Comparison of South Carolinas Health Care Program and National Health Insurance of Canada - Research Paper Example

Compare South Carolina’s health care program(s) to the health care delivery systems of Canada (National Health Insurance) Abstract- The health of a nation’s population depends on the effective utilization of the various health care programs that are developed keeping in mind their socio-economic, financial, and cultural conditions, preferences and needs. To provide health care to the populations, the different governments consider different factors and plan strategies for the same. The two countries, the US and Canada, have been implementing health programs for a while and although the goal is to reach to millions of people who otherwise may lack medical and health care facilities at lower costs, the success of each program involves all the stakeholders in the program and their promoting the same. Also, as identified by the Organization for Economic Co-operation and Development (OECD), the governments of the different countries are responsible for shaping health insurance markets of their respective countries. Governments either directly develop and implement the programs or take the help of insurance companies to identify, develop and implement these various programs to reach millions of people. Like every other country, the US also has identified the need for implementing health care programs for its citizens. The Medicaid program of South Carolina is different from the US Medicaid program in that it offers four different options for health care and is developed with the needs of the local residents in mind. According to the state’s plan, while the existing primary care case management networks offer the regular services as the national Medicaid program, the new programs offer pharmacy benefits and durable medical equipment along with the mandatory Medicaid services. Canada has a medicare program for almost its entire population and is called Medicare program with 13 integrated health insurance plans which share certain common features and basic standards of coverage. The percent of the national health economy spent on providing is lesser in Canada and almost double in the US. South Carolina’s new Medicaid program can be considered to be more effective than the federal government’s Medicaid program in terms of increased power of negotiation and increase in choice of the plans to the beneficiary. However, it can still draw from the Canadian program to make it more effective and reduce costs and wait time while improving the quality and increase coverage. Table of Contents- 1. Introduction 2. Why healthcare 3. Healthcare in South Carolina 4. Comparing with Canada’s National Health Insurance 5. Conclusion and recommendations References 1. Introduction- The needs of every citizen considered under the purview of health care are addressed either individually or collectively by the different private and public bodies. There are various medical facilities and regulations for providing basic and high-end medical care to almost every citizen in each country. Dealt wither by private or public bodies it involves costs to provide for the medical and health care facilities. OECD has regulations for providing health care to the different strata of the society and regions. In this paper we would discuss the health care programs of two different places, South Carolina and Canada, how they differ and why Canada’s National Health Insurance scheme is much desired by those in the United States. A brief of the health care programs and their implementation in the different regions and the success of each of them would be studied. Further, the problems faced in implementing the programs and the recommendations for improvements are also made. 2. Why Health care? World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity” (McKenzie, et al, 2004, p5). The health of a nation’s population depends on the effective utilization of the various health care programs that are developed keeping in mind their socio-economic, financial, and cultural conditions, preferences and needs. While the needs for health care vary widely from individual to individual, communities, age, gender, occupation, etc. there have been rigorous exercises to cover almost all of them under some or other program. And when it is the need for the whole of the country’s population, the government’s intervention and interest in providing the same is recognized by all the governments across the world. It is a famous phrase that says, “the health of a nation is perceived as the health of its people”, which is a major perception among the developed and the developing countries alike. Hence, governments have taken special interests in providing or facilitating better health care to their populations at all times. To provide health care to the populations, the different governments consider different factors and plan strategies for the same. Some of these are found to be simple and some too intricate, like in the case of the US. The United States of America and its neighbor, Canada both have been extending health care to their respective populations with some basic differences which tell why one is considered to be more desirable than the other. The two countries have been implementing health programs for a while and although the goal is to reach to millions of people who otherwise may lack medical and health