A Comparative Analysis Of The UK And US Health Care Systems

Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

A Comparative Analysis of theUnited Kingdom and the UnitedStates Health Care Systems

Abbie McClintock Roe, MSHSA; Aaron Liberman, PhD

With America entering a new period of debate about the future of its health care system and withseveral alternative models now being tested in individual states, this article explores thesimilarities and differences between the National Health Service of the United Kingdom andAmerica’s varying approaches to addressing the health services needs of its citizens. The focus ofthis article is in identifying opportunities to benefit from the relative strengths and avoid orcorrect the weaknesses inherent in each system. Key words: employer-based system (USA),

National Health Insurance, National Health Service (UK), universal health care

HEALTH CARE FINANCING and deliverysystems are popular topics of study

throughout the world. Their popularity isdue not only to the universal human needfor health care, but also to the various meansof the delivery systems and financing aroundthe world. These many differences dependgreatly on each country’s political culture,history, and level of wealth.1

As a topic that has a profound impact onthe current and future generations, healthcare is a central theme of the political andsocial culture in the United States. In par-ticular, access to health care is frequentlyhighlighted on television news programs,heard throughout political ‘‘promises,’’ anddiscussed within social groups. This sug-gests that the American public is comingcloser to demanding better access to healthcare. A common misconception through-out the United States is that countries whooffer national health care systems, such asCanada and the United Kingdom, provide‘‘free’’ health care. Although many services

are provided ‘‘free at the point of delivery,’’2

generally speaking, these national healthcare systems provide services predominantlythrough the means of citizen taxation.1

Americans are considering increased gov-ernment involvement in health care; there-fore, it is important to understand how thiscould be accomplished and the impact itcould have on society.

This article is designed to review 2countries’ health care financing and deliverysystems: the United States of America and theUnited Kingdom. These 2 countries haveclose historical and cultural ties, but whenit comes to health care, the United Statesand the United Kingdom are significantly dif-ferent. Because they differ so greatly, bothcountries could learn from each other tocreate better policy and systems and thusimprove health care delivery to their respec-tive citizens.

INTERNATIONAL COMPARISON

The World Health Organization, a UnitedNations agency, issued a report in June2000 that ranked the health systems of191 countries across the world, which wasthe first of its kind to include such a largescope of the globe. The United Kingdomranked 9th and the United States ranked 17thhighest in overall system performance. These

The Health Care ManagerVolume 26, Number 3, pp. 190–212Copyright # 2007 Wolters Kluwer Health |Lippincott Williams & Wilkins

Author Affliations: Department of Health Professions,

University of Central Florida, Orlando, Florida.

Corresponding author: Aaron Liberman, PhD,

Department of Health Professions, University of Central

Florida, 4000 Central Florida Blvd, Orlando, FL

32816-2200 ([email protected]).

190


results were behind France (first), Italy(second), Spain (third), Austria (fifth), andPortugal (sixth). The study also showed thatonly 57% of the UK population said theywere either fairly or very satisfied with theirhealth system. That percentage was evenlower for the United States at 40% fairly orvery satisfied.3

The Organisation for Economic Co-operationand Development (OECD) is an organizationheadquartered in Paris, France, that studiescomparative data of 30-member countries.4

These 30 industrialized countries are Aus-tralia, Austria, Belgium, Canada, Czech Re-public, Denmark, Finland, France, Germany,Greece, Hungary, Iceland, Ireland, Italy, Japan,Korea, Luxembourg, Mexico, Netherlands, NewZealand, Norway, Poland, Portugal, SlovakRepublic, Spain, Sweden, Switzerland, Turkey,and of course, the United Kingdom and theUnited States.5

According to a 2006 OECD comparativedata study, the total health expenditure in2004 by the United Kingdom was 8.3% oftheir gross domestic product (GDP) andthe United States was 15.3% of their GDP,whereas the mean of all 30 countries was8.9%. This same study reports health expen-diture in the United Kingdom as US $2,546per capita and US $6,102 per capita in theUnited States, whereas the 30-country meanwas US $2,550. Not surprisingly, publicspending differs quite significantly betweenthe United States and the United Kingdomas well. Of their respective 2004 total healthexpenditure, public spending in the UnitedKingdom was 85.5% and in the United Stateswas 44.7%, whereas the 30-country meanwas 73%.6

The United States ranked highest by far ofall 30 countries in total health expenditurepercentage of GDP and per capita spend-ing and lowest of all 30 OECD countries inpublic expenditure percentage. The UnitedKingdom was slightly lower than the meanfor both health expenditure percentage ofGDP and per capital spending and the fourthhighest of the 30 countries in public healthexpenditure.6 This tells us is that the UnitedStates spends considerably more money in

total and per capita on health expenditurethan many other comparable countries andthat it is the American people and privateorganizations that are spending the majorityof this money. It is important to focus onthe percentage of GDP because of the eco-nomic concept of opportunity cost, whichsays that the higher the percentage of GDPspent on health care, the lower GDP avail-able for other goods and services.7

The OECD releases many other pieces ofcomparative data, including life expectancyat birth, remuneration of health profes-sionals, health expenditure by function, andtobacco consumption. Taking 2 comparativepieces of data, in 2004, 25% of the popula-tion in the United Kingdom and only 17% ofthe population in the United States reportedto partake in daily consumption of tobacco.8

And as of 2003, the life expectancy at birthwas 78.5 years in the United Kingdom and77.5 years in the United States.9 There aremany factors that could play a role in theseresults; however, taken factually, althoughthe United States has a lower rate of tobaccoconsumption and spends a higher percent-age of their GDP on health care, the UnitedKingdom has a higher life expectancy atbirth. These results are a clear indication thatit is essential for the American public andhealth care managers to understand healthcare spending and delivery to progress to amore productive and effective health caresystem in the United States.

TYPES OF HEALTH CARE SYSTEMSTHROUGHOUT THE WORLD

There are many trends and patterns of healthsystems throughout the world. Olin Andersonand Milton Roemer both developed analyticalmodels to chart these different types of sys-tems, and each of these 2 models places theUnited States and the United Kingdom atopposite ends of the spectrum. As illustratedby Anderson’s model, all health systems in theworld can be placed on a ‘‘continuum based onthe level of government involvement in thefinancing and organization of health services.’’1

Anderson describes the role of government as

Comparative Analysis of the UK and US Health Care Systems 191


either market maximized, characterized by lim-ited government, or market minimized, char-acterized by government programs basedon distributive justice1 which promotes theequal allocation of goods and services to allmembers of society.10 On this scale, Andersonplaces the United States at the far end of market-maximized and the United Kingdom’s NationalHealth Service (NHS) at the far end of market-minimized.1

As defined by his work in National Health

Systems of the World, Roemer’s analyticalmodel places health systems into 3 basecategories. These categories are the entrepre-neurial model, the mandated insurance model,and the NHS model, which are each orga-nized by wealth and degree of governmentinvolvement. The entrepreneurial model isone based on the purchasing of private healthinsurance by individuals or employers. TheUnited States’ health system is an example ofan entrepreneurial model. Scientific medicaladvancement in technology and research andcost-saving practices are both beneficial re-sults of the entrepreneurial model. One ofthe key disadvantages of the model, how-ever, is the apparent inequality of the distri-bution of health care resources. An exampleof this inequality is seen in the rising num-ber of uninsured in the United States.1 As ofthe most recent Census Bureau data avail-able, there were approximately 46 millionuninsured Americans in 2005, which is ap-proximately 15.9% of the US population.11

This figure has risen steadily since the expan-sion of Medicaid in the 1980s.12 Entrepreneur-ial models, such as the United States, operateunder a voluntary insurance market, which isone where ‘‘employment-based health insur-ance is purchased from private companies.’’1

These countries also tend to encourage,produce, and depend on the private owner-ship of health care resources and privateemployment of health care staff.1

The mandated insurance model is onein which insurance coverage is compulsoryand is generally funded by social insurance.Social insurance, also known as social secu-rity, is one in which the health system isfunded through insurance purchased with

contributions made by workers and em-ployers. The German health system is anexample of a mandated insurance model. Inthe early 1990s, the Clinton administrationborrowed from the German System in anattempt at US health care reform.1 Althoughthe Clinton administration was unsuccess-ful at full-scale national health care reform,13

on April 12, 2006, Massachusetts Gov MittRomney signed Chapter 58, what is betterknown as Massachusetts’ ‘‘universal’’ healthinsurance bill. Chapter 58 is based on themandated insurance model as it is designedto provide health insurance to nearly all res-idents of Massachusetts.14

The NHS model is ‘‘characterized by univer-sal coverage, general tax-based financing, andnational ownership and/or control of thefactors of production.’’1 This model is exem-plified by both the United Kingdom andCanada’s national health programs and usesgeneral tax revenue for the majority of itsfinancing. In NHS countries, the governmentitself is most likely to own the health careresources and employ the health care staff.1

THE UNITED KINGDOM

The United Kingdom of Great Britain andNorthern Ireland is more commonly knownas the United Kingdom. This country is madeup of 4 constituent countries, which in-cludes the 3 occupying the island of GreatBritain: England, Wales, and Scotland, andthe northeast territory of the island ofIreland, simply called Northern Ireland. TheUK government estimated the populationin the United Kingdom in mid-2005 to be60.2 million, and of this total, 50.4 million, or83.7%, lived in England.15 According to De-

partment of Health: Departmental Report

2006, England’s ‘‘Identifiable Expenditureon Services’’ for the 2003-2004 fiscal yearwas GBP £58.3 billion, whereas Scotlandreported GBP �£18.3 million, Wales re-ported GBP �£148.4 million, and NorthernIreland reported GBP �£1.9 million.16 Eachof these 4 countries has its own operatingNHS. There are similarities and ties between all4 organizations, so essentially, they are all

192 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2007


NHSs, but they operate separately to servethe needs of their respective citizens.17

The government of the United Kingdomguarantees the right to health care accessto all citizens through its program calledthe National Health Service.1 The NHS isa market-minimized, national health servicemodel1 and is the prominent means for oneto obtain health care services in the UnitedKingdom.18 It is made up of multiple sub-systems broken down by each of the 4 coun-tries and further into local organizations or‘‘trusts.’’ The NHS, however, is essentiallyone system, one organization that provideshealth care access to the citizens and res-idents of the United Kingdom. This fullycomprehensive system includes health carefacilities and staff, technology and phar-maceuticals, financing, coverage, and de-livery.17 There is a growing private healthcare industry in the United Kingdom,18 its2 largest private insurers being AXA PPPHealthcare and BUPA.19 However, for pur-poses of this discussion and for directcomparison, the NHS in England will pre-dominantly be explored during this analysis.

