USA

Table of contents:
1. Evolution of the U.S. health care policy
2. Structure of the U.S. health care system
3. State health care programs
4. Types of insurance
5. Regulation and supervision in public health services system

1.Evolution of the U.S. health care policy

The fact that the U.S. health care police is among the best in the world, is a
commonly accepted fact. Many countries work hard on this issue in order to
create a health care system that would in whatsoever way resemble the
system implemented by the United States. The United States of America is
the owner of the most expensive health care system in the world. This is
primarily due to the fact that U.S. spends on the health care system more
than any other country both in absolute figures and as related to the GDP per
capita. For instance, in 2007 U.S. spent approximately 7439 USD on the
health care of its each citizen (Roehr,2008).
According to CIA World Fact book, the level of the child death rate and life
expectancy in the USA both occupy the 40th positions in the world. Despite
all the financial support, historically the period of 1997-2003 revealed that
the reduction of death rate in USA was the slowest as compared to other
industrially developed countries. At the same time in 2006 the US statistics
center after analyzing the information from the annual national public inquiry
of a state of health, stated that about 70% of the US population referred to
their health as excellent or very good (Mahar,2006). Such subjective
evaluation of the national health is a very impressive and very important.
At the present moment US uses around sixteen percent of its GNP and it is
expected that by the year of 2017 this percentage will reach the level of
twenty percent. The main source for such potential growth is a set of state
programs, which in its turn made lead to the destabilization of the national
economy. Correspondingly, this issue needs further analysis and the
implementation of a larger percentage of the privet sector of health
care(Roehr,2008).

A spite all the impressive figures and numbers, the history has proved that
USA is the only country in the world which does not have a universal system
of health. 64% out of the 84% of the US citizens that have health insurance,
are insurances covered by the employer. Only 9% acquire the health
insurance as an individual private order; 27% of the US population obtains its
insurance owing to various state programs (Roehr,2008). Certain state
programs provide the invalids, elderly people, veterans and low-income
groups with medical aid, and emergency health care for all US citizens
notwithstanding their ability to cover it. Almost the half of the expenses of
the country are the expenses of such state programs, therefore the US
government is the largest insurer of the nation.

2.Structure of the U.S. health care system

The US health care system is represented on three major levels: family
medicine, hospital help and public health services. Medical services within
the territory of the United States are provided both by private or legal
establishments. Various commercial, charitable and state organizations offer
patients both out-patient and stationary services (Mahar,2006).
About 47 % of all expenses on public health services of the USA, are
expenses for hospitalization, about 2 % are house service, 10 % are
medicamentous treatment and 10 % are the maintenance at geriatric
homes. The remained 11 % cover services of dentists, ophthalmologists and
other experts of narrow background(Roehr,2008).
Family medicine is considered to be a rather developed structure in the USA.
Family doctors examine and observe patients and if necessary, direct them
to narrow experts or to a hospital. Such doctors receive payment directly
from patients. As a rule, the family doctor has his own office or cooperates
with other experts. Hospitals make the largest component of the general
amount of medical services of the USA(Wangsness,2009).
Hospitalization is the most expensive and most important component of the
industry of public health services of this country. However, recently there are
appreciable shifts towards other establishments, mainly polyclinics, points of
first aid and geriatric homes. Out-patient services are slowly, but confidently
replaced by hospitalization, and home visiting service by staying in geriatric
homes.
In the USA there are two types of hospitals: the ones having property rights
but frequently operated by big private corporations, and the hospitals that
are non-profitable hospitals which are controlled by district and state
authorities, religious communities or independent public organizations
(Mahar,2006). US hospitals render a certain volume of the out-patient help in
the ERs and in specialized clinics, but basically they are intended for

rendering the hospitalization of the patients. A vast amount of attention is

given to emergency aid. Besides, USA has a network of hospices for terminal
patients with expected life expectancy of six month and less. Such hospices
are usually subsidized by charitable organizations and the government.
However, in the USA, as well as in other countries, the concept of the outpatient help includes rendering of medical services without hospitalization of
the patient. This makes a big share of rendering of medical aid to the
population. Treatment in-home basically is made at the expense of the
sisterly organizations and usually is ordered by the doctors. The private
sector of out-patient medical aid is presented by personal doctors (experts in
internal and family medicine, pediatricians), narrow background experts, for
example gastroenterologists, cardiologist, nurses and other medical
personnel(Roehr,2008).

