Original Article

The US health-care system: A proposal for reform

Received (in revised form): 25th June 2010

Nicolas Odier
is a PhD student in Clinical Research in Public Health in Medical University of Marseille (France) and Head of Project Development for Korian Company (France). His career spans several years, as a health-care consultant and manager.

ABSTRACT The US health system is a prime example of a market-based health-care system in need of reform. Compared to systems of major European countries, the US system generally has lower quality care despite higher costs and covers a smaller percentage of the population. Unlike European models, which provide governmentally centralized care, the US system is decentralized and primarily operates on a contract basis between private actors (private insurance companies, health-care institutions and health-care professionals and clients seeking care). The majority of funding is provided by labour income generated in the private sector. As a result, the global economic crisis has detrimentally affected the US health-care system to a larger degree than European models. The increase in unemployment in the United States decreases the number of insured people, and the economic crisis puts additional nancial pressure on employers to reduce health coverage of retained employees. But even before the economic crisis, the US health-care system ranked lower than systems of major European countries. Recognizing these inefciencies, former Presidents Clinton and G. W. Bush, along with the current President Barack Obama, have sought to reform the US health system. However, lobbyists representing private insurance companies, health professionals or the pharmaceutical industry have managed to thwart all attempts at major reform. Hence, the challenge before the United States remains: How in these conditions can a reform be proposed that would decrease costs, increase quality and expand coverage to include as many people as possible? Journal of Medical Marketing (2010) 10, 279304. doi:10.1057/jmm.2010.17 Keywords: health-care; public health; reform; United States of America; health insurance; health coverage

INTRODUCTION
Even though social welfare rights are not enumerated in the US Constitution, as the New Deal the federal government has implemented several programmes to help those most in need through nancial assistance to the 50 states. Each state has organized its distribution of funds within

Correspondence: Nicolas Odier KORIAN SA, Development, 32, rue Guersant, Paris 75017, France

the parameters established by Congress. Such a system is pluralistic and decentralized. Although many social welfare programmes were passed in the 1930s, President Franklyn D. Roosevelt had not thought it possible to create national health-care coverage because of the intense opposition he thought it

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would create. Indeed, the recent congressional election is a testament of the population on the controversy of the national medical coverage. As a consequence of the decision not to have a governmentally organized health-care system, health coverage has continued to not be mandatory and is considered to be the responsibility of the individual or the individuals employer. Gaps of coverage have been the inevitable result. As a consequence, for US politicians, the best social insurance has been, and continues to be, full employment. Thus, successive governments to the New Deal have sought to improve the general welfare primarily through maintaining economic growth, creating wealth and reducing unemployment. Although the health-care system continues as it has for decades, the employment situation has changed considerably. The 2008 economic crisis has increased unemployment, and with it has widened gaps in health coverage. In 2009, nearly 50 million people lacked health insurance, 28 million people received foods stamps, and enrolment ballooned in federal programmes to feed needy students after school.1 In addition, the threat of the collapse of the Big Three US auto manufacturers in 2009 (formerly deemed too big to fail) created a crisis for 2 000 000 employees and retirees who risked losing their coverage.2 If we add to this situation the retired American baby boomers who will swell Medicare, plus the rising cost of private insurance, the nancial burden will be stronger on individuals and will reduce the competitiveness of American private enterprise. The risk of explosion of US decit could so shatter the whole system. Transforming the US health-care system was the centrepiece of the now-President Obamas campaign platform. Shortly after his inauguration, President Obama proposed to reduce costs and improve

quality of care through the establishment of a national public insurance programme, which would compete with private insurance programmes, and through the ending of discrimination in purchasing health insurance. However, the US Senate had competing priorities and introduced a bill that emphasized eliminating discriminatory denial of private health coverage to individuals, and included a public option that the states could choose to participate in. The Senate bill passed in January 2010, but it does not provide for a public option; whereas the bill of US House of Representatives would have allowed this option. The Senate version of the bill was passed into law in March 2010. Nevertheless, politicians on both sides of the aisle acknowledged that health-care reform has just begun and that further changes (or rollbacks as advocated by critics) are yet to come. The aim of this study is to present models of other health systems, critique each model, analyse the results across studies among OECD member countries, and nally to propose elements that would assist in effective reform of the US health-care system. To borrow the title of an article by Theodore R. Marnor, Professor at Yale University, the debate on reform in the United States shall not create false expectations.