Evolution of the UK health care system

Although it has only been approximately60 years since the establishment of the NHS,not surprisingly, there were quite a fewhealth policy provisions introduced through-out British history before the NHS. Datingback to the 17th century, workhouses servedas institutions where the poor of Britain couldfind the means to meet such basic needs asnourishment, shelter, health care, and avail-able work. Although the conditions at theworkhouses were notoriously horrendous,these establishments served as the publicsolution to meet the basic needs of the poor.As a means to control their health services,the 1834 Poor Law Amendment Act was in-tended to limit outdoor relief, defined as medi-cal care provided outside the workhouses,and encourage indoor relief, defined as medi-cal care provided within the workhouses.20

As another public health initiative, the1848 Public Health Act was established toconstruct the water and sewage systems as

a means to control and limit the spread ofinfectious disease. The 1867 MetropolitanPoor Act began the development of PoorLaw infirmaries, which were actual separatebuildings from the workhouses that pro-vided health services to the poor. Althoughthis Act seems to have been in direct con-flict with the 1834 Poor Law Amendmentwhich sought to limit outdoor relief, itserved as an important step toward the rec-ognition of the state’s responsibility to pro-vide hospitals to the poor and thus thedevelopment of the NHS.20

Other notable public health policies inBritish history include the 1906 Education(Provision of Meals) Act that led to thedevelopment of a school meals service andthe 1907 Education (Administrative Provi-sion) Act that began school medical service.The 1911 National Insurance Act providedfree general practitioner (GP) care for certaingroups of working people who earned lessthan GBP £160 per year, and the 1929 LocalGovernment Act resulted in the governmentcontrol of administering workhouses andinfirmaries at the county level. Only 17 yearsbefore the National Health Service Act, theLocal Government Act was yet another step to-ward a government-provided and government-controlled health system.20

Before the NHS’s inception, receiving ap-propriate health care in the United Kingdomtended to be a luxury, not a right. Those whocould not afford to pay for traditional healthcare relied upon sometimes dangerous homeremedies, on the charity of medical profes-sionals providing free services to the poor,or from those services provided within thedeplorable conditions at workhouses. TheGreat Depression encouraged the popularperception in Britain to demand health careas a right, not a privilege.21 The creation ofthe NHS did not essentially begin as a meansto provide new or different health servicesto the population, but as a way to provideappropriate and responsible health servicesto all, regardless of the ability to pay.20 Itbegan as a political and social movementat the end of World War II which led tothe National Health Service Act in 194620;



however, the NHS itself did not begin ope-rations until July 5, 1948.22

UK health care systems andinfrastructure

Department of Health—The governmentbody responsible for the NHS in Englandis the Department of Health. The Depart-ment of Health’s objectives are simply to im-prove the overall well-being of the people ofEngland. This is executed by directing, sup-porting, and leading NHS and social careorganizations to provide fair, high-qualityhealth services and to offer choices to pa-tients and value to taxpayers.23

This government body is led by democrat-ically elected members of parliament (MPs)and headed by the Secretary of Health, cur-rently Patricia Hewitt MP. The additionalroles leading the Department of Health areMinister of State for Health Services, Minis-ter of State for Delivery and Reform, Minis-ter of State for Quality, Minister of Statefor Public Health, and Parliamentary UnderSecretary of State for Care Services. Each ofthese roles is filled by elected MPs, par-liament being the legislative body in theUnited Kingdom which is similar to the USCongress. Although these MPs are electedby the masses, they are appointed to theirrespective roles in the Department of Healthby the Prime Minister of the United King-dom, currently Gordon Brown.23

There are many other levels of individualswho make up England’s Department ofHealth leadership. These roles include depart-ment directors and board members such asthe NHS chief executive, permanent sec-retary, chief medical officer, chief nursingofficer, and director of finance and invest-ment. There are also national clinical directorsfor such areas as emergency access, mentalhealth, heart disease and stroke, primary care,learning disabilities, cancer, diabetes, chil-dren, influenza, and kidney services.23

National Health Service—Introduced in1948, the NHS is the name given to theoverriding government national health or-ganization in the United Kingdom. Since2002, the NHS in England is essentially run

at a local level by organizations known asstrategic health authorities (SHAs) and trusts.There are 10 SHAs throughout England, andeach is responsible for a number of varioustypes of trusts. Primary care trusts (PCTs) aremade up of GPs, dentists, pharmacists, andopticians and tend to be at the heart oforchestrating the health care delivery andexperience to patients. National Health Ser-vice trusts, also known as acute trusts, area secondary level of care and are made upof NHS, or government-run, hospitals. Am-bulance trusts are the local organizationsresponsible for responding to and assess-ing emergency situations. Care trusts are es-sentially social services organizations thatare designed to coordinate multiple servicesto meet the needs of those patients whomight require a more complex level of treat-ment. Mental health trusts provide servicesto those patients who have more severemental health conditions.17

The NHS also offers many other servicesbesides those that are directly provided bytrusts. National Health Service walk-in cen-ters, NHS direct and NHS direct online, theInformation Centre for Health and SocialCare, and non–NHS-related key partners arealso important functions and services pro-vided through the NHS.17

Strategic health authorities—Strategichealth authorities are the strategic bodyof the NHS at a local level, and as of July1, 2006, there were 10 SHAs throughoutEngland. They support and link their localcitizens, PCTs, and other local and nationalNHS organizations by monitoring serviceperformance, developing improvement plans,and increasing the health services and re-sources available. Strategic health authoritiesare also the governing body to carry out theinitiatives and programs of the national NHSbrought down to the local level.17

Primary care trusts—Introduced in April2002, PCTs are predominantly responsiblefor meeting the health needs of their localcommunity. They are local organizations towhich most patients of the NHS must use astheir initial points of health care delivery.Although few, there are some circumstances



when it is not required by the NHS forpatients to first visit a PCT when seekingmedical treatment.17 When PCTs were firstintroduced, if a patient needed to visit amedical professional, one would be requiredto visit the PCT based on the postcode of hisor her registered place of residence. Al-though these assigned PCTs still exist andNHS and the PCTs encourage complianceto the assignment, it has only been recentlythat NHS patients can visit a PCT outsidetheir designated area.24

As the nerve center of the NHS, PCTs arein control of approximately 80% of the totalNHS budget.17 The NHS organization per-ceives the use of these local PCTs as the bestway to understand the needs of the com-munity on a local level. The role of the PCT isto direct the health needs of each individualto the correct practitioner or group to re-ceive health services, such as to GPs, hos-pitals, and dentists. Primary care trusts alsoact as representatives to the NHS of theirlocal community and assess the GP practicesin their area.17 Primary care trusts truly serveas the lead organization in providing andorchestrating the health care needs of thepopulation in England.25

There are many services and practitionersprovided through the PCTs. Primary caretrusts manage one’s primary care, which isconsidered the initial contact when oneseeks medical services. These organizationsare made up of multiple GP practices, dentaloffices, optical care locations, and pharma-cies. There are currently 152 PCTs, and eachreports to 1 of the 10 SHAs. Each PCT hasa headquartered location, such as at a hos-pital, and is governed by executive manage-ment and board members.17

National Health Service general practicesare those that are made up of GPs and nursesand can include many other health profes-sionals such as midwives, physiotherapists,and occupational therapists. They providea wide range of diagnosis, treatment, edu-cation, and medical testing to their NHSpopulation. There are approximately 300 mil-lion visits to a GP per year in England. Everycitizen of the United Kingdom has the right

to register with their local GP, and NHS pa-tients are never charged to visit a GP. If theGP is unable to provide the service needed,he or she should then refer the NHS patientto an NHS hospital or specialist.17

National Health Service trusts (acutetrusts)—The NHS trusts, also known as acutetrusts, are responsible for the NHS hospi-tals. Acute trusts manage the hospitals’ de-livery of high-quality health care and fiscalefficiency, as well as develop strategic im-provement of health services. Acute trustsmay be training hospitals attached to medicaluniversities or a regional or national centerfor specialized care, or may also provide ad-ditional community services such as healthcenters, clinics, or home health services.17

Introduced in April 2004, NHS foundationtrusts, also known as foundation hospitals,are hospitals with exceptional performanceratings and are distinguished through anNHS application process. Foundation hospi-tals are run by local managers, staff, andmembers of the public with little bureau-cratic control from the centralized NHS. Al-though they still operate as a part of the NHSand within NHS standards, foundation hos-pitals have much more freedom in manag-ing and providing health services to theirlocal community than the other nondistin-guished NHS hospitals. There are currently54 NHS foundation trusts in England.17

National Health Service hospitals andacute trusts employ a significant amount ofthe NHS workers. This includes not onlyclinicians, such as doctors, nurses, and phar-macists, but also physiotherapists, radiolo-gists, language therapists, psychologists, andnonmedical professionals such as adminis-tration, reception, information technology,engineers, and security.17

