Structure of the healthcare system

Who should be guaranteed basic healthcare coverage?

Who should receive financial support for health care? Everyone? Even persons with profound health problems? Immigrants? Illegal aliens? The elderly? The poor? (Define poor.) Infants and children? (When is a person no longer a child?)

Several programs guarantee health care to certain groups. Currently, most states have support programs at least for women, infants and children (WIC), and the 2009 Children's Health Insurance Reauthorization Act (CHIPRA) bill supports care for many youngsters. When Medicare was established nation-wide in 1975, it created widely applicable coverage for citizens age 65 and older. Medicaid, a federal-state combination program administered by the states, covers many who have chronic medical disabililties or handicapping conditions. The Veterans Health Administration (VHA) covers persons who have served in the U.S. Armed forces.

What constitutes basic healthcare coverage?
           
All decisions about coverage will irritate some groups. Probably the greatest support exists for covering ordinary care – conditions such as sore throat, respiratory infection, skin eruption, gastric pain, accidental injuries, etc. However, further questions are inescapable. Shall coverage include preventive care, such as vaccinations? What about chronic conditions? Debilitating handicaps? Mental health? End-of-life care? The list can be extended indefinitely.

How do we pay for healthcare coverage?
           
Ultimately the system is paid for by consumers and taxpayers. We may pay directly (insurance premiums, co-pays, deductibles) or indirectly (government programs and employer healthcare programs funded by taxes and by prices of goods and services, respectively). When healthcare coverage is tied to employment, then businesses pay private insurers, too. Essentially, three groups now pay directly for services rendered:

• individuals (through payments and co-payments)
• private insurance companies (through post-service payments)
• government (through post-service payments plus institutional support – such as VHA)

           
In general, proffered changes recommend one of three payment systems: single-payer (citizens are taxed and the government pays the bills); dual-payer (patients deliver a co-pay and private insurance or government programs pay the balance); or a combination (patients deliver a co-pay and both other entities pay something).
Obviously, each possibility has its own complexities.

How is the price of coverage set?
           
As direct payers, individuals have little control over the cost of the services provided: we expect to pay what we are billed. However, that is not the case for payments by private insurance and the government. Instead, they announce what they will pay (either as a percentage of the charge or in absolute dollars) for a given service, such as a chest X-ray. Then the medical care provider either can bill the patient for any remainder or “accept assignment” and forego the balance.
           
Americans pay a high price for the care they receive.
In “The Evolution of the Health Care System in the United States,” Rhondda Tewes reminds us that “. . . the United States spends twice as much per capita on health care as other industrialized nations that provide health insurance to all their citizens. And yet we lag behind those nations on all three indicators of healthy lives: high life expectancy, low preventable mortality and low infant mortality” (http://www.lwv.org/SocialPolicy).

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Roles of professional participants in the system
Effect on the U.S. economy