care facilities at lower costs, the success of each program involves all the stakeholders in the program and their promoting the same. There is more bureaucracy in the US which makes it less efficient than the simpler Canadian government’s National Health Insurance. McKenzie et al. define the public health as the health status of a defined group of people and the governmental actions and conditions to promote, protect, and preserve their health (2004, p6). Hence, government’s initiative in this direction is of paramount importance and the various stakeholders play their roles in developing them. Both the developing as well as developed countries have realized the need for improved health services and at reasonably affordable prices. With such initiatives, every government is then challenged with the task of implementing the right kind of programs to benefit the target population and ensure their safety and health. “Government occupies a central role in shaping health insurance markets and their impact on health systems” (OECD, 2004). As the basic health care facilities can go a long way to ensure that the country’s future is healthy and secure to an extent, the focus is more on providing them for the underprivileged who cannot afford such care and the marginally placed population. However, there are many insurers who have made programs for the masses and other population with a paying capacity. These programs have ensured that every citizen of a country can have access to the basic and at times other important health care facilities with the investment and the risk of such care being distributed equally among the members. As observed in the paper published by OECD, “health systems are financed through a variety of mechanisms, of which health insurance is one. Health insurance can be defined a way to distribute the financial risk associated with the variation of individual’s healthcare expenditures by pooling costs over time (pre-payment) and over different individuals (pooling)” (OECD, 2004). Governments either directly develop and implement the programs or take the help of insurance companies to identify, develop and implement these various programs to reach millions of people. One thing in common is the care that is implemented has to reach the right segment and the profit or loss aspect is not of importance for most of the programs. However, with insurance companies facilitating the health care programs, there is a business aspect attached to this program much to the disappointment of the people, and the companies trying to make this a profit-oriented business. Due to the involvement of insurers in this national program, the cost of providing health care to the population is becoming more than expected and the bureaucracy involved, the scope for malpractice have all increased along with limiting the reach of these programs. 3. Health care in South Carolina- Like every other country, the US also has identified the need for implementing health care programs for its citizens. It has been trying to provide better health facilities for its marginal population which is diverse in nature. The American government’s growing realization that many Americans were still not reaping any of the benefits of 60yrs of medical advances has led to introducing the healthcare programs which the elderly or poor who could not normally afford to purchase. Hence, in 1965, the US congressional government had introduced two healthcare programs called the Medicare and Medicaid. While Medicare is a program to assist the elderly and the disabled to be covered by paying their medical bills, Medicaid is to cover the millions of poor Americans who otherwise would not have been able to afford the bills for their health needs. On the whole, these two programs by the US congress have been able to cover millions of elderly, poor and disabled to have access to the basic medical facilities at affordable prices and also improve the standards of health (McKenzie et al, 2004, p18-19). Both the congressional government and the local state governments share the responsibility of paying the bills under these two programs and hence are publicly funded. US congressional government along with the local state governments provides these programs to almost 43 million uninsured people as of 2001 and the percent of the nation’s economy that is spent on these programs is estimated to be around 17 percent as on 2002 (Public Citizen, 2004). However, although the national health scheme should be providing these facilities with the nation’s tax economy, there is an increase in the public-private partnership in the country. Private insurers are increasingly running this business with various flexible options and enrolling the beneficiaries to gain through the improved service provided by them. These private insurers are responsible for the implementation and monitoring of the publicly funded programs. This makes the process time consuming and costly as the beneficiaries have to wait for long periods and need to see the physician the insurer recommends. Also, the increased bureaucracy increases the time taken for reimbursement. On the other hand, the access to the different medical services is made available and is more accessible and flexible due to the presence of the private insurers in the US. However, each state with its different insurers have a wide range of programs with some very unique to the place and