3. State health care programs

Those American citizens, who do not have private insurance, are eligible for
the action of such state programs as Medicare, Medicaid, and also other
programs for the needy population offered by different states and local
authorities. One of the researches showed that 25 % of none-insured US
population can participate is such state programs, but nevertheless for
certain reasons have not got under their action(Roehr,2008).
One of the major purposes of the US government is the expansion of the
sphere of action of these programs on all levels of the population and
especially for those US citizens, who truly need them. For example,
the Tricare program is a program for the veterans and their families. In 1997
the federal government has introduced the program of the state insurance
for children from families that have an income which is higher than
the Medicaid admission rate but nevertheless is not sufficient in order to
purchase insurance(Mahar,2006). By 2010 this program has helped millions
of children, but in many states it has already faced the problem of
insufficient financing.
The government of the USA pays the expenses of the public health services
by means of two basic programs Medicaid and Medicare. These two
programs allow providing medical services which are either free of charge or
at a very low cost, to poor or indigent citizens of the country.
Medicaid annually provides medical aid to over 40 million Americans with
low level of incomes, and Medicare provides medical aid to a similar amount
of elderly patients and people with limited physical possibilities
(Roehr,2008).
Medicare is a famous insurance state program for senior people who are
older than 65 years which was implemented in 1967. Before its
implementation almost the half of the elderly population of the United States

did not obtain the required volume of medical services. This program
coordinates the insurance of all the American citizens who are older than 65
years old and also of those citizens, who are approaching this age and have
serious health pathologies. Thus, at the present moments more than 97% of
the elderly population, citizens with serious kidney pathologies and about 4
million of invalids are insured by the Medicare program.
This insurance program covers medical aid during acute conditions right up
to hospitalization, various diagnostic procedures, medical services at home
and short stay in geriatric homes. Besides, patients can receive some
preventive services, for example vaccination against hepatitis B, flu,
pneumococcus and other. Such services as long hospitalization, nurse
visiting service, hearing aids and prescription drugs are not covered by this
program. Medicare is a rather effective program. It is partially financed from
the special tax on workers: part f it is paid by the worker and the other part
by the employer. As a whole, this tax is about 15 % of the income of working
Americans. The other Medicare part is financed from the general proceeds
of surtax.
The Medicaid state program was introduced in 1966 and is aimed at
insuring American citizens from low-income families. Elderly people, people
with severe injuries, invalids, pregnant women and children are also eligible
for this program. This program also covers up to 40% of the newborns, about
30% of children of all age groups and about 40% of the HIV positive
individuals(Cunningham, 2006).
Medicaid deals with five basic services: stationary and out-patient
treatment, consultations of various experts, stay in geriatric homes,
laboratory diagnostics and radiological methods of research. This program
pays for geriatric homes for aged people who require permanent care and
cannot do anything without outside help.
Staying in such establishments is very expensive: up to 100 dollars a day,
therefore, the amount of savings of the majority of such people is not
sufficient for this purpose. Patients in geriatric homes get the largest portion
of the Medicaid money (Cunningham, 2006).
The Medicaid program is financed both by the federal government and the
states. The federal government pays the share of the Medicaid expenses
from the proceeds from the general tax. That makes approximately half of all
the expenses and the rest is paid by the government of each state.
In 1966 the Congress of the USA has passed the law which reformed the
system of social security in the USA(Cunningham, 2006). Since then, each
state of the country submits to the federal government a plan of the required
medical services for different groups of the state population covered by
Medicaid. After the approval of this plan the states began to use federal
money along with their own incomes for financing medical services. There is

a different Medicaid program in each state which converts this program into
a system that is difficult to manage.

4. Types of insurance
Payments for health services are made by each person individually at the
expense of his/her own means, as well as for any other rendered service. The
insurance model provides division of financial risks according to which, each
individual or its employer brings the established monthly payment
(Wangsness,2009). Such mechanism of division of means frequently allows
paying a full spectrum of necessary medical services. Nevertheless,
sometimes it is necessary to pay a certain sum for rendered services the
so-called franchise, or to pay extra for each given procedure (Mahar,2006).
Today the majority of employers use the so-called management insurance
organizations which organize the rendering of medical services at a price
that is considerably lower than the one paid by the worker in case of private
individual appellation. The basic feature of such organizations is the
conclusion of selective contracts which is basically a contact with several
suppliers of medical services that allows achieving lower prices. Besides,
these organizations often offer schemes of the decrease of the excessive
medical expenses for the employer. In order to minimize the expenses, the
patient needs to be preliminary examined the broad specialist before
obtaining specialized aid. Management insurance organizations include
health maintenance organizations and preferred provider organizations. The
first ones cover only the medical services provided by the hospitals with
which they have a contract. The second ones allow getting medical aid not
only within the network of its hospitals but also outside the contracted
hospitals. Modern employers give preference to health maintenance
organizations(Roehr,2008).
Though the American system of public health care is the most expensive in
the world still it has certain defects. Many US citizens cannot receive
adequate medical aid, the number of diseases in the country does not
decrease, and preventive actions frequently do not bring expected result.
However USA constantly take steps in the direction of the elimination of such
defects and the system in generally directed to the improvement of the
health of the population. Considering the close interrelation between the
system of financing and the organizations providing medical services it is
possible to say, that new mechanisms of financing lead to changes in the
system of rendering of medical services and simultaneously become one of
determinatives on the way to the improvement of the national health.

Moldova

Moldova has a low standard of state funded healthcare. Healthcare in the

country is available to all citizens and registered long-term residents. The
Ministry of Health oversees the health service in the country and all citizens
are entitled by law to equal access to a minimum amount of free healthcare.