ORGANIZATION OF EUROPEAN HEALTH SYSTEMS

Everyone aims to maintain good health, and each European country has organized a health-care system in response to this interest according to its respective historical, political and moral aspirations. Each system has coordinated the activities of health professionals with the various partners involved in health-care nancing. This complex arrangement called a health system must try to reconcile individual

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freedom with community welfare. In simplied terms, the parts of a health system could be likened to building blocks whose main materials consist of the demand for care, the provision of care, funding and the links between them. The demand for care would stem from several actors: employers, employees, independent workers, the elderly or disabled, people with low incomes and the general public. The provision of health care would be performed by a number of providers: general practitioners (GPs), medical specialists, pharmacists and health-care facilities in the private and public sectors. Funding of health care would come from various sources: the national government, regional or state governments, public insurance companies and private insurance companies. The links would essentially be ows of cash, people and information between the funders, providers and receivers of health care: Cash ows: insurance premiums, taxes, reimbursements, cost sharing, grants, wages, fees, capitation payments and the overall budget. People ows: choice, passing mandatory inclusion on a list. Information ows: nomenclature exchange, negotiation of fees, activity levels, advertising, information on individual health and epidemiology. Developing a health system would entail creating a montage of each of the above pieces. This construction must meet certain conditions set by society: meeting the needs of care, access to care, community well-being, nancial balance and fairness, among others. The nal construction of the health system would thus result from the values and priorities of society.

Bismarck health system

In 1883, at the initiative of Chancellor Otto von Bismarck, Germany was the rst country to establish a system of social protection for workers. The Ministry of Health set the operational rules and delegated executive power to states or regions for health projects such as the planning of public hospitals. The Bismarck system continues to exist in Germany and relies on public health insurance (PHI) funded mainly by contributions from workers and businesses. Today, private insurance funded by individual contributions supplements and completes the system. Services are differentiated between ambulatory care (private practices and pharmacies) and hospital care (private or public health establishments). The private and public sectors coexist. Within the private for-prot system, physicians are independent contractors who receive their fees directly from the public health fund, while remaining staff is employed directly by the for-prot entity. Within the private non-prot and public spheres, all health professionals are employed directly. In ambulatory care, health professionals are independent contractors. The private non-prot and public spheres receive an annual operational endowment from the public health fund based on the previous years fees, with corrective factors applied as appropriate. In contrast, private for-prot institutions and ambulatory care providers are paid from the public fund according to a per-service fee schedule. Any excess nancial obligation lies with the individual or the individuals private insurance (if the individual has purchased such insurance). The German example has served as an inspiration to Austria, Belgium, France, Luxembourg and the Netherlands.

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Beveridge health system

This model was implemented in Great Britain after the Second World War under the aegis of Lord Beveridge. Beginning in 1948, the National Health Service (NHS) has taken control of the British health system, and since 1991 the Social Insurance System has been in force. Inspired by Social Democrats, this model is based on universal access to health care and taxation for health spending. It rests on three basic principles called the Three Us: Universality: Every citizen is protected against all social risks regardless of employment status. Unit: A different administrative agency handles each type of risk. Uniformity: Each individual receives services according to his or her needs, regardless of income. The state provides free health care to all citizens and lawful residents who express a need. Funding is provided by income taxes proportionate to income. Healthcare providers are autonomous and are at liberty to choose where to work and what treatments to prescribe for their patients. They also have the freedom to contract with the private and/or public spheres. However, to serve the public, each physician must sign a contract with the NHS. Primary care is provided by GPs who serve as the entry point into the health system outside of emergencies. Each patient elects a GP to be assigned to who provides services at no charge to the patient. Alternatively, the patient may choose to receive private care and may purchase private insurance for this purpose. NHS hospitals have been transformed into autonomous public entities called trusts. These trusts, independent and non-governmental, provide secondary and tertiary care. They enter into contracts with providers and purchasers of care

(GPs and the NHS) for all of their medical services. This creates competition between the trusts for medical services, which should encourage cost reduction. Denmark, Finland, Ireland and Sweden have founded their health systems on this model. With slowing economic growth owing to oil shocks, rising costs of care owing to medical innovations, and widening decits in social welfare programmes, governments have successively or simultaneously used different tools and funding reforms to control increasing health-care expenses. In France, for example, many reforms have been passed in an attempt to save the system. The Hospital Act of 1970 instituted public hospital services and the health card, which is used to determine the allocation of resources. Then in 1983, a system of annual block grant funding was established for hospital services. This annual allocation, xed a priori for each hospital, replaces per day reimbursement, considered inationary. The Hospital Act of 1991 strengthened the content of the health card, developed alternatives to hospitalization and created the framework of the regional health organization (SROS). With the introduction, in the early 1990s, of the national expenditure target (OQN), clinics are being set an annual target budget; the annual differences in allocation are based on the previous years actual costs rather than a set increase on the previous years budget. The Ordinances of 1996 instituted the Regional Agencies of Hospitalization (ARH) and regionalized budgets with the aim of improving the complementarity of the provision of care within the same geographical area. The ARH regulates health-care costs through annual appropriations determined by federal Social Security funding and the national goal of health insurance costs (ONDAM).