the needs of its people. It is noted that there are about 755 plans in Seattle alone and the public-private partnership for providing the healthcare facilities in the US account to a high number of insurers leading to increased bureaucracy and overheads with increasing business orientation ultimately resulting in increasing competition and cost of service that the beneficiary and the government have to cough up (Public Citizen, 2004). South Carolina’s governor Mark Sanford proposed a defined and customized healthcare program for its people which would be similar to the private healthcare system, and is named ‘Healthy connections’. This is found to be a flexible program with the option for the recipients to choose from four different programs based on their needs hence making them more cost-conscious while creating market-based incentives. There are four programs that have been proposed to compete with the private insurance programs to benefit the beneficiaries by giving them the freedom to choose their healthcare plan according to their health needs and manage their cash. Although this initiative is unique to the state of South Carolina, both the federal and the state governments share the cost of providing the healthcare programs (Herrick, 2005). The Medicaid program of South Carolina is different from the US Medicaid program in that it offers four different options for health care and is developed with the needs of the local residents in mind. The new plan would offer a wide of products and is implemented with a business like approach. The new plans are the managed care and preferred provider (PPO) networks. According to the state’s plan, while the existing primary care case management networks offer the regular services as the national Medicaid program, the new programs offer pharmacy benefits and durable medical equipment along with the mandatory Medicaid services. Since the increased number of programs have to be chosen among by the beneficiary, they are also counseled to choose from the different programs to suit their needs best. The beneficiaries are in a position to act as customers as in any business. This gives them an advantage to invest wisely in the program of their choice based on their specific needs by comparing the prices too (Herrick, 2005). Director of South Carolina’s health care program notes that this initiative in the state has been able to define a new power to the consumers by giving them the choice to opt for a well-suited plan with the different insurers vying for them to purchase their plans. This is seen to give the beneficiaries respect among the health care providers who normally would have had the power of implementing the program and hence command greater control over the process. While the involvement of the insurers is still present in the Medicaid program of South Carolina, the focus shifts to the beneficiary instead of the insurer. As Sanford’s spokesman reminds the intention behind such a program, “The governor believes allowing Medicaid recipients to take ownership of their own health care will reign in costs, create market-based incentives, and help them to become more cost-conscious consumers” (Herrick, 2005). 4. Comparing with Canada’s National Health Insurance- Canada has a medicare program for almost its entire population and is called the National Health Insurance (NHI) program or alternatively, Medicare. “Canada has 13 interlockign provincial and territorial health insurance plans and all of these plans share certain common features and basic standards of coverage” (Health Canada, 2004). Lemco (1994) observes that although the US and Canada both have similarities in the distribution of the population, economies that are increasingly integrated, and constitutional federalism, the pattern and style of medical care started to differ since Canada introduced its national insurance in 1971 (p70). He further notes that the Canadian NHI scheme is intended to cover almost its entire population and the terms and conditions are universal when compared to the US Medicare and Medicaid programs (p80). Further, since the Canadian plan is simple in terms of implementation where the beneficiary’s physician needs to fill a single simple form for availing and for reimbursement of the bills and are directly sent to the government for the payment release (Public Citizen, 2004), the time for reimbursement of the bills and the bureaucracy is minimized to the extent. It can be observed that while the typical American providers take 60-120 days for reimbursements of the bills, the Canadian providers in contrast take nearly 30 days for the same (Lemco, 1994, p73). The decrease in wait time can be attributed to various factors. First, there is a simple and direct form of treatment by specialists which the physicians are free to recommend to the patient with out the need for approval of the administration. Second, the claiming of bills by the physicians is direct and all they need to do is simply send the invoice to the government directly and receive it in about 30days as there is no bureaucracy involved in the form of third party or private insurers who otherwise would be bothered to run this as a profit making business, increasing the cost and time as a result. Further, there is an increase in accountability in the Canadian health care system as the middle-men or the insurers are done away with and there is clear concentration of