National Health Service hospitals operateas a means to meet the demand for second-ary care in the United Kingdom. Secondarycare is considered either emergency care orelective care. Elective care is usually whenan NHS patient is referred to the hospitalthrough primary care services, such as by aGP, for specialized medical care. Examplesof elective care are hip replacements or



kidney dialysis. Emergency care is attendedto in the hospital department known inthe United Kingdom as accident and emer-gency department (A&E). Patients are treatedin or admitted through the accident andemergency department generally because oftheir need for health services in response tosudden trauma, such as chest pain or anautomobile accident.17

Ambulance trusts—Ambulance trusts areresponsible for responding to conditions thatrequire immediate action, the transportationof patients in need, and certain after-hourscare needs. Urgent needs are generallygenerated through the 999 emergency sys-tem (similar to the United States’ 9-1-1emergency service). When a call is placedto 999, the ambulance trust control roomwill categorized the emergency as eithercategory A: immediately life threatening;category B: serious, but not immediately lifethreatening; or category C: nonurgent, non–life-threatening condition.17

For all 3 categories, a rapid response teammay be sent to the scene. The ambulance orparamedic team will assess if the patientneeds to go to the hospital and, if so, treat andstabilize the patient for transportation. Forthose patients who have been assessed tonot be transported to the hospital, the highlytrained medic team may treat on the sceneand then provide advice for follow-up care.If the ambulance trust control room doesnot feel it necessary to send an ambulanceto a category C condition, then they aretrained to provide over-the-phone suggestionssuch as treatment advice, referral to one’sGP, or even a referral to a local NHS walk-incenter.17

Care trusts—Care trusts are NHS trusts inEngland that coordinate the health care andsocial care service needs of an NHS patient.They provide combined health and localauthority social care under one organizationas a means to protect the patient from fallingthrough the cracks when one is in need ofservices from multiple organizations. Caretrusts may carry out such services as primarycare, social care, and/or mental health careand cater to those who require this type

of combined effort, such as the elderlywho tend to need multiple levels of service.There are currently only 10 care trusts inoperation in England; however, there areplans to introduce more in the future.17

Mental health trusts—Mental health trustswork with local council social servicesdepartments to provide health and socialcare to those who have mental healthproblems. These services range from psycho-logical therapy to specialized care for severemental health conditions. Less severe mentalhealth problems, such as depression, be-reavement, or anxiety, are traditionallytreated by primary care services and are notnecessarily managed by the mental healthtrusts. These services can include medica-tion, counseling, and/or support groups.17

Other NHS services—There are many ad-ditional services offered by the NHS that donot necessarily fall under the direct responsi-bility of any of the aforementioned trusts.National Health Service walk-in centers aredesigned to offer NHS patients access tohealth care services without the need forappointments. They are often located nearaccident and emergency departments of NHShospitals or in public locations such as trainstations and ‘‘high streets’’ which is the termused for the central business district ofUK towns.17

National Health Service direct and NHSdirect online offer health advice and infor-mation 24 hours a day, 365 days a year. Na-tional Health Service direct is available vialive telephone discussions with staffednurses and health advisors. National HealthService direct online provides NHS informa-tion and health advice via the internet athttp://www.nhsdirect.nhs.uk/. Services pro-vided on NHS direct online are a self-helpguide, a health encyclopedia, answers to com-mon health questions, a mind and bodymagazine, as well as the ability to search forone’s local health services.17

Current initiatives and future proposalsin the United Kingdom—The NHS Plan

Announced in the year 2000, ‘‘The NHSPlan’’ is a 10-year government program



designed to modernize and improve theNHS system.26 Because there had not beensignificant reform since the NHS’s incep-tion in 1948, The NHS Plan has been de-scribed as the biggest overhaul since itsfounding.18,27 The NHS Plan’s purpose is tocreate a 21st century health care system28

that puts the patients at the heart of deci-sion making26 and creates a more consumer-driven service.2 In part, The NHS Planplaces blame for its current problems onthe politicking it took in 1948 to createphysician buy-in for the new program andthat it will take a great effort for physi-cians to give up power to the people.29

The NHS prepared to fulfill The NHS Planthrough increased funding and organiza-tional renovation. In fact, the NHS is theonly health system in the industrializedworld that is committed to increasing, notdecreasing, its health expenditure. The goalof The NHS Plan is to mirror the EuropeanUnion’s average spending of 8% of GDPon health care.2,27 It has been several yearssince the launch of The NHS Plan. Some ofthe initial goals have been and are on theirway to being achieved26; however, therehave also been some new and reformedgoals since 2000.24

This national program was the first of itskind. There were 4 key initiatives set forthby The NHS Plan. First was the general uti-lization of 2 new health service programs.National service frameworks were set tocreate national treatment standards for suchmedical illnesses as diabetes, cancer, andkidney conditions. Originally established in1999, the National Institute for Health andClinical Excellence was created to attain thehighest level of care in the NHS by provid-ing guidance on public health, health tech-nologies, and clinical practice.30 Anotherinitiative set forth by The NHS Plan was achange in the financial rewarding and train-ing of health care professionals to improvequality and better meet patient needs. Yetanother initiative of The NHS Plan was tocreate a higher level of autonomy for thosehealth services and systems that performedwell and greater support for those that

needed improvement. Lastly, The NHS Planintroduced an initiative for more infor-mation and choices for patients, includingmore highly responsive health services fromthe NHS.31

Some of the patient-specific initiativesof The NHS Plan in 2000 were to cut hospitalwaiting times to 3 months for outpatientsand 6 months for inpatients by 2005, providefor GP appointments within 48 hours by2004, and offer a free NHS retirement healthcheck. Some of the workforce-specific ini-tiatives were to create new quality-basedGP contracts32; develop 335 mental healthteams to increase crises response time, cre-ate new roles, responsibilities, and bettertraining for NHS staff; and to employ 20,000more nurses, 7,500 more physician con-sultants, 2,000 new GPs, and 6,500 otherhealth professionals. General service and or-ganizational initiatives were to create 7,000extra hospital beds and 100 new hospitalplans by 2010, provide an extra GBP£900 million to develop intermediate careto improve patient recovery, make medicalnursing care in nursing homes free,28 cre-ate agreements between the NHS and theprivate sector for use of private facilities,develop a national independent advisorypanel for major hospital changes such asclosures, and merge the budgets of socialservices with the NHS.33

As a result of The NHS Plan, the NHSbudget had doubled from 1997 to October2006, and it is expected to triple by 2008.18

As of March 2007, there have been a numberof The NHS Plan initiatives addressed andaccomplished within the NHS in England.26

In January 2007, the number of people onthe inpatient waiting lists was 774,000, oneof the lowest since the NHS began collect-ing the data in 1988. This wait list totalis down 2,000 from 776,000 in December2006 and down from 1,158,000 in 1997.There was an increase by 42% of criticalcare beds from 2,362 in January 2000 to3,359 in January 2007, which includes anincrease of 84% of high-dependency beds.Responding to urgent GP referrals for can-cer treatment, more than 95% of patients



only waited a maximum of 2 months(62 days), which exceed the NHS opera-tional standard.34 Between 1997 and March2007, a total of 116 new hospitals and 188new primary care facilities have openedthroughout England, which exceeds the goalof 100 new hospitals proposed in The NHSPlan in 2000.35 Also since 1997, there are85,305 more nurses in the NHS in England,and approximately 30,000 NHS nurses havebenefited from leadership programs.36 De-tailed earlier, care trusts and NHS founda-tion trusts were both results of the initiativeslaid out in The NHS Plan in 2000.

In 2005, the Department of Health ques-tioned and surveyed more than 140,000people on their thoughts, ideas, and con-cerns for the NHS in England in relation toThe NHS Plan. The Department of Healthpublication, Our Health, Our Care, Our

Say: A New Direction for Community

Services, addresses the results of this na-tional quest and sets a new and extendedcourse for improvement in the NHS inEngland over the subsequent 5 years. Thisresulted in numerous new and extendedinitiatives within the NHS. For example,information prescriptions are to be directlyprovided to long-term patients and theircaregivers to further educate them on theircondition and where within the NHS sys-tem they could gain further access to infor-mation and services. The new NHS lifecheck is a self-assessment tool designed tohelp to determine one’s health risks anddecide whether to consult a health trainer toestablish a personal health plan. Individualbudgets were to be introduced within theNHS for those long-term care patients inneed of health and social care, and by 2008,all PCTs should provide access to an in-tegrated personal health and social careplan to these patients through a joint healthand social care team. The prime minister’s1999 Strategy for Carers, which promotescaregivers’ rights and provides financialgrants, was to be updated to provide furthersupport to caregivers. To meet the needsof their communities, GPs will be requiredto conduct and respond to surveys given to

their patients regarding the medical servicesat the GP practice.37

Pricing structure and responsibility ofpayment in the NHS

National Health Service medical servicesreceived by NHS patients are considered‘‘free at the point of delivery.’’2 Therefore,when an NHS patient uses an NHS service,such as a PCT, acute care trust, NHS walk-incenter, or NHS direct online, they do so freeof charge—they are not asked for money upfront, nor do they receive a bill for servicesreceived. However, it is important to under-stand that NHS subsystems and their respec-tive providers receive compensation fortreating NHS patients, just not directly fromthe patient at the time services are received.National Health Service compensation isfunded by general taxation,38 and becausethe NHS is made up of government-salariedemployees, provider compensation is usuallyin the form of a salary and/or bonuses, andsubsystem funding is usually based on a con-tract between the provider and the NHS.24

In 2004, 8.3% of the UK total GDP ex-penditure was spent on health care.6 Thepercentage of public expenditure of healthcare GDP in the United Kingdom was85.5%,6 which would make private expendi-ture 14.5%. Although the NHS is ‘‘free at thepoint of delivery,’’2 this private expenditureamount clearly shows that there are someinstances where private parties do contrib-ute toward the purchasing of health careproducts and services.