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The Act of 27 July 1999 launched new methods of nancing health-care institutions, public and private, based on a pathology-based pricing (DRGs). DRGs apply to all health institutions, public and private, regardless of the type of care (that is, hospitalization with or without accommodation, home care and outpatient consultations). The Order of 4 September 2003 simplied and regionalized approaches to planning: the health card was removed, the SROS became the sole planning tool and all authorizations were delegated to the ARH. The French health system, originally based on the Bismarck model, has evolved by increasing its funding from social taxes extracted from the general social contribution and reimbursement of social debt. In addition, an individuals care expenses have increased because of an increase in the list of non-reimbursed drugs in the number of people with supplementary private insurance.

Benets are paid from public spending, and additional private insurance plans exist usually in the form of health insurance offered by employers or purchased by individuals. Most coverage is through voluntary contracts with private insurance policies, and most insurance coverage is through employers. In terms of public coverage, people aged 65 and older are covered by the federal Medicare programme, poor families are eligible for Medicaid, and qualied persons with severe disabilities who are unable to work can join the Medicare programme and have access to supplemental Medicaid coverage.3,4

The private sector

The principle of a competitive market for health care is supposed to ensure both economic efciency and fairness. Fairness is understood here as access to health care, differentiated by the terms of the contract between the individual and the insurance. The rules of free market between insurance companies and between health-care providers should regulate the market and should propose better coverage at a lower cost. In the United States, private health insurance coverage is strictly voluntary. Most policies are purchased as part of a group policy, and are an important component of employment contracts, particularly in large companies. The insurance premium is usually partially funded by the employer as a means to attract and keep valuable employees. Companies with fewer employees are more at risk of having a higher average cost for coverage owing to the higher premiums for a riskier employee. In contrast, owing to the sharing of risk in group policies, larger employers such as large private companies, and federal and state governments are more able to bear the nancial burden of insurance

ORGANIZATION OF THE US HEALTH-CARE SYSTEM

Essentially of a liberal inspiration, the American health-care system has been based on private insurance without principle of universal coverage and a public funding based on taxes. But government federal intervention is necessary and has created, for example, two programmes: Medicare and Medicaid. The American health system is decentralized without any obligation to have or provide insurance. This system has several subsystems for different populations, and it is not uncommon for people to belong to different subsystems simultaneously, for example to be simultaneously covered by a public programme and private insurance. The public system combines measures of social insurance for the elderly and assistance programmes for the severely disabled and disadvantaged families.

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Table 1: Distinctions among the forms of MCO Doctors HMO staff model HMO group model PPO POS Employee network Practice in and out of network Capitation payment Compulsory network Payment for service Practice in and out of network Payment for service Practice in and out of network Insured Utilize HMO practitioners network Utilize HMO practitioners network Utilize practitioners in preferred network Financial penalty for out-of-network doctor Choosing a GP required High deductible for out-of-network doctor

premiums, especially when employees can be classied as good risks. Group policies and contributions to health insurance premiums by employers, while optional, are considered an optional benet granted by the employer. In US statistics, these contributions to private coverage are included in the calculation of health expenditures. For the same reasons as in Europe, the private insurance industry in the United States has created regulatory tools to stem increases in the costs of health care. For example, in the 1970s Managed Care companies were introduced to regulate care. Managed Care companies involved contracts for hospital and ambulatory care between private insurers, the insured and care providers. Their objectives included streamlining the provision of care, monitoring the effectiveness and appropriateness of care and controlling consumption and costs.5 The most important distinctions among the forms of Managed Care organizations are (Table 1): Health Maintenance Organizations Preferred Provider Organizations Point of Service.6

Medicare and Medicaid are mainly funded through taxes, and are limited to certain categories of vulnerable people. They were established under the presidency of Lyndon B. Johnson in the mid-1960s. Other governmental programmes exist, such as the State Childrens Health Insurance Program that supplements Medicaid, which will not be detailed in this article. Medicare basic coverage for the elderly and disabled Medicare covers the elderly (65 years and older) and the severely disabled regardless of income level. This programme has two specic components, one compulsory and one optional, which are nanced in different ways. Hospital insurance (HI) This compulsory component is funded primarily through a mandatory payroll tax of the private sector, which supplies up to 85 per cent of a fund with assets invested in Treasury bonds, the HI Trust Fund. The payroll tax of 2.9. per cent is generally divided equally between employer and employees. HI funding is only partial, as it covers hospital expenses up to a deductible (US$876 in 2004); its coverage is limited to 150 days, with individual contributions required for stays beyond 2 months. Recuperative stays are capped at 100 days. This insurance also guarantees home care and some hospice costs.

The public sector

The federal government does not directly provide medical care, except for members and veterans of the armed forces through the Veterans Administration. The two major federally public programmes

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Supplementary medical insurance (SMI) This is an optional component and can be purchased by a holder of HI. It is funded by beneciary premiums (25 per cent) and the federal budget for the remaining 75 per cent. The SMI partially covers the cost of consultations, home care and laboratory tests. Medicaid coverage for the poor This coverage is a free insurance, subject to a means test. It is funded jointly by state and federal governments. Medicaid varies from state to state depending on the states budget. This insurance is based on the principle of structural measures, with the intent to partially compensate for inequalities of resources and population specicities in terms of health and epidemiology. The care and medical consultations outside the hospital sector are supported, but funding for drugs is subject to an income ceiling that varies among states.4,7 In 2006, President G. W. Bush created a third optional component to guarantee a partial assumption of the cost of prescribed drugs.