The State System

The basic package of free healthcare is limited to emergency assistance and
treatment and treatment for acute illness. However, different medical
organisations take varied views on what procedures are offered and where.
Financing of Moldovan healthcare is predominantly done through taxation,
but there are pilot plans in operation whereby employers pay a flat rate
contribution to a healthcare fund for each person they employ. There is no
option for opting out of the state scheme. Vulnerable groups like retired
citizens, the disabled or those who have lost the income from the
breadwinner have their contributions paid by the state, as long as long as
there are no other possible means of making the contribution i.e. no other
member of the family can afford to pay the contribution for them. When
healthcare contributions are paid by the state, the beneficiary only receives
a minimal amount of healthcare.

Fees
In addition to taxation, one third of healthcare finance comes from out-ofpocket payments from the patient. Citizens have to pay for prescription
medicine (children under five are exempt) and medical treatments deemed
nonessential, like cosmetic surgery, dental care, massage and some
laboratory investigations. Patients also make under-the-table payments to
doctors, consultants and nursing staff. Such payments may be in the form of
a gift or actual monetary payments.

Private Healthcare
There is a private health system in Moldova; however, the system is used by
a limited number of people like MPs and wealthy entrepreneurs because the
treatments are extremely expensive. Patients who use private doctors make
out-of-pocket payments directly to the doctors to pay for the cost of their
treatment. Private practice is still limited to a small number of consultancies,
which offer diagnostic rather than curative services. Fees for private
healthcare are fixed centrally, but doctors make up their money through
additional out-of-pocket payments.

Health Posts
All communities in Moldova have access to healthcare. In rural areas, there is
a network of 1011 health posts. They are staffed by a feldscher, a midwife
and general assistants and they offer a basic package of care including
general cover, maternal and child health services, comprehensive
developmental checks, immunisation, health education and a basic 24-hour
emergency cover.

Health Centres
There are 189 health centres in rural areas, each staffed by three doctors.
Some health centres have facilities for inpatient care. Many of the services
provided by the health centre are similar to those provided by the polyclinics
in more densely populated areas.

Polyclinics
Towns and districts with a population over 3,000 people are served by
polyclinics, which are staffed by doctors of internal medicine, paediatrics,
obstetrics, gynaecology and dentistry. Nurses, midwives and medical
assistants also operate from the polyclinics. Each doctor is assisted by two
medical nurses. Polyclinics in densely populated areas also offer some
medical and surgical treatments on an outpatient basis.

Consultants
Consultants are senior doctors who have completed a higher level of
specialised training. In Moldova, there are 15,700 specialist doctors
throughout, who are highly trained. Consultants regularly accept under-thetable payments in lieu of services provided. There are numerous specialist
fields of medicine in Moldova like gynaecology, oncology, paediatrics and
dermatology. There is often a waiting list to see consultant doctors.

General Hospitals
Hospitals and clinics exist in all major towns and cities of Moldova; there is
usually at least one hospital per district or municipality. In total, there are
100 hospitals across the country (which includes rural hospitals and Central
District Hospitals), five Outpatient Clinics, a Dentistry, a Psychiatric and a
Dermatology Hospital in the capital city of Chisinau. Additionally, there is a
railway, a military and a trade union hospital. Waiting lists are long and
facilities and equipment are poor. Some hospitals in the capital cannot even
afford running water between the hours of 8pm and 6am. General hospitals
provide services to patients referred from district and municipal health
institutions. Patients are referred to general hospitals by doctors and
consultants.

Rural Hospitals
Rural hospitals offer a limited service, which includes basic specialist
treatment and some surgery. Cases that are more complex are referred to
the regional hospital. All rural hospitals offer a 24-hour emergency service
with doctors operating an emergency rota system from their homes.

Central District Hospitals (CDH).

The CDH cover most surgical eventualities but Moldovas declining economic
conditions have meant that surgical activity in CDH is now limited. In many
areas, CDH can now only carry out surgery in emergency cases and much of
the need for non-emergency surgery goes unmet.

Emergency Care
Emergency care is available free for everyone including those without state
health insurance. Emergency departments are open non-stop all year. You
may use their services if you need immediate attention, or if your GP refers
you to them, or if there is no GP service available.

Private Clinics
Whilst there are a small number of private GP practices, there are no private
clinics or hospitals.

Dentists
Dental care is deemed a non-essential service and all treatment must be
paid for by the patient directly to the dentist.

Pharmacies
Medicines are in short supply; shortages exist for antibiotics, anaesthetics,
analgesics, medicine to treat tuberculosis and drugs used in oncology
amongst others.
Pharmacies in Moldova are not stocked to western standards, labels are not
in English, and there is a chance that the medicines are not approved, and
could have been tampered with on the black market.
There are private and state pharmacies, although most of the state
pharmacies are in the process of privatisation. Within the private
pharmacies, there are security measures in place to make sure all products
are not tampered with and are approved. Children under five years old
qualify for free prescription medicine.