There are some NHS services that are not‘‘free at the point of delivery.’’ The Depart-ment of Health imposes flat charges to NHSpatients to receive pharmaceutical, dental,or optical products or services. For exam-ple, when an NHS patient fills a prescriptionat the pharmacy in England, they must pay aflat rate to receive the pharmaceutical prod-uct. As of April 1, 2007, the fee per prescrip-tion is GBP £6.85, which is up from theformer GBP £6.65. This is a flat fee and doesnot depend on the price of the pharma-ceutical; therefore, the out-of-pocket (OOP)cost to the patient is the same whether the



pharmaceutical is a high-cost specialty med-ication or a low-cost maintenance medica-tion such as for diabetes or high bloodpressure.39

This charge of GBP £6.85 per prescriptionis only some of the total health careexpenditure spent by private parties in theUnited Kingdom. Another example of moneypaid by private parties is by those thatchoose to purchase access to private healthcare. Although the NHS is funded throughgeneral taxation,38 there is a growing marketfor private health care in the United King-dom.18 The private health care system in theUnited Kingdom is provided through privatehealth insurance, private physicians, andprivate hospitals, all of which are separatefrom the NHS services.19 United Kingdomresidents are not mandated to use the healthcare services provided by the NHS; however,there is no concession to those who pur-chase their own private insurance to visitprivate physicians and hospitals. This meansthat those who purchase private insurancestill are paying for the NHS services throughgeneral taxation.40

Primary care trusts control 80% of theNHS’s budget.17 Because of initiatives setforth by The NHS Plan, contracts betweenthe PCTs and GPs are considered quality-based, because although the NHS still pro-motes its recipients to register with the PCTassigned to their postcode, these new con-tracts have introduced the ability to visittrusts outside their geographic region.24

Primary care trusts are funded throughallocation from the Department of Health.The Advisory Committee on Resource Allo-cation uses a weighted capitation formulato determine the distribution of resourcesacross primary and secondary care in Eng-land. Weighted capitation allows for re-source commissions at similar levels ofhealth care for populations with similarhealth care needs.41

THE UNITED STATES OF AMERICA

The United States is the only industrializedcountry that does not offer universal health

care to its population42; therefore, in directopposition to the United Kingdom and allother industrialized nations, access to healthcare in the United States is not guaranteed bythe government.1 The US government hashistorically played a passive role in healthcare. Not only does the government notmandate universal health care, but it alsodoes not require citizens to obtain healthinsurance coverage on any level. Under theEmployee Retirement Income Security Act of1974, the United States allows full employerdiscretion on health insurance offerings.12

The health care system in the United Statesdiffers greatly from that in the UnitedKingdom. Whereas the United Kingdomis considered a market-minimized nationalhealth system, the United States health caresystem operates as a market-maximizedentrepreneurial system. This is one in whichthe government has minimal influence andfinancial responsibility for the health care ofthe masses and where private parties areencouraged and promoted to reign responsi-ble.1 Also as stated earlier, the United Statessits at the far end of highest health carespending per capita, highest health carespending percentage of GDP, and least pub-lic financial contribution of the 30-membercountries in the OECD.4

Of the approximately 300 million people inthe United States, 46 million were consideredto have been uninsured in 2005.11 In theUnited States, those without insurance cover-age are meant to pay for the health careservices they receive. That being said, themost common reason for bankruptcy in theUnited States is due to unmet health care bills.A recent study done by Harvard Universityfound that 68% of those who filed for medicaldebt bankruptcy had some form of healthinsurance, 50% of all bankruptcies involvedmedical debt, and every 30 seconds someonein the United States files for bankruptcy be-cause of a serious health problem.43

Evolution of the US health care system

By the end of The Great Depression andWorld War II, there was a significant hospitalbed shortage in the United States. Not only



did hospital construction slow during thistime, but many hospitals closed because ofthe economic downturn of the country. TheHospital Survey and Construction Act of1946, more commonly known as the Hill-Burton Act, represented the United States’involvement in regulating the availability ofhospital beds by providing funding throughfederal grants. This Act essentially called forthe construction and refurbishment of thehospital systems throughout the UnitedStates. At the inception of the Hill-BurtonAct, 3.2 community hospital beds per 1,000people in a geographic region were avail-able, and although the Hill-Burton programwas terminated in 1974, its goal of 4.5 per1,000 was accomplished by the 1980s.44

Private health insurance in the UnitedStates also grew out of The Great Depres-sion. In 1929, Baylor Hospital began allow-ing for 21 days of hospital stays per yearto those who paid a 50-cent premium eachmonth. This ‘‘prepayment’’ concept spreadwith encouragement from the AmericanHospital Association. Also in 1929, the firstBlue Cross plan was established to guaran-tee hospital coverage for childbearing-agedschoolteachers in Dallas, Texas. Blue Shieldbegan in the early 1900s in the PacificNorthwest when mining and lumber campspaid physicians to provide medical care fortheir laborers. The Blue Cross and BlueShield Association is the merger betweenthe two, Blue Cross representing hospitalcoverage and Blue Shield representing phy-sician services. Today, approximately 25%of insured Americans are covered by a Blueplan, which is a part of a network of 43independently and locally run Blue Crossand/or Blue Shield organizations.45

As one of the first attempts to curtail theincrease of health care spending in theUnited States, the National Health Plan-ning and Resources Development Act of1974 created a network of governmenthealth planning organizations, called healthsystems agencies. These health systemsagencies were intended to control the al-location of health resources and the in-creasing cost of medical care in the United

States. The Act required states to enactcertificate-of-need laws that required hospi-tals to apply for a certificate of need fromtheir host state before acquiring majorequipment or beginning construction. Al-though many states still require some kind ofcertificate of need, federal funding to thehealth systems agencies ceased in 1986.44

The current private health insurance in-dustry, which is extremely complex andmultifaceted, grew out of the managed caremovement in the early 1990s. Managed careis essentially a term coined as an attempt tocontrol health care costs by controlling, orlimiting, the access to care. Before the man-aged care movement, in fee-for-service orcost reimbursement models, providers hadmuch more leniency to decide what servicesto provide and what fees to charge for thoseservices. The managed care movement at-tempted to control what health insurancecompanies and employers saw as an overuti-lization of medical services by providers.45

US health care systemsand infrastructure

Health care services in the United Statescan either be public health care or privatehealth care. Public health care is the healthcare that is considered a function of thepublic or the government. Areas in whichpublic or government agencies provide a levelof public health care are in the prevention ofdiseases, the promotion of health, the report-ing and controlling of communicable diseases,the control of environmental factors such asair and water quality, and the study andanalysis of indicators of data on the health ofthe public.45

The US Department of Health and HumanServices is the principal federal agency thatcontrols many of the subagencies thatperform these government health care ser-vices. These organizations include the Cen-ters for Disease Control, Food and DrugAdministration, National Institutes of Health,and the Agency for Healthcare Research andQuality.45

Each geographic region in the United Statestends to be made up of multiple regional



health delivery systems. In most metropoli-tan areas, there are many different systems.For instance, in the central Florida area,there are 3 health systems: Florida Hospital,Orlando Regional, and Healthsouth. Each sys-tem traditionally is made up of networks ofhealth professionals and institutions such asphysician practices and hospitals.

When one seeks medical attention in theUnited States for an episodic or nonchroniccondition, it is typical for one to first visit aprimary care physician. Primary care is de-fined as the first point of contact withmedical services with the intent to provideinitial diagnosis and treatment. Primary careproviders (PCPs) are typically GPs, pediatri-cians, internists, obstetricians, nurse practi-tioners, physician’s assistants, and midwives.Primary care providers tend to see patientsfrom all ages, genders, and ethnicities whoare experiencing a wide range of medicalconditions. Therefore, PCPs must be widelyeducated on a large variety of illnesses andfrequently work with secondary and tertiarycare specialists in providing a full level oftreatment to the patient.45

Secondary care is a stage of medical ser-vices when a patient is in need of specializedmedical attention often received in the hos-pital setting and attended to by specialtyphysicians. Whereas primary care focuses onepisodic or nonchronic conditions, second-ary care addresses more chronic, persistent,or traumatic conditions. Often, a secondarycare physician works with PCPs to treat thepatient and return them to the PCP’s care.Secondary care represents a growing propor-tion of the health care needs of Americansdue to a growing level of chronic conditionsin the United States.45

Emergency care is a form of secondarycare and is defined as the care received whenthe absence of immediate medical attentionmay result in permanent injury or death.Depending on the severity, emergency careis usually treated in a hospital as triagedthrough the emergency department. Urgentcare services attend to less severe emergencycare, and if one does not choose to visit ahospital or physician office, there are numer-

ous urgent care/walk-in facilities locatedthroughout the United States. These urgentcare/walk-in facilities can either be affili-ated with a hospital system or as an in-dependent entity.45 A new phenomenon inthe United States is called retail health care,where retail stores such as Wal-Mart, areoffering walk-in health care facilities thatare often run by nurse practitioners andprovide limited services for fairly minimalfees.46

Tertiary care is really considered a higherlevel of specialized, or subspecialized, sec-ondary care. It requires intensive inpatientcare and often a prolonged length of stay inthe hospital. Patients receiving tertiary careoften have complex illnesses that requirehighly technical medical care, such as coro-nary artery bypass grafts or organ transplants.Tertiary care centers and providers are oftenaffiliated with academic medical institutions.Similar to secondary care, tertiary care pro-viders work closely with the patient’s PCPto gain access to the patient’s medical andpersonal history.45

Health insurance and coverage in theUnited States

As of 2000, 84.2% of the non-elderly USpopulation had some form of health insur-ance coverage, and two thirds of this cover-age was employer sponsored.45 The UnitedStates is essentially an employer-based system,which is a large contributor as to why theunemployed are also generally uninsured.44

There are multitudes of health coverageorganizations, plans, and systems through-out the United States. The basic concepts ofsome of the more popular means of healthcoverage will be discussed in this article.