ASSESSMENT MYTHS AND REALITIES

The United States is a unique reference point for an international comparison of health systems. Representing not only the free-market model of care, the American health system occupies a singular position that is easily identiable. Among all countries, the United States ranks: rst in total per capita expenditure; rst in total volume of drug consumption; rst in the share of GDP devoted to health; rst in spending for private health services. Indeed, as shown in Table 2, spending on health in the United States (16 per cent of

GDP) is the highest among all OECD countries. It is notable that the French system, which has universal coverage and a particularly high cost of labour, costs only 11 per cent of GDP. Spending per capita in the United States is also higher, at $7290 contrasted to $3601 in France. The American public share in health spending is the lowest among OECD countries, as the system lacks substantial public funding. In contrast, European countries have signicant public funding topped by the United Kingdom, with 82 per cent of expenses paid by public funds. Paradoxically, if the percentage of drug expenditures (12 per cent) in the United States is lower than in OECD countries, it is quite clear that the expenditure per capita for drugs is highest in the United States at $878. This is explained by the price of drugs, which is higher in the United States than in other countries. With all the expenditures and resources (particularly in the form of high-tech equipment) in the US health system, one would expect favourable or comparable health outcomes with OECD countries, but in fact the results are disappointing.7 The higher incomes of US doctors can be explained by their relative rarity. Table 3 shows that the medical density per 1000 populations in the United States is 2.43 as compared to 3.5 in Germany. This lack of doctors is counterbalanced by a high proportion of nurses per 1000 inhabitants, 10.57 in the United States compared to 7.73 in France. Similarly, the capacity of host beds is much lower than in major European countries (3.1 versus 7.1), but the rate of heavy equipment is much higher in the United States (25.9 versus 8.2). This result is emblematic of the picture of American medicine in which advanced technology has taken precedence over traditional medicine.

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Table 2: Economic indicators for health expenditure (2007) Series Total health expenditure, % GDP Total health expenditure per capita US$ PPP Percent of total health expenditures from public funds Total expenditure on pharmaceuticals, % total expenditure on health Total expenditure on pharmaceuticals per capita, US $ PPP Year 2007 2007 2007 2007 2007 France 11.0 $3601.00 79.0 16.3 $588.00 Germany 10.4 $3588.00 76.9 15.1 $542.00 United Kingdom 8.4 $2992.00 81.7 United States 16.0 $7290.00 45.4 12.0 $878.00

Data obtained on 20 December 2009, 14h46 UTC (GMT) of the OECD. Stat.

Table 3: Equipment and personal health indicators Series Practising physicians, density per 1000 inhabitants Practising nurses, density per 1000 inhabitants Total number of hospital beds per 1000 inhabitants Acute care beds per 1000 inhabitants Units of magnetic resonance imaging per million inhabitants Number of CT scanners per million inhabitants Year 2007 2007 2007 2006 2007 2007 France 3.37 7.73 7.1 3.7 5.7 10.3 Germany 3.5 9.94 8.2 5.7 8.2 16.3 United Kingdom 2.48 10.02 3.4 2.8 8.2 United States 2.43 10.57 3.1 2.7 25.9 34.3

Data obtained on 20 December 2009, 14h46 UTC (GMT) of the OECD. Stat.

We might postulate that this high-tech emphasis benets patients, but a closer inspection reveals that the health of Americans is lower than that of European countries such as Germany and France, although epidemiological differences exist between the countries. As shown earlier, the US health system is ambivalent on a number of indicators: the number of per capita medical consultations is very low because of its lack of open access and the high price of consultation; the average length of stay equals that of other countries; the proportions of technical care, where associated risks are important, are many. France and the United Kingdom, as shown in Table 4, have a lower

proportion of technical procedures as compared with the United States. The perfect example is the Caesarean section rate, which is 42 per cent higher in the United States than in France. Finally, the indicators in Table 5 round out the comparative performance of the American system on a number of negative and positive points: infant mortality rate is 44 per cent higher than in France or Germany; loss of potential years of life is 3438 per cent higher than in the United Kingdom and France; diabetes death rate is 31 per cent higher than in Germany; overweight population is 30 per cent higher than in France; obese population of is 20 per cent higher than in France;

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Table 4: Indicators for medical and technical procedures Series Physician visits per capita Average length of stay in hospitals for acute care, days Coronary bypass or CABG per 100 000 people Coronary angioplasties, per 100 000 people Caesarean sections, per 1000 live births Year 2006 2007 2006 2006 2006 France 6.4 5.3 30.9 190.8 194.5 Germany 7.4 7.8 129.1 536.1 277.8 United Kingdom 5.1 7.2 43.4 93.2 256 United States 3.8 5.5 84.5 436.8 311

Data obtained on 20 December 2009, 14h46 UTC (GMT) of the OECD. Stat.

