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Healthcare in the United States and India
The healthcare systems in the United States and India have starkly different origins: the former arose out of employer based insurance coverage while the latter began through government funding. As Sai Ma and Neeraj Sood document in a report on India's healthcare challenges, the Indian government faced the challenge of redesigning their healthcare infrastructure after their independence in 1947 (2008). The Bhore Committee, assembled by the central government, established that unsanitary conditions, poor nutrition, inadequate health education and a lack of prevention must be addressed in order to improve the quality of life for India's population. To meet these needs, the central government established a three-tiered system consisting of primary health centers (PHCs) to meet basic health needs, subcenters (SCs) for public health concerns, and community health centers (CHCs) for more specialized care. Doctors employed at these facilities received training at publically funded universities and patients could access care at no cost. The central government provided funding and oversight while the primary responsibility for healthcare administration fell to the states. Despite the establishment of this national infrastructure, the Indian government never intended to abolish private practice. In the 1950's, private healthcare services made up a small percentage of India's total healthcare system; since the 1980's, medical tourism, government cuts and a push from the middle class for more high tech care have all resulted in the rise of the private sector. This trend has reduced the quality of public care while creating private care that the vast majority of Indians are unable to afford (Ma and Sood 2008). Juxtaposing India's healthcare challenges with the United States' unique set of issues elucidates the problems inherent to both systems.
The United States health insurance system grew out a need to fill hospital beds during the Great Depression: Blue Cross pioneered employer based insurance for schoolteachers (Roberts 2009). The effectiveness of their system caught on and led to a period during the 1950's where consumer demand for services was high and doctors received ample reimbursement from insurance providers. However, coverage for the poor and elderly was still low. During Lyndon Johnson's administration, Congress passed a law that established Medicare and Medicaid, which covered citizens over 65 and the poor, respectively. With increasing coverage and guaranteed government reimbursement, cost soon became the nation's primary concern. For cost control, Nixon introduced the idea of a Health Maintenance Organization (HMO), which he argued would reduce expenditures through competition and reward groups for keeping people well (Roberts 2009). The American Medical Association lobbied against HMOs and they did not have the completely revolutionizing effect that Nixon desired. They reached their peak popularity during the 1990s, when President Clinton introduced his healthcare proposal (Roberts 2009). The proposal, which never passed, argued for a national health board that could regulate groups of competing insurance providers while putting a cap on premiums. The problem of rising costs has continued to the present. The Patient Protection and Affordable Care Act, passed in 2010, aims to reduce costs: however, the subject of improving U.S. healthcare infrastructure has never been more pressing (Manchikanti et al. 2010).
India experiences poorer health outcomes than the U.S. By most metrics: life expectancy is 64 years in India and 78 years in the U.S.; infant mortality is 69 per 1,000 live births in India and 8 per 1,000 live births in the U.S.; the incidence of tuberculosis is 190 cases per 100,000 people in India and 3 cases per 100,000 people in the U.S. (WHO). The majority of life years lost to poor health in India are attributable to communicable diseases (56%) like malaria and tuberculosis, while noncommunicable conditions and injuries make up the remainder. Vaccine preventable illnesses are responsible for 7% of the total life years lost in India (Ma and Sood 2008). In the U.S., noncommunicable conditions, like diabetes, cancer and heart disease, are responsible for the majority of life years lost (76%) while communicable diseases (9%) and injuries (18%) have a less significant impact (WHO 2011).