Health insurance is a contractual relation-ship and a shared financial risk between theinsured (ie, patient member) and the insurer(ie, insurance company). The insurer isproviding or reimbursing all or some of thecost of medical care provided to the insuredif the insured seeks medical attention cov-ered under the policy or contract. The in-sured is paying a premium usually in theform of a monthly payment to protect



oneself against the risk of a full paymentfor seeking medical care. Many times, theinsurer is not only responsible for themonthly premium, but is also responsibleto pay for some of the medical care receivedin a form of deductibles, coinsurance, co-payments, and OOP maximums.45

Government-sponsored health care in theUnited States—As discussed previously, al-though the United States health system isconsidered predominantly funded by privateparties, there is a considerable contribution(44.7% of health care GDP6) made by pub-lic funding. Medicare, Medicaid, which in-cludes the State Children’s Health InsuranceProgram (SCHIP), and Veteran Affairs is con-sidered government- or public-sponsoredhealth care. The Centers for Medicare andMedicaid is a federal agency that is respon-sible for the administration of the US Medi-care and Medicaid programs. As a result of1965 Amendments to the Social SecurityAct, both Medicare and Medicaid serve asthe major forms of public health insurancein the United States and are the combina-tion of previously smaller programs.45 Al-though Medicare and Medicaid are bothgovernment-funded health programs in theUnited States, both are generally adminis-tered through private intermediaries, suchas Blue Cross, Blue Shield, or other managedcare organizations.12

Medicare—The Centers for Medicare andMedicaid is the federal agency that managesthe Medicare and Medicaid programs in theUnited States. Medicare is a federal healthinsurance program designed to provide cov-erage to those older than 65 years as well asto the disabled. Recipients must be a citizenor permanent resident of the United Statesand must have worked themselves or beenmarried to someone who has worked forMedicare-covered employment for at least10 years. Medicare-covered employment de-ducts payroll taxes under the Federal Insur-ance Contributions Act as a means to fundthe Medicare program.45 Medicare has beenone of the fastest growing federal programsin the United States, growing at 15% eachyear in its first 30 years. The program began

on July 1, 1966, with 19.1 million enrollees,and as of 2004, there were approximately42 million enrollees. Medicare has a power-ful influence on the US health care industry,because it is a major source of revenue forhealth care providers and its policies andregulations tend to have a ‘‘ripple effect’’ onUS health care delivery.47

Medicare coverage is broken down into 4distinct parts, A-D. Part A is consideredinstitutional care (ie, hospital care). Part Bis a voluntary enrollment plan that requires asmall monthly premium and covers profes-sional services, such as physician visits.45

Part C is a mandate of the Balanced BudgetAct of 1997 and offers parts A and B re-cipients the option to enroll in one of manyprivate managed care plans to combine thetwo under one benefit.44 Part D is a pre-scription drug benefit that operates under acomplex system of multiple private entitiesand formularies. In December 2003, theMedicare Prescription Drug, Improvement,and Modernization Act was signed in bythe president of the United States; however,the benefit itself was not available until itslaunch in February 2006.48

Medicare is not a fully comprehensivehealth coverage program and in fact relieson significant OOP expenses from Medicarerecipients. To cover these OOP expenses,most Medicare recipients enroll in additionalcoverage such as Medicare health main-tenance organizations (HMOs), retirementcoverage from former employers, Medigapplans, and Medicaid.45

Medicaid—State Medicaid programs arecombined federal and state-funded healthinsurance plans that are offered to qualifiedrecipients who fall below a particular level ofincome and also take into account one’sassets and resources. Most Medicaid recipi-ents are children, the elderly, blind, disabled,and those who qualify for federal incomeassistance. The cost share formula betweenstate and federal funding is based on the ratioof state to federal per capita income. Eachstate can differ in their income qualificationand in the means of providing Medicaid. Asignificant difference between Medicare and



Medicaid is that Medicaid programs tend tocover long-term care (ie, nursing homes) andin fact are the largest single contributor tolong-term care services at more than 44% ofits total expenditure in the United States.45

As a function of Medicaid programs, theSCHIP was created as a result of the Bal-anced Budget Act of 1997. The SCHIP servesas a way for states to meet the growingnumber of uninsured children. There are3 options under SCHIP, which are to createa fully standalone program, expand theMedicaid program to include children, oruse a combination of both strategies.45

Veterans Affairs—The US Department ofVeterans Affairs, formerly called the VeteransAdministration, offers health care benefitsto those who qualify through the VeteransHealth Administration. Eligibility for VeteransAffairs benefits is based on those nondishon-orably discharged from active military servicein the army, navy, air force, marines or coastguard (as well as the merchant marines whoserved during World War II). The VeteransAffairs is a complex health care system thatprovides medical services to qualified recip-ients at a number of hospitals, long-termfacilities, medical centers, and clinics, includ-ing dental, mental health, and substanceabuse, located throughout the UnitedStates.49

Private-sponsored health care in the UnitedStates—There are many different ways onecan obtain private health care coverage in theUnited States, but the most common meansis through an employer benefit program. Itis estimated that two thirds of non-elderlyAmericans who carry health insurance arecovered under employer-sponsored pro-grams.45 This is where an employer contractswith one or more private health care compa-nies to provide health insurance to itsemployees. Those employees are usually onlyeligible if they meet a minimum requirednumber of hours of work per week, suchas 30 hours. Because employer-sponsored healthinsurance is usually offered to a large groupof employees, it is also known as group in-surance.50 Group insurance is a beneficialmeans of obtaining health insurance as it

tends to offer less expensive premiumsbecause of the risk of the insurance companypaying out claims is lower when the risk isspread out over the entire group.44

Of the insured non-elderly Americans,approximately 6.6% purchase their healthinsurance individually.45 Individual insuranceis usually the same type of health insuranceoffered through an employer, but the pre-miums tend to be higher because the riskis not shared among a group51 and manyrequire the recipient to submit a physicalexamination. Because of the concept of risksharing, group insurance usually does notrequire the individual member of a grouppolicy to take a physical examination.45 Moststates allow for insurers to deny coveragedue to an undesirable risk, such as in thecase of pre-existing conditions.51

There are generally 4 types of healthinsurance in the United States: conventionalcoverage, HMOs, preferred provider organi-zations (PPOs), and point-of-service (POS)plans. As of 2002, of the Americans workerscovered under employer-sponsored pro-grams, 5% were in a conventional plan, 26%were in an HMO, 52% in a PPO, and 17% in aPOS plan.45 Conventional coverage is a typeof health insurance that offers coveragefrom practically all physicians and hospitalsin the local region, sometimes including cov-erage throughout the United States.45

Health maintenance organizations werecreated as a direct attempt to control accessand cost. Traditionally, in HMO plans, agatekeeper is used as a means to authorizea referral to a specialist, a pharmaceuticalproduct, or a procedure. These gatekeeperscan either be nursing staff of the HMO planor health professionals at primary carephysician practices. In fact, HMOs tend torequire insured members to register directlywith a primary care physician. Health main-tenance organizations are essentially a net-work of health care providers throughout adesignated region who are contracted toprovide health services to the enrolled pa-tient population of the HMO network.Those insured under the HMOs must attendthese network providers for the HMO to



cover the cost of their services. The incen-tive to the provider to become a member ofthe network is often an increase in patientvolume. The contracted rates between theHMOs and providers can therefore be at asignificantly discounted rate because of thisincreased volume.45

Preferred provider organizations were de-veloped as a result of negative patient andphysician reaction to the HMO/gatekeepermodel. Although the premiums can be 50%higher than HMOs, when PPOs were firstintroduced, the network of providers tendedto be less limiting and did not require arelationship with a PCP or gatekeeper. Pre-ferred provider organizations encouragetheir insured members to use their networkproviders by covering a higher cost (ie, 90%);however, if an insured member chooses toattend an out-of-network provider, the PPOmay still cover a smaller percentage of cost(ie, 60%). Because of the popularity of thePPO system, HMOs have begun to moveaway from the need for referrals, allowingfor what is called open access, and in anattempt to control costs, PPOs have begunto add HMO-like services such as programsto manage utilization. These current trendssuggest a movement in the US health in-surance industry to merge these 2 conceptsand find a middle ground.45

Point-of-service plans are thought to bethat middle ground. Those insured undera POS plan are encouraged to attend a PCPfor a referral to an in-network provider, orspecialist, when needed; however, it is notrequired. When visiting an in-network pro-vider, the POS plan–insured patient tendsto pay a small amount and little or nodeductible. If one chooses to visit an out-of-network provider, POS plans tend to re-quire a deductible to be met, or the patientmust pay a higher coinsurance; however,the out-of-network visit does not require areferral by a PCP.45

Employers can also offer health insurancethrough a concept called self-insurance.Approximately 60% of all US workers arecovered by these self-funded health plans.As opposed to offering employees access

to health insurance from a health insur-ance company, self-insurance is when theemployer has the opportunity to purchasea number of health services either di-rectly from medical groups or hospitals,or they contract as a part of a networkof health services. Third-party adminis-trators are organizations that administerand manage the health insurance of self-insured employers.45

Labor unions are another means for oneto obtain health insurance coverage. Theseare organizations of workers who band to-gether as either employees of the same or-ganization or with those in a similar laborindustry to negotiate with employers on suchtopics as wages, hours, and working con-ditions. Union members collectively worktogether to accomplish these negotiationsto their benefit by threatening to or bywithholding labor to drive up the price ofproduction.45 Many labor union organiza-tions provide some level of health insur-ance coverage to their members similar toemployer-sponsored insurance in the formof group insurance.44

There are many different areas of cover-age health insurance that organizations canoffer to their members. Although mosthealth insurance coverage refers specifi-cally to hospital and/or physician services,there are additional areas that can be addedon as a higher level of benefit. These areasinclude prescription, optical, dental, andmental health, among others. These bene-fits tend to be managed differently than thehospital and physician services and canalso be managed by outside vendors. Forexample, prescription benefit managers areorganizations that contract directly withhealth insurance plans to manage andprovide prescription services to their in-sured members by providing a network,a formulary, customer service, and claimprocessing.45 This can sometimes be rec-ognized by the insured as a separate card,known as a drug card. Some recognizablenames of national prescription benefitmanagers are Medco, Caremark, and Ex-press Scripts.