Table 5: Epidemiological indicators Series Life expectancy at birth, total (years) Infant mortality, deaths per 1000 live births Years of potential life lost, all categories, women, years Years of potential life lost, all categories, men, years Suicides, deaths per 100 000 persons Acute myocardial infarction, deaths per 100 000 persons Cerebro-vascular deaths per 100 000 persons Cancer deaths per 100 000 persons Diseases of the respiratory deaths per 100 000 persons Diabetes deaths per 100 000 persons Tobacco consumption, % population smoking daily Alcohol consumption, litres per capita (population aged 15 and over) Overweight or obese, % of total population with a BMI greater than 25 kg/m3 Obesity, % total population with BMI greater than 30 kg/m3 Year 2006 2006 2005 2005 2005 2005 2005 2005 2005 2005 2006 2006 2006 2006 France 80.7 3.8 2292 4805 14.6 21.4 29.9 165.6 30.6 10.9 25.0 13 37.0 10.5 Germany 79.8 3.8 2284 4222 9.7 46.3 42.9 159.3 38.3 16.2 10.1 United Kingdom 5 2644 4324 6 45.3 52 173.3 75.3 6.7 22.0 11 62.0 24.0 United States 78.1 6.7 3633 6291 10.1 37.9 33.4 157.9 59.8 20.3 16.7 8.6 67.3 34.3

Data obtained on 20 December 2009, 14h46 UTC (GMT) of the OECD. Stat.

cancer death rate is 5 per cent lower than in France; consumption of tobacco is 10 per cent lower than that of France; consumption of alcohol is 5 litres per capita lower than that of France. Other results are equivalent to the European results and do not call for a particular analysis.

AREAS OF REFORM
Consequences of the current US system
Browsing through the literature on the American health system, most authors agree that the US health-care system is expensive the most expensive in the world, in fact and that 15 per cent of Americans are not covered, with many more underinsured.

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Figure 1:

US health insurance coverage.

Indeed, 46 million Americans live without health coverage (Figure 1). The reasons are many: employer does not offer coverage; private insurance is too expensive; private insurance denies coverage; individual is ineligible for public programmes; individual seeks insurance only if he or she is sick. The problem of the uninsured adds to social insecurity. It is not uncommon for an insured who has contributed to his or her insurance premiums for many years to be denied coverage for expensive treatments or even have his or her contract cancelled. Health spending now amounts to over $2000 billion per year or 16 per cent of the US GDP to pay for a health system ranked thirty-seventh in the world by the WHO. At this rate, within

10 years, these costs will absorb 1/5 of the national wealth.8 As shown in the graphs below, the health expenditure per capita increased by 86 per cent between 1998 and 2007 (Figure 2), while the average contributions of companies and employees to cover a family increase by approximately 130 per cent between 1999 and 2009 (Figure 3). The following chart (Figure 4) details the distribution of US health-care costs between 1997 and 2007. Time does not seem to inuence the allocation, as no variation greater than 5 per cent is observed. The cons are that hospital costs represent the largest share with 31 per cent (however, approximately 60 per cent of these expenses generally consist of labour costs). The next-largest share is consultations that account for 22 per cent. The biggest difference observed is in the cost for drug prescriptions, which

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Figure 2:

National health expenditure per capita.

Figure 3:

Average health insurance.

have increased by 3 per cent over the same period and which now account for 10 per cent of US health spending. The share of home care represents 8.5 per cent of health spending of which 5.9 per cent is nursing costs. Finally, 16.2 per cent of other health spending is composed of the costs of administration and management (7 per cent), research, structures or equipment. Figure 5 on the following page shows the factors inuencing the rise in health

costs. The main external factor is the ageing population, as the elderly consume more health services. Several other factors contribute to strong increases in the cost of care: Intensifying care: The medical advance generates new demands for care, which are not controlled; the medico-economic evaluation of these innovations shows that they do not improve efciency. Thus, the price of drugs most often contributes to the growth of health

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Figure 4:

Distribution of national health expenditures.

spending. For example, during the last decade, prescription drugs increased by 80 per cent, patents for new medical procedures by 100 per cent, protocols of university hospitals by 200 per cent and genetic testing by 1500 per cent. Affordability: Unlike a social insurance system in which prices of most goods and services are regulated, prices in the US system are in large part based on the free market. But when the sellers of care are competing in an imperfect market, private insurance companies are not always able to inuence the pricing of the suppliers of care, especially as their customers are often free to consult outside the contracted networks. Moreover, the price of health care includes indirect costs associated with unnecessary procedures resulting in defensive medicine in response to fear of litigation. Regarding the cost of medical goods, insurers are relatively powerless to sufciently counterbalance monopoly situations in the pharmaceutical industry. New pharmaceuticals enjoy exclusive patent rights in the United States for 20 years, and as a result drug prices in the United States are the highest in the world.