responsibility thus increasing the quality of service (Lemco, 1994, p80). This initiative also ensures the cost reduction of the same kind of service as in the US as the costs incurred on the bureaucracy is eliminated and it is observed that this can save the government of Canada a considerable amount which can be utilized to cover every citizen under the health care program and also increase the quality of service. It is noted that in 2004, while Canada spent about 16.7 percent of its national health fund, the US spent about 31 percent of the same for these health care programs (Public Citizen, 2004). It is also observed that Canadians are more satisfied with the health care they receive than the Americans which are more managed. This dissatisfaction can also be attributed to South Carolina’s predominantly managed care with its delays in receiving treatment and reimbursement of bills, although it can be having far more options than the regular federal Medicaid program. Further, the increased accessibility of the health care service to almost all of the population can ensure that the quality of life is improved. Pappa and Niakas (2006), note that “perceived health status or health-related quality of life (HRQoL) is a very important predictor of health service utilization”. However, the Canadian system is not without its share of problems and the major problem it faces is inadequate funding the program (Brown, 2004). This has resulted in lesser hospital beds when compared to the US but since the basic health care facility is provided to almost every citizen in Canada, there is a decreased need for specialty treatments on a regular basis as opposed to the US where many of the insured and uninsured still need to be covered effectively under the federal program. 5. Conclusions and recommendations- While South Carolina has managed care for its poor, disabled, children, women and the elderly, Canada on the other hand provides a much simpler method of providing health care to almost all of its population. The US has a high level of bureaucracy in the form of public-private partnership and thus results in lesser responsibility on any particular party, which also does not enable any single point of accountability. Further, the American health care scenario is complex with its myriad plans, insurers and differing policies which make it tough to attribute responsibility and accountability for the costs, implementation and quality of service. South Carolina’s new Medicaid program can be considered to be more effective than the federal government’s Medicaid program in terms of increased power of negotiation and increase in choice of the plans to the beneficiary. On the other hand, Canada’s Medicare system is more open and direct and is found to be quite simple with enhanced accountability and responsibility by the provider. Although it offers limited services to its population, it has been successful in covering almost its entire population under its 13 different simple plans for health care. Due to lesser bureaucracy in this country, the time for obtaining treatment and reimbursement is also less and is a highly desirable outcome. Further, the cost savings from decreased bureaucracy can be reinvested into the same program to increase the quality and scope of the service. It can be observed that South Carolina can effectively adopt some of the implementation plans from Canada for further cost savings by reducing the number of insurers and the bureaucracy. It can also do good to frame a less complex referral practice and give the beneficiaries the choice of specialists that too at the state level without the need for federal or insurer’s approval. South Carolina’s managed care can be made available on request for the segment of people who need to be counseled and this can be on request and by the administrative staff at the service provider. Also, accreditations of the service providers can help limit as well as improve the quality of service by the private providers. Setting a time frame for the processing of bills and the waiting time for specialist treatment can also help South Carolina to further improve the effectiveness of its unique and customized heath care program. References- 1. Herrick, D (2005). South Carolina Plans Tailored Medicaid. The Health Institute. http://www.heartland.org/policybot/results/17756/South_Carolina_Plans_Tailored_Medicaid.html. 2. Pappa, E and Niakas, D (2006). Assessment of health care needs and utilization in a mixed public-private system: the case of the Athens area. BMC Health Service Research. http://www.biomedcontral.com/1472-6963/6/146. 3. 2004. Study shows National Health Insurance could save $256 billion on Health care paperwork: Authors say Medicare drug bill will increase bureaucratic costs, reward insurers and the AARP. Public Citizen. http://www.citizen.org. 4. Brown, B (2004). In critical condition: Health care in America Canada’s way. The Chronicle. http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2004/10/14/BUGR28JFEN59.DTL. 5. McKenzie, JF et al (2004). An introduction to community health. Jones and Barlett publishers. 5th ed. Pp 5-19. 6. Private Health Insurance in OECD Countries. OECD Health Project. Pp 20-26. 7. Lemco, J (1994). National Health Care. University of Michigan Press. Pp 70-80. 8. Canada’s Health Care System (Medicare). 2004. Health Canada. http://www.hc-sc.gc.ca/hcs-sss/medi-assur/index-eng.php. Read More