There is a dramatic difference in the proportion of GDP that the U.S. And India spend on healthcare. India spends 1-4% of its total GDP on healthcare costs (WHO; Shiva Kumar 2011; Ma and Sood 2008), while the U.S. spends 16%, or $6,402 per capita as of 2008 (NPR). Of that $6,402 figure, $2,884 (45%) is paid for by government, $2,676 (42%) by private insurance (52% paid by employers and 48% by employees), and $842 (13%) is paid directly by consumer out-of-pocket expenses (NPR). In contrast, consumers pay 78% for healthcare costs directly out-of-pocket in India while the government contributes roughly 15% (Shiva Kumar et al. 2011). The market for private insurance companies has not yet been tapped but it is expected to grow rapidly in the next decade. Only 10% of Indians have at least one family member covered by some kind of insurance at this time (Shiva Kumar et al. 2011). The direct cost to consumers has created an access barrier: the working poor pay 40% of their income for healthcare expenses while richer, urban workers spent 2.4% (Varatharajan, Thankappan, and Sabeena, 2004). In fact, out-of-pocket healthcare payments push 6% of the population below the poverty line each year (Berman, Ahuja, and Bhandari 2010). A government report established that there are 10% fewer PHCs than needed and 50% fewer CHCs than needed due to lack of funding (Ma and Sood 2008). All of these factors contribute to unequal access to care.
The low government healthcare spending in India is inadequate to provide well-staffed, state-run health centers; as a result, many people in India go to private practitioners and pay directly for services (Ma and Sood 2008). Medical tourists, who travel to India for procedures at costs more affordable than in their home countries, have contributed to the development of state of the art hospitals (Shetty 2010). These facilities, which are often subsidized under the condition that they provide care to low-income groups, tend to be too expensive for most people to afford. Public health projects, such as vaccination efforts, do not reach all of India's citizens, particularly those in rural areas that do not have easy access to a PHC (Ma and Sood 2008). The World Health Organization reports that there are 26.7 physicians per 100,000 people in the United States but only 5.8 per 100,000 people in India (WHO 2011). Increasing funding to the publically supported medical education programs in India could increase this ratio and lead to better service provision. Both the United States and India are able to offer high quality, Joint Commission International (JCI) Accredited services to their populations: affordability and access remain the major concerns (Shetty 2010).
India's policies for regulating healthcare are laxly enforced while U.S. policies are significantly more developed. India's constitution delineates responsibilities for states and for the central government: policy is mostly centralized while states are responsible for administration (Ma and Sood 2008). Enforcing regulations is problematic for India. For example, if the Medical Council finds a procedure or drug ineffective or dangerous, they cannot stop doctors from using that treatment. While professional organizations and state governments set guidelines or best practices, doctors practice medicine as they see best (Ma and Sood 2008). Additionally, in India's fee for service model, providers set prices. Prices are theoretically contained by market forces (Ma and Sood 2008). In the U.S., the Food and Drug Administration oversees the safety of pharmaceuticals. Prices are theoretically controlled by market forces between the federal government, insurance companies, doctors and consumer demand. The litigious nature of U.S. society and state boards hold practitioners accountable to standards of care (Roberts 2009).
The Indian government has the task of providing healthcare to over a billion people. The country has the capability to train excellent doctors and build state of the art medical facilities, as evidenced by growing medical tourism (Shetty 2008). Despite its economic growth, preventable communicable diseases like dengue fever, tuberculosis, malaria, HIV and pneumonia still have negative health impacts on the Indian population (Arora and Banerjee 2010). These diseases will continue to contribute to India's poor health outcomes until public funding addresses unhygienic living conditions, poor sanitation, inadequate public medical facilities and a lack of affordable care. With no risk pooling, individuals face out-of-pocket medical expenses that drive them into poverty: private insurance or an increased investment in government services would serve to decrease the disproportionate burden on the poor.
The U.S. faces a different problem: containing out of control healthcare costs. Despite spending more than 16% of its GDP on healthcare, the U.S. does not provide universal coverage, its doctors overuse procedures and its citizens are unhealthier than citizens in other developed countries. The employer-based system does not provide universal coverage, although the mandate in the PPACA will penalize individuals that do not purchase health insurance in 2014 (Manchikanti et al. 2010). This act, which also prevents the worst abuses by insurance companies, theoretically will help to contain costs through its mandate. The U.S. has managed excellent…[continue]
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