Administrative costs of private insurance: Several factors combine to contribute to the high cost of managing health coverage. The duplication of xed costs and of marketing costs generated by competition between insurance companies is a heavy budgetary burden. We may add to the total a surcharge in the order of several billion dollars per year paid by insurance companies to develop techniques to avoid costly insured.9 One can also observe that despite sophisticated biomedical technology, American medical services are far from being models of safety and quality. Indeed, two recent surveys published by the Institute of Medicine indicate signicant problems related to quality of care. The rst report, To Err is Human: Building a safer health system, gives a point of view on the literature on medical errors and concludes that serious misconduct leading to patient injury is avoidable. The second report is a supplementary study, Crossing the Quality Chasm, which shows that medical procedures too often have negative side effects and their benets can remain virtual.

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Management costs

Labor costs

American way of life

Drug costs

Medical advances

Rising health costs

Aging population

Rising costs of Medicare and Medicaid

Rise in insurance premiums

Increased financial pressure on households

Financial pressures on enterprises

Unemployment increase

Competition distortion among insurance providers

Member contributions increase

Fewer business contracts

Declining purchasing power

Increase in the number of people without health coverage Figure 5: The factors inuencing the rise in health cost.

In this context, the practice of medicine has become a real business. The management of physicians and patient uses many techniques to strictly control costs. The choice of medical services, provider and treatment options follow a purely nancial logic with little consideration of the costs and benets to the patient.

Financial benets encourage practitioners and hospitals to reduce costs. Even if lifestyle partially explains the poor ranking of the American health-care system, it is likely that many other factors play a role, such as: the weak infrastructure of routine medical services, adverse effects of the intensive use of high technology,

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unnecessary medical procedures and the frequency of medical errors, which result in physical injury or death.10 Although the ageing population is usually cited as the most important cause of healthcare costs in the US, it would seem that technical innovation is a more important driver of healthcare ination. Indeed, medical advances constitute the main factor in the rising cost of health care: using the same age and pathology data, we spend more today than in the past. Two opposing effects: 1. the development of new medical technologies allows for cost savings; 2. but it triggers a demand for expensive treatments that would otherwise have been unavailable. This second effect seems to outweigh the rst. Indeed, the projections of Congressional Budget Ofce (CBO) indicate that the rise in health-care costs will exceed that of retirement. Other factors for rising costs include the rising standard of living and the increase in the rate of obesity. The distinction between the volume and price of health care shows that it is mainly the price that is accelerated by technological advances and that inuences the rise in health costs.11

an increased role for preventive medicine. The majority of Americans are adequately insured through their employers and fear government intrusion. Many Americans believe that it is not for the President or Congress to propose the nationalization of insurance, but rather that consumer choice for private options should be expanded and/or a regulated public option should be added. Obamas proposed reforms include new requirements on private insurers and employers, the creation of a public option, nding cost savings in Medicaid and Medicare and enhancing the role of GPs. The proposed reform imposed on private insurers would be: to not refuse a client; to no longer apply discriminatory premiums; to offer minimal coverage to all insured. All companies with more than 25 workers must offer insurance under the penalty of an additional fee. The proposed public option would be to extend Medicare for people unable to afford private coverage. In addition, the creation of a public insurance option would make private insurance more competitive, affordable and transparent. In order not to worsen the decit, President Obamas proposal hinges on nding cost savings in Medicaid and Medicare programmes. To serve those ends, an initial agreement was reached with hospitals to save $155 billion over 10 years. Moreover, a specic tax would be imposed on insurers and people with incomes over $200 000 per year. Furthermore, to improve the practice of preventive medicine, the President wants to enhance the role played by local GPs, thus lowering costs. The top-three objectives of President Obama seem pertinent to health-care reform in the United States, but the proposed

Reforms proposed by the US executive and legislative branches

Reforms proposed by President Obama In October 2008, President Obama did not hesitate to say that health coverage should be a right. Obamas top-three objectives in his proposed health-care reform were: compulsory coverage for all Americans; while not worsening the decit;

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methods in achieving those goals are blurred and their outcomes appear ambitious. Indeed, a number of questions arise: How to mandate that insurers not refuse any client or charge discriminatory premiums? How to extend Medicare coverage while simultaneously seeking savings? Will Americans accept that a public option is needed and would control the costs of private insurers? Will Americans accept additional taxes to nance proposed reforms? How to develop a policy around the shortage of physicians, especially GPs? Reforms proposed and adopted by the Senate Overall, the reform passed by the Senate (and ultimately signed into law) is less ambitious and less costly for the public purse than that proposed by the House of Representatives. The Senate has adopted: reforms based solely on private insurance providers (no public option); an expected new tax for the highest income earners or luxury insurance tax, and a tax increase for everyone; reform costs reduced to $871 billion from $1000 billion; health coverage expanded to 31 million Americans (among the current 46 million uninsured); family coverage extended to children up to 26 years of age; prohibition of an insurers refusal to provide coverage and prohibition of discriminatory premiums. Reforms adopted by the House of Representatives This text should guarantee health coverage to 32 million Americans who currently lack insurance. The aim is to cover 95 per cent of people under 65 years already being protected by Medicare.