Current initiatives and future proposalsin the United States—universalhealth care

Universal health care is when an entire

population is guaranteed the right to some

level of access to health care services. Health

care is considered a ‘‘public good’’ in many

countries throughout the world, which

means that it is primarily provided by the

government.51 Universal health care can be

in many forms such as in the United

Kingdom as one health system, the NHS, or

in Germany as a mandated health insurance

program.1 Although the United States does

not offer universal health care to its entire

population, the federal government does

provide fairly comprehensive health care ser-

vices to specific populations, such as to

those who qualify for Medicare, Medicaid, or

Veteran Affairs coverage.

The United States is the only industrial-

ized country in the world that does not offer

universal health care to its population.42

In 1993, both Democrat and Republican

leaders, as well as nearly every major health

care interest group including the American

Medical Association and the Health In-

surance Association of America, supported

an employer mandated universal coverage

health care program in the United States. On

September 23, 1993, President Bill Clinton

announced his plan for mandatory insurance

to the House of Representatives which re-

ceived positive feedback. But within a year,

focus on the economy, the Whitewater scan-

dal, and direct opposition ended this health

care reform movement. Americans seemed

less worried about access to health care

because of a decrease in the unemployment

rate, and inflation has slowed, leaving em-

ployers less concerned about the rising

health care costs.52

Although universal health care did notcatch on in the 1990s, it seems as if healthcare reform will be an important topicduring the 2008 election season.53 Aspresident of Kaiser Family Foundations, anorganization that has tracked US healthcare reform efforts for decades, Drew

Altman says the idea of universal healthcare has made a charging comeback sincethe most recent elections in November2006. Although national exit polls in the2006 election season did not include anyquestions on universal health care, in early2007, health care reform has not only beenheard throughout statements made by theemerging presidential hopefuls but alsoaddressed by George W. Bush, the residingUS president.54

It is the Democratic Party that is focus-ing on ‘‘universal health care.’’ Sen JohnEdwards of North Carolina, Sen HillaryClinton of New York, and Sen Barack Obamaof Illinois have all announced their intentionof providing universal health care to theentire US population if elected presidentin 2008.55-57 Although as of March 2007, mostDemocratic candidates had not announcedtheir official plans for health care reform,there is a common thread in their ideology,such as providing health coverage at anaffordable price to individuals and familiesand requiring employers to provide or helpfinance employee health insurance by reduc-ing costs and creating new tax credits.56

These candidates’ plans for universalhealth care are similar not only to the Clintonadministration’s unsuccessful attempt athealth care reform in the 1990s,13 but alsoto the 2006 Massachusetts Health Care Re-form Plan. The Massachusetts bill seeks toprovide health insurance to all Massachusettsresidents14 by requiring employers to pro-vide health insurance to employees as well asexpanded coverage and requirements forcovering children and illegal immigrants.58

In the United States, Massachusetts is the firstof many that have begun to plan or im-plement universal health care programs.

Other states such as Connecticut, Mary-land, New Hampshire, New Jersey, Vermont,West Virginia, and 4 counties in Californiahave begun to reform their SCHIP programsto widen their coverage for children. Alsoin 2006, Illinois passed a state bill calledAll Kids to expand its SCHIP program andprovide health care coverage to all chil-dren in the state of Illinois.58 Although the



pseudomandated insurance model failed inthe 1990s,1 because of Massachusetts’ andthese other states’ initiatives, a more accept-ing position on universal health care in theUnited States is gaining momentum espe-cially in regard to covering children.

There are 4 main alternatives being ex-plored in the United States regarding this‘‘children first’’ approach to universal healthcare. First is a single federal program tocover all children that is similar to the sin-gle federal Medicare program. The secondis a hybrid program of the Medicaid andSCHIP programs, which seeks to insurethose children not covered under employer-sponsored or private plans. The third is afederal wraparound program that wouldinsure those children not covered underemployer-sponsored, other private or publicprograms such as Medicaid and SCHIP.Although it did not pass in Congress, anexample of a wraparound program was theMediKids Health Insurance Act of 2005.The fourth children-first approach calls foran expansion of the current SCHIP pro-gram that would relax eligibility criteria andrequire parents to provide health insuranceto their children.58

Although President George W. Bush hasnot focused much of his administration’sattention on the US health care system, hisJanuary 2007 State of the Union addressunveiled a new change in the taxation ofhealth insurance premiums, which is de-signed to help more Americans affordprivate health insurance. The president’shealth care reform plan contains 2 parts.First, it proposes a standard health care de-duction so that all Americans can receivethe same tax breaks when paying for pri-vate health insurance regardless if they arepurchasing health insurance through anemployer or individually. The second partis to provide federal funding to states forthem to assist their citizens in obtainingprivate health care.54

Health care reform essentially focuseson the growing population of uninsuredAmericans. The uninsured patients posea concern to the United States because

those without coverage are increasinghealth care costs to the whole population.As a result of cost shifting45 and increasedhealth care GDP,4 they will likely to put astrain on taxpayers who finance Medicareand Medicaid.53 The position of the mainDemocratic presidential candidates is thatuniversal health care is the solution throughmandated insurance.56,57 The current Repub-lican position is that, by providing taxincentives, more Americans will benefit fromlower cost health care and be able to investin the private health care industry.54 Essen-tially, the result is the same behind these2 concepts—to create access to affordable,quality health care to all Americans.

Pricing structure and responsibility ofpayment in the US health care system

Financing of the health systems in theUnited States varies just as greatly as doesthe means for access to health care cover-age. There are many entities and partiesinvolved in financing the health care sys-tem of the United States. As stated earlier,in the United States, 44% of the health careGDP is spent by government or publicfunds,12 and therefore, approximately 56%of health care GDP is spent by privateparties. In 2004, the total percentage ofGDP spent on health care in the UnitedStates was 15.3%.1 According to current pro-jections, national health care expenditurewill reach US $2.8 trillion in 2011, 17% ofGDP, and grow at a rate of 7.3% between2001 and 2011.44 Because of this increase,it is essential for US health care managersand the American public to understand howhealth care is financed to contribute to thesolution of this ever-growing problem.

One of the most unique features of thehealth care industry in the United States isits dependency upon agency relationships,which is when one party acts on behalf ofanother. For instance, a health insuranceorganization acts as an agent for its mem-ber when processing payment for medicalservices. A medical group’s administratoracts as an agent for a physician when ne-gotiating a contract. And a physician acts as



an agent for a patient when treating orreferring that patient for treatment. Healthcare in the United States is distinguishedby these agency relationships, specificallyin the financing of the industry. Third-partypayers, or simply ‘‘payers,’’ is a term usedfor health insurance organizations that pro-vide payment or reimbursement for medi-cal services, whether it is a public plan,employer group, or others. Essentially, pay-ers are the ones who ‘‘pay’’ on behalf oftheir members.59

The 2 agencies usually responsible forpaying for most of the health care servicesprovided in the United States are payerorganizations and patients. Regardless ifthe payer is for-profit, nonprofit, or public,payers must be fiscally responsible andmindful businesses, not altruistic organiza-tions; therefore, they must make a profit tosurvive. With some exceptions, when oneobtains a policy with a payer in the UnitedStates, one is usually contractually obligatedto pay a monthly or bimonthly premiumfor his or her coverage. It is commonfor employers to pay for some or all oftheir employees’ premiums, which is calledcost sharing, and they do so at a discountwhen offering group insurance.44 Payersseek to make a legitimate profit from thesepremiums as they are taking a financialrisk on their members that the premiumsthat they receive for the policy will be intheir financial favor. Therefore, for thissystem to be effective and for them to con-tinue to provide insurance, the total moneythey take in for premiums must exceedthe total money they pay out in claimsor reimbursement.45

Most health insurance policies will requirethat the insured members not only pay pre-miums, but that they also contribute to thecost of the medical care that they receivein the form of deductibles, co-pays, and/orcoinsurance. A deductible is a fixed amountthat the insured must first pay OOP beforethe payer will contribute to any medicalservices.45 These deductibles vary greatlyfrom policy to policy, from payer to payer.For instance, one could have an individual

deductible of US $500; therefore, that in-dividual must pay for the first US $500worth of medical services received beforethe payer will contribute.

