are the problems regarding the rising costs and lack of access to health system which constitute a real crisis phenomena; so that, the U.S has became the only country in the developed world that doesn’t provide health care for all its citizens. In other words, there is a sort of hodgepodge regarding the private insurance and public insurance. As a result we find a “non-system” that creates various gaps in coverage.

Many individuals not covered by private insurance are covered by government insurance programs which include Medicare, Medicaid and others public system such as S-CHIP, VA, TRICARE, EMTALA, Indian health service and Federal Employees Health benefit Plan.

Medicare is a federal program administered by the United States government, it provides health insurance coverage US citizen or people who has been a permanent legal resident for 5 continuous years; they must be 65 and over, or if they are under 65 they have to be affected by disability.

This program is partially financed by payroll taxes imposed by the Federal Insurance Contributions Act and the Self-Employment Contributions Act.

As far as benefits are concerned the program has two parts: Hospital insurance and Medical insurance

Medicaid refers to the program which is designed for low-income and disabled. By federal law, states must cover very poor pregnant women, children, elderly and disabled. What is important is that childless adults are not covered, and many poor individuals make too much to qualify for Medicaid. The states and the district of Columbia are responsible for administrating this program. It is financed by the taxes of the states and federal government: every dollar that a state spends on Medicaid is matched by the federal government at least 100%. In poorer states, the federal government matches each dollar more than 100%. Overall, the federal government pays for 57% of Medicaid costs. Medicaid offers a set of benefits; despite this, many enrolees have difficulty finding providers that accept Medicaid due to its low reimbursement rate

As far as other public systems are concerned we mention S-CHIP, VA, hospitals and clinics.

As regards The State Children’s insurance Program (S-CHIP), the program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.

The Veteran Administration (V.A) is a federally administered program for veterans of the military. It is responsible for administering programs of veterans’ benefits for veterans, their families, and survivors. The benefits provided include disability compensation, pension, education, home loans, life insurance, vocational rehabilitation, survivors’ benefits, medical benefits and burial benefits.

EMTALA (Emergency Medical Treatment and Active Labor Act) requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.

TRICARE is for military personnel. The responsible organization for administration of TRICARE is the U.S. Department of Defense Military Health System, which organized the TRICARE Management Activity (TMA). The TRICARE contracts with several large health insurance corporations to provide claims processing, customer service and other administrative functions to the TRICARE program., military retirees, and their dependents

When we deal with Private Health Insurance, we refer to Employer-sponsored insurance and Private non-group.

Employer-sponsored insurance represents the main way in which Americans receive health insurance. Employees provide health insurance as part of the benefits package. This insurance is administered by private companies, both for-profit and non-for-profit and it is financed both through employers (who usually pay the majority of the premium) and employees (who pay the remainder of the premium). Benefits depend on health insurance plans: for example some of them cover prescription drugs, while others do not.

Private non-group are also called “individual market” and covers part of the population

that is self-employed or retired. In addition, it covers some people who are unable to

obtain insurance through their employer. In contrast to the employment-based

insurance because the individual market allows health insurance companies to deny

people coverage based on pre-existing conditions. Private non-group, whose plans are

administered by private insurance companies, are financed by individuals who pay an

insurance premium out-of-pocket for coverage . Risk in the individual market depends only

on the health status of the individual, in contrast to the group market, in which risk is

spread out among multiple individuals. As such, low-risk, healthy patients will have a low

premium, whereas the opposite is true for high-risk, sick patients.

The financing of health care centers around two streams of money: the collection of money for health care, and the reimbursement of health service providers for health care. In the United States, the responsibility for these two functions is shared by private insurance companies as well as the government, both of which are known in policy terms as “payers.” As such, the United States can be thought of as a “multi-payer” system.

Individuals and businesses pay income taxes to the government; there is a payroll tax on employers and employees to finance Medicare. Businesses pay all or most of the premium for employer-based insurance for employees, and employees pay the remainder. On the individual market, individuals pay for all premiums out of pocket. Employer-based insurance premiums and individual insurance premiums are collected by private insurers.

Obviously it is considered a a direct payment to a provider for health

Government uses money generated from taxes to reimburse providers who take care of patients enrolled in these programs. It uses also tax dollars to pay private insurers a health insurance premium for federal employees and other public employees.

Private insurers accept premiums from individuals, businesses, and the government. In turn, they reimburse providers for taking care of patients with private insurance.

Health service providers such as doctors, allied health professionals, hospitals, and other health care facilities take care of individuals. They are reimbursed for their services by private insurers and the government.

Videos showing the situation in the US.

Footnotes

http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm ▲
Canada's Health Care, http://www.hc-sc.gc.ca/hcs-sss/medi-assur/index_e.html ▲
Gross Domestic Product= Prodotto interno Lordo ▲
The case for universal health care, Retrieved on 09th May 2008, http://www.amsa.org/uhc/CaseForUHC.pdf ▲
"Italian Healthcare Project: Public Healthcare, National Health Service". August 2006. http://www.expatsinitaly.com/health/nhs_ssn.html ▲
"Il Servizio Sanitario Nazionale: Una Grande Istituzione al Servizio della tua Salute". http://nikkkola.blogspot.com/ ▲
"Sanita` Privata". 2006. http://portale.unibocconi.it ▲

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Health care in the USA

Public healthcare (Nicola Canton)