Finally, the text adopted provides for a set of measures that allows most Americans to receive health coverage. To achieve this aim, the statute has a set of measures aimed at promoting the use of health insurance: Insurance is mandatory The principle of reform is to make insurance compulsory from 2014. The development aid for low-income families who earn too much to still qualify for Medicaid. The aid will also allow Americans now denied any possibility of treatment in the event of a problem to afford health insurance. A system of penalties is established Uninsured Americans will pay a ne of 0.5 per cent of income per family starting in 2014, and in 2016 the penalty will increase to 2.5 per cent. For companies with over 50 employees that do not offer health coverage or that offer inadequate coverage, a penalty of $700 per employee will be imposed. Funding of abortion The law therefore provides complex accounting arrangements to ensure that public money is not used to fund this type of medical procedure. States are also free to prohibit private insurers from offering policies that cover abortion procedures. Financing reform Under the new law, savings of $483 billion over 10 years would be realized through reforms to Medicare, the government-run health insurance programme intended for those 65 years and older. Industry players will nance part of the reform ($2.3 billion per year for the pharmaceutical industry), and Americans who have insurance pay a luxury tax. The CBO, an independent body, projected that the estimated cost of the reforms would be $940 billion over 10 years. In addition, according the CBO, these same measures should reduce future decits by $138 billion in the future,

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including the projected cost reduction resulting from improved preventive care. Moreover, the adopted reform will: allow parents to include their children in their health insurance until age 26; prohibit private insurers from denying health coverage; prohibit private insurers from charging exorbitant fees and increasing premiums without justication. The text nally adopted by both chambers of Congress (and signed into law) nevertheless has a number of weaknesses: In the best-case scenario, 15 million Americans without insurance will not have access to low-cost insurance by this reform. By rejecting a public option, the reform relies just on competition between private insurers where each insurer must participate with the requirement of a transparent market. It is ironic that to fund the reforms to help 31 million people without coverage, many budget cuts were proposed in public programmes that cover the most vulnerable individuals. The law proposes the option of increases in tax to nance reimbursement prices for the pharmaceutical and medical products; a proposal to x the prices would have been better. Millions of people with average incomes must acquire a health insurance whose cost can range up to 9.5. per cent of their income, so that their insurance will cover on average only 70 per cent of their medical expenses. The insurers will receive a public subsidy of $477 billion with the aim of extending their coverage at the lower cost end of the market. Many health professionals think that this money would be better targeted at direct subsidies to low-income households.

Those insured at only the most basic level will be restricted to a very limited choice of physicians and their health benets are likely to be eroded. The cost of health may continue to increase, as in Massachusetts, where a large part of the reform was inspired. The discriminatory rules may be used by insurers at least until 2017, while other provisions of the law will take effect only from 2014. Womens right to abortion will be further eroded by the discrimination and constraints in insurance for this act in relation to other medical acts. In the best-case scenario, 15 million Americans will remain uninsured and will not be affected by this reform. By rejecting a public option, the reform relies only on effective competition among private insurers, where each insurer will participate with the requirement of a transparent market. It is ironic that to fund the reforms to help 31 million people without coverage, many budget cuts were proposed in public programmes that cover the most vulnerable individuals. The proposal overlooks the option of setting reimbursement prices for the sale of pharmaceutical and medical equipment, and instead increases tax on such equipment. The report released by HHS on 22 April 2010 shows that the reform of health adopted will increase by about 1 per cent over 10 years of health spending. This article conrms that an additional 34 million Americans will receive health coverage. From 2014, most Americans will be uninsured or pay a ne, but people on low incomes will be exempt. The analysis by the Congressional Budget Services estimated that 4 million households will be hit with nes for not having insurance coverage. The report concerned the status of Medicare, which

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will incur cost reductions in the reform. The report also considers that between 2010 and 2019, the costs of extending health coverage might be more important than the planned reductions, and probably even the long-term reductions. If it is easier to highlight the wanderings of a reform, it is more difcult to predict the consequences without a model. However, in 2006, Massachusetts passed a law on the health system known as chapter 58, similar to the reform that was passed by Congress. The law adopted by Massachusetts has created an individual mandate and a mandate for businesses, which requires persons who have sufcient income and businesses over 11 employees to purchase health insurance under the threat of tax penalties. A new regulation was put in place: subsidies are distributed to ensure that people can; Medicaid has been expanded; fusion of individual market and small groups to create a connector that allows individuals and companies of small sizes to identify the different insurance. A study by Yelowitz and Cannon of the Massachusetts Health Plan (Much Bread, Little Gain, published by the Cato Institute) used data from a 2008 population study to examine the structure of health coverage in that area. Before the 2006 reform, about 10 per cent of the population of Massachusetts was without medical coverage. This proportion, according to the governor, declined to 2.6 per cent, but the study by Cannon and Yelowitz shows that the CPS expects 3.8 per cent and then the Chapter 58 to bias, as the uninsured could hide their true situation in order to escape penalties. The number of uninsured is closer to 5.1 per cent,