Even after the insured members meet theirdeductible amount, they are usually stillresponsible to pay for part of each medicalservice received as co-pays or coinsurance.Co-pays and coinsurance are similar in thatthey are partial contributions to medicalservices received. A co-pay is a flat amountpaid by the insured for a medical service,such as a visit to a physician’s office orhospital. Co-pay amounts usually increasewith the level of medical services received.For instance, under the same policy, a visit toa PCP may be a US $10 co-pay, whereas avisit to a specialist may be a US $25 co-pay orto the emergency room a US $100 co-pay.44

Coinsurance is when the insured pays fora percentage (ie, 20%) of the total cost ofmedical services received. Coinsurance per-centages may remain the same regardless ofthe level of care, but because the cost forservices increases from a PCP to a specialistto the emergency room, the patient is usuallyincrementally paying more in coinsurance.44

Additional benefit services, such as phar-macy, optical, dental, and mental health, alsooperate under this co-pay or coinsurancemodel, depending on the policies.

Many polices also include stop-loss provi-sions called OOP maximums and lifetimebenefit limits. An OOP maximum is anamount the policy outlines up front as thetotal amount the policyholder would haveto pay for covered medical services in agiven time period, which is usually 1 year.Amounts paid by the policyholder for de-ductibles, co-pays, or coinsurance applies tothe OOP maximum; however, premiums donot. An OOP maximum will differ betweenindividual and family plans and can, forexample, be anywhere from US $1,500 toUS $5,000 or more. Some policies may alsocarry a lifetime benefit limit, which is thetotal amount a payer is willing to pay duringthe lifetime of the policy for all covered medi-cal services. Lifetime benefits limits tend tobe either US $1 or $2 million.44



It is important for one to take into accountthe medical services that one feels may be intheir or their family’s future when selectinga policy. For instance, it might be appealingif a coinsurance-modeled policy has a lowerpremium than a co-pay modeled policy.However, one must keep in mind thatpaying higher premiums yet flat rate co-paysmay suit one’s needs if there is an expec-tation for a large medical bill, such as fora chronic condition or birthing delivery.Therein lays the financial risk. It is impossibleto fully predict one’s future health careneeds. If an insured finds himself or her-self at a financial disadvantage because ofan unexpected surgery, accident, or illness,he cannot change his mind midpolicy, es-pecially as a member of group insurance.Employer-sponsored group insurance canusually only be changed or obtained duringa time period called ‘‘open enrollment,’’60

which many times are offered once a yearfor a 30-day period.60 Generally, if a policyoffers a high level of coverage, meaning thepayer is contracted at a higher risk to paymore for medical services, the higher theprice of the premiums.45

Employer-sponsored coverage is federallytax exempted for the employer,12 and cer-tain laws allow for personal tax deductionas well. Approved health care contributionsare medical care deductions approved by theInternal Revenue Service such as insurancepremiums, hospital services, long-term care,and dental, chiropractic, and acupuncturetreatment.61 There is a growing industry oforganizations designed to help manage theindividuals’ financial contribution to theirhealth care. For example, flexible spendingaccounts can be offered from employers as apart of a benefits package, which allows forthe employee to deduct a voluntary amountfrom their salary to reimburse InternalRevenue Service–qualified OOP medical ex-penses. Health savings accounts are volun-tary tax-exempted accounts set up with ahealth savings accounts trustee to pay foror reimburse Internal Revenue Service–qualified medical expenses. Health savingsaccounts are only available to those who are

uninsured and those with high deductibleindividual health insurance.62

The charge for medical services in theUnited States depends greatly on the meansfor providing payment. Payers contract withproviders at negotiated rates. These ratestend to be based on either the Prospectivepayment system (PPS)47 or usual, customary,and reasonable charges, which are predeter-mined charges for medical services based onparticular geographic region.50

Prospective payment system was estab-lished through the language of Amendmentsto the Social Security Act in 1983. Prospec-tive payment system imposes a system ofreimbursing hospitals for services providedto Medicare recipients. Hospitals are reim-bursed based on a diagnostic code, or codes,assigned to the patient called diagnosticrelated groups. Under PPS and based on theassigned diagnostic related groups, hospitalsare paid a set fee to provide treatment toMedicare patients regardless of the cost oftreatment. When PPS was originally intro-duced, there was a concern that patients maybe discharged ‘‘quicker and sicker,’’44 be-cause the hospital only received that flatpayment regardless of treatment provided.This turned out not to be the case as careprocesses were found to have improved andmortality rates were found to have eitherlowered or remained unchanged.44 Manyprivate and state Medicaid plans haveadapted the PPS as a means to set chargesin their own contracting.47

Capitation is a managed care conceptoften used by HMOs as a means to controlhealth care costs. It is when an HMO paysa set amount per member per month toa medical care provider in order for thatprovider to make contracted medical ser-vices available to those registered members.The per-member-per-month covers all con-tracted medical services provided to theregistered member at no additional cost tothe HMO. This becomes a problem to thehealth care provider when there is a risk ofexcess utilization because of the need for ahigh volume of services.59 Capitation is usedas a means to shift some of the financial risk



off of the HMO to the provider and is used asan incentive for the provider to limit unnec-essary services. Because the provider doesnot get paid for any additional care, capita-tion serves as a deterrent to overutilize.50

The Emergency Medical Treatment andActive Labor Act of 1986 was designed toprevent hospitals from turning away thosewho showed up at emergency rooms, even ifthe situation was not considered an emer-gency, yet were unable to show an ability topay.45 The Emergency Medical Treatmentand Active Labor Act results in what isknown as charity cases, which is when oneis treated by or admitted to the hospitalwhen there is no expectation to receivepayment for services. Uncompensated care isconsidered a combination of charity, such asthose receiving services protected by theEmergency Medical Treatment and ActiveLabor Act, and bad debt, which is generatedby those admitted with a commitment topay, such as in the form of coinsurance, butdo not make the payment. Accountingregulations do not allow hospitals to con-sider uncollected charges on charity cases asgenerated revenue because there was neveran expectation of collected payment. Baddebt, however, is considered an expense foraccounting purposes, which is similar prac-tice in other industries regarding uncollectedaccounts receivables.45 Uncompensated careis found to indirectly affect those able to payby shifting and dispersing these uncollectedexpenses to those that are able to pay. Costshifting is when a hospital, or any health careprovider for that matter, raises prices to oneset of buyers while reducing the cost toanother set of buyers. This can be directlyin the form of cost-shifting fees charged topatients or applied to managed care in theform of cost-shifting premiums collectedfrom members.45

COMPARISON OF THE HEALTHSYSTEMS OF THE UNITED KINGDOMAND THE UNITED STATES

The current health systems in the UnitedKingdom and the United States largely

grew out of The Great Depression andWorld War II. Facing similar economicchallenges in a postwar world, both gov-ernments experienced political and socialpressure to provide their respective popu-lation better access to health care. Theyhave since progressed in opposite directionsin their system development.

The British government’s solution wasuniversal health care with one fully com-prehensive national health system. Thissystem, the NHS, answered the Britishpeople’s immediate demand for a guaranteeto health care access when it began oper-ation in 1948. At the end of World War II, itwas the private sector in the United Statesthat largely took on the responsibility ofhealth care access. Beginning with thedevelopment of Blue Cross and Blue Shield,the US market saw a steady increase inhealth insurance companies and programs,including the creation of the governmentMedicare and Medicaid programs in the1960s. Because the United States does notoffer universal health care, the privatehealth industry, along with Medicare, dic-tated much of the inevitable progressiontoward the managed care movement.45

Although the US and the UK healthsystems differ significantly in the level ofgovernment involvement and social respon-sibility, both systems operate very similarlyin terms of delivery. Both tend to use primarycare as the first point of entry and operateunder regional, functional, and specialtysubsystems. Although these subsystems areowned and operated by the government inthe United Kingdom and by private entitiesin the United States, it is truly in the re-sponsibility of payment where there is anobvious deviation.

The UK population has access to NHShealth care facilities and services that arefunded through general taxation. Althoughhealth care access is provided and paid forby the UK government, it is the people,through taxation, who essentially pay fortheir own health care. The NHS Plan seeksto greatly involve the patients and frontlinestaff in its future, yet the administration of



the entire NHS system really serves as afunction of the UK government.

In the United States, access to health carefacilities and medical services are largelypaid for by a combination of payers (whetherpublic or private), employers, and patientcontribution. The US health system relieson the function and policy influence ofboth public and private organizations tooperate as an enterprising, free market.Although approximately 44% of US healthcare expenditure is publicly funded, essen-tially all funding originates from privatehouseholds in the form of payroll deduc-tions, taxes, and donations.12

Although health care funding in theUnited Kingdom is government controlledand health care funding in the United Statesis predominantly private controlled, bothessentially are only made possible by thecontributions made by the people. The maindifferences are the level of governmentinvolvement and mandatory taxation ver-sus voluntary contributions. The UnitedKingdom provides health care access toall using a similarly run health deliverysystem to the United States, whereas theUnited States is suffering the economicburden of their uninsured. Therefore, theUnited States has essentially failed in pro-viding Americans with affordable health

care options and education on the impactit has on the economy.

The United States is fundamentallyfounded upon its guarantee of rights andfreedoms to its citizens. Formal education isconsidered and accepted as a right to all inthe United States. Not only does the UnitedKingdom recognize similar rights and free-doms as the United States, but it also includesthe right to receive proper access to healthcare.1 And just as if one chooses private overpublic education in the United States, onehas the opportunity to choose private overpublic health care in the United Kingdom.40

Although there is a movement in theUnited Kingdom for greater involvementbetween the NHS and private health care,63

there is also a movement in the UnitedStates for health care reform that mayinclude the implementation of a universalhealth care system. Therefore, 2 health caresystems that have historically been con-sidered at opposite ends of the spectrumhave begun to explore new ways ofapproaching their respective systems andhave found benefits in the function anddelivery of each other. Essentially, these sys-tems are more similar than they are differ-ent, and their goal is the same—to providehigh-quality, affordable access to health careto their respective populations.

REFERENCES

1. Sanders J. Financing and organization of national health

systems. In: Fried B, Gaydos L, eds. World Health Sys-

tems:ChallengesandPerspectives. Chicago–Washington,

DC: Health Administration Press. 2002:25-38.

2. Klein R. Britain’s National Health Service revisited.

N Engl J Med. 2004;350(9):937-942.

3. Blendon R, Kim M, Benson J. The public versus the

World Health Organization on health system perfor-

mance. Health Aff. 2001;20(3):10-20.

4. Organisation of Economic and Co-operative Devel-

opment: about OECD. http://www.oecd.org/about/.

Accessed February 22, 2007.


opment: member countries. http://www.oecd.org/

document/58/0%2C2340%2Cen_2649_201185_

1889402_1_1_1_1%2C00.html. Accessed February 22,

2007.


opment: OECD in figures 2006-2007. 2006. http://

ocde.p4.siteinternet.com/publications/doifiles/

012006061T02.xls. Accessed February 22, 2007.

7. Anderson G, Poullier J. Health spending, access, and

outcomes: trends in industrialized countries. Health

Aff. 1999;18(3):178-192.


opment: OECD health data—tobacco consump-

tion. 2006. http://www.oecd.org/dataoecd/7/40/

35530101.xls. Accessed February 22, 2007.


opment: statistics and indicators for 30 countries—

LE total population at birth. 2006. http://www.oecd.

org/dataoecd/20/51/37622205.xls. Accessed February

22, 2007.

10. Stanford Encyclopedia of Philosophy: Distributive

Justice. 1997. http://plato.stanford.edu/entries/justice-

distributive/. Accessed March 28, 2007.



11. Rosenbaum S. A dose of reality: assessing the Federal

Trade Commission/Department of Justice report in

an uninsured, underserved, and vulnerable popula-

tion context. J Health Polit Policy Law. 2006;31(3):

657-670.

12. Stone D. United States. J Health Polit Policy Law.

2000;25(5):953-958.

13. Braun P, Caper P. Information needs in a changing

health care system: capitation and the need for a

population-oriented view. J Ambul Care Manage.

1999;22(3):1-10.

14. Eaton S. Definition of ‘affordable’ a key issue in new

Massachusetts health care reform law. Mass Nurse.

2006;2, 3.

15. National statistics online: population estimates.

2006. http://www.statistics.gov.uk/CCI/nugget.asp%

3FID%3D6. Accessed February 28, 2007.

16. Department of Health. Department of Health:

Departmental Report 2006 (Cm 6814). Norwich,

UK: The Stationery Office Ltd; 2006.

17. NHS in England: about the NHS—how the NHS

works. http://www.nhs.uk/england/AboutTheNhs/

Default.cmsx. Accessed January 18, 2007.

18. Becker C. Foreign exchange. CFOs in the U.K. seek

greater collaboration between finance, clinical teams

as the National Health Service pursues reforms. Mod

Healthc. 2006;36:35, 39.

19. Dean M. National Health Service and private hos-

pitals to work together. Lancet. 2000;356:1663.

20. Ham C. Health Policy in Britain. 5th ed. Hampshire,

UK: Palgrave Macmillan; 2004.

21. Davey, Smith G. The UK National Health Service and

the national health: 1948-98. Crit Public Health.

1999;9(1):69-74.

22. NHS in England: history of the NHS. http://www.

nhs.uk/england/aboutTheNHS/history/default.cmsx.


23. Department of Health: about us. http://www.dh.

gov.uk/en/Aboutus/index.htm. Accessed February

12, 2007.

24. National Health Service. The NHS Plan: a plan for

investment, a plan for reform. A summary (Cm

4818-I). London, UK: Department of Health; 2000.

25. Bradshaw PL. Politics, power and control in the

British National Health Service—will anything really

change? J Nurs Manag. 2001;9:311-313.

26. McMurtrie L. Commissioning a patient-led NHS: part

of a 10-year modernization plan. Equip Serv. 2006;

1:6-7.27. Klein R. The troubled transformation of Britain’s

National Health Service. N Engl J Med. 2006;355(4):

409-415.

28. Glasby J. Mixed blessings: is The NHS Plan revolu-

tionary? Br J Nurs. 2000;9(18):2001.

29. Jowitt M. The NHS Plan—first impressions. Mid-

wifery Matters. 2000;86.

30. Pearson S, Rawlins M. Quality, innovation, and value

for money—NICE and the British National Health

Service. JAMA. 2005;294(20):2618-2622.

31. Department of Health. Raising Standards—Improving

Performance in the NHS. London, UK: Department of

Health; 2003.

32. Kuzel A, Devers K. The UK National Health Service

and pay-for-performance: lessons for the United

States. Ann Fam Med. 2006;4(3):275-276.

33. The Government announces new national plan to

revolutionize NHS. Br J Nurs. 2000;9(15):962.

34. Burnham replies to NHS critics: waits at record lows

and intensive beds at record high. 2007. European

Intelligence Wire. http://www.ucfproxy.fcla.edu.

Accessed March 18, 2007.

35. Mapping the success of the NHS building schemes

since 1997. 2007. European Intelligence Wire. http://

www.ucfproxy.fcla.edu. Accessed March 18, 2007.

36. Bradshaw P. Modernizing the British National Health

Service (NHS)—some ideological and policy consid-

erations. J Nurs Manag. 2003;11:85-90.

37. Department of Health. Our Health, Our Care, Our Say:

A New Direction for Community Services (Cm 6737).

Norwick, UK: The Licensing Division; 2006.

38. Rawlins M. NICE work—providing guidance to the

British National Health Service. N Engl J Med. 2004;

351(14):1383-1385.

39. Department of Health: NHS costs and exemptions.

http://www.dh.gov.uk/prod_consum_dh/idcplg%

3FIdcService%3DGET_FILE%26dID%3D129863%26

Rendition%3DWeb. Accessed March 30, 2007.

40. How the NHS works. 2001. http://news.bbc.co.uk/

vote2001/hi/english/main_issues/sections/facts/

newsid_1182000/1182618.stm. Accessed February

24, 2007.

41. Department of Health: NHS revenue allocations.

2005. http://www.dh.gov.uk/en/Policyandguidance/

Organisationpolicy/Financeandplanning/Allocations/

DH_4108515. Accessed March 4, 2007.

42. Ruger JP. Health, health care, and incompletely

theorized agreements: a normative theory of health

policy decision making. J Health Polit Policy Law.

2007;32(1):51-87.

43. National Coalition on Health Care: health insurance

cost. 2004. http://www.nchc.org/facts/cost.shtml.


44. Shi L, Singh D. Delivering Health Care in America.

Sudbury, MA: Jones and Bartlett Publishers; 2004.

45. Stahl M. Encyclopedia of Health Care Manage-

ment. Thousand Oaks, CA: Sage Publications, Inc; 2004.

46. DeMoro R. Wal-Martizing healthcare: mini health

clinics in big retail stores make buying healthcare

like buying any household product. California

Nurse. 2004;100(8):7.

47. Kulesher R. Medicare—the development of publicly

financed health insurance. Health Care Manag.

2005;24(4):320-329.

48. King J, Penn D, Perfetto D, Singh E, Williams R,

Zeruld W. Narrative review: the U.S. pharmacopeia

and model guidelines for Medicare part D formu-

laries. Ann Intern Med. 2006;145(6):448-453.

49. United States Department of Veterans Affairs: health

care—Veterans Health Administration. http://www1.

va.gov/health/. Accessed February 12, 2007.



50. Henderson J. Health Economics and Policy. 3rd ed.

Mason, OH: Thomson—South-western; 2005.

51. Agency for Healthcare Research and Quality: individ-

ual health insurance: are you ready for change? 2002.

http://www.ahrq.gov/news/ulp/indinsurancetele/.


52. Starr P. What happened to health care reform? Am

Prospect. 1995;20:20-31.

53. Derose KP. Reliving history and renewing the health

care reform debate. Ann FamMed. 2006;4(5):388-390.

54. GOP.com: Republican National Committee: afford-

able, accessible, and flexible health coverage. 2007.

http://www.gop.com/Issues/HealthCare/. Accessed

March 28, 2007.

55. Hillary for President: statement of Hillary Clinton

announcement of the ‘‘Better Health Care Together’’

campaign. 2007. http://www.hillaryclinton.com/

news/release/view/%3Fid%3D1305. Accessed March

28, 2007.

56. John Edwards 08: health care. http://johnedwards.

com/about/issues/health-care/. Accessed March 28,

2007.

57. Obama ’08: creating healthcare system that works.

http://www.barackobama.com/issues/healthcare/.


58. Berman Stephen. Universal coverage for children:

alternatives, key issues, and political opportunities.

Health Aff. 2007;26(2):394-404.

59. McLean R. Financial Management in Health Care

Organizations. 2nd ed. Clifton Park, NY: Thomson—

Delmar Learning; 2003.

60. Washington State Office of the Insurance Commis-

sioner: a consumer’s insurance glossary. http://www.

insurance.wa.gov/consumers/glossary.asp. Accessed

March 31, 2007.

61. United States Department of the Treasury: Internal

Revenue Service—publication 502. http://www.irs.

gov/publications/p502/ar02.html. Accessed March

31, 2007.

62. United States Department of the Treasury: Internal

Revenue Service—publication 969. http://www.irs.

gov/publications/p969/ar02.html. Accessed March

31, 2007.

63. Petratos P. Does the private finance initiative promote

innovation in health care? The case of the British

National Health Service. J Med Philos. 2005;30:627-642.


A Comparative Analysis Of The UK And US Health Care Systems

Health & Medicine

Transcript of A Comparative Analysis Of The UK And US Health Care Systems