half that before the reform. Should we therefore attribute this result to the action of mandates or subsidies distributed? Regarding the assessment of health, no studies, between 2005 and 2008, could prove an improvement or deterioration thereof. In the absence of signicant results in statistical sense of the term, it does not seem that the Chapter 58 has changed anything about the state of health. The Cato institute study also indicates a crowding out of private plans as employers cease to offer healthcare to those eligible for public assistance. Thus, if in the Massachusetts health coverage was good scope, coverage by private insurance declined in some segments of income relative to other states in the region. The most important consequence of the reform of Chapter 58 is undoubtedly increasing the cost of insurance. Since the implementation of the reform, 96 per cent of insurance rms have increased their prices and the insurance coverage of rms has become 2146 per cent more expensive than the national average. This cost includes not only the expenditure of federal and Massachusetts health, but also additional private spending induced by the rules and mandates. In addition, the obligation to ensure individuals and companies must have insurance with higher coverage in order to comply with minimum standards set by the state. This extra cost has been assessed by Yelowitz and Cannon and third of the total cost. The results of the study by Yelowitz and Cannon show that adaptation of a health system that is more interventionist and without a credible alternative to the US public created adverse consequences for Americans. Theodore R. Marnor,12 professor at Yale University, said that before the economic crisis, experts believed that the

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model of the Canadian health system was politically unacceptable, but experts recognized that a tax increase was the most prudent plan for American society. However, the current proposals for reform will neither allow the establishment of a health insurance programme that is affordable for all Americans, nor create a more effective means to control rising health-care costs. Some suggestions of Theodore R. Marnor could be interesting to follow: a single tariff community rating, that is to say, the same rate for all insurance plans; the obligation to ensure all people and refuse to insure someone (the latter was chosen); minimum coverage and denition of the basket of services (the rst proposal was approved); marketing audits to avoid misleading advertising; a prospective risk adjustment to reect predicted differences in costs related to the health of participants, with retrospective payments to offset the high costs that must be effectively assumed by the plans. The reform as it is passed into law could be blocked by the current fragmented funding of the health-care system. The control probability of effectively costs is even slimmer. The cost control is always expensive, controversial and ultimately necessary.

clause and contradict the tenth Amendment to the Constitution on the distribution of powers. The Attorney General of Virginia, who intends to initiate an action in the Federal Court, has said that Congress has no power to regulate commerce within the States and hence to force citizens to buy healthcare insurance. The last part of this article presents a new proposal to reform the US healthcare system. This proposal would address the many shortcomings of the current reform to expand coverage and reduce costs further. It builds on the organization and regulation of major European health systems. It must be compatible with American history and values (Figure 6). France has a protable private sector made up of both For-Prot and Not-For-Prot organisations. However, France, like many countries, is in a crisis of funding for its health system whose main cause is public sector inefciency. There exists in this system a perfect distinction between institutions of public care, private health-care establishments. It is from this observation that we present a system between liberalism and interventionism. Indeed, a government must establish rules to regulate the market, it must put in place a structure that allows control of this market and, if the market does not respond to requests, it must establish supplementary regulation. Federal Agency of Health (FAH) A new agency, the FHA would be charged with the following objectives: dening the multi-year federal health programme that aims to promote health through prevention, education, treatment and the Public Health Programme (PHP); establishing standards of good medical practice and medical acts;

A new proposal for reform: A matter of philosophy and politics

Even once accepted by the House of Representatives, healthcare reform will undoubtedly continue. Eleven attorneys general have the intention to initiate a class action on behalf of their state. The states argue that the reform might violate the commerce

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WHITE HOUSE SENATE Secretary of Health

Federal Agency of Health Federal Health Program State Health Agencies

Federal Health Insurance

Public Health Insurance

Private Insurance

Standard coverage

Minimum coverage

Standard coverage

Supplementary coverage

Extent coverage

Professionals and institutions of health contracting with the federal agency

Professionals and institutions of health not contracting with the federal agency

Figure 6:

Organization for a new health care.

setting prices for medical services and acts; setting and managing drug prices; monitoring and punishing insurance companies that violate the prohibition of the refusal to insure or that impose discriminatory premiums;

establishing an efcient system of medico-administrative information sharing. The FAH will submit its objectives, share its results and defend its budget before Congress.

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State Health Agencies Each health agency operating on the state level must: promote the federal health programme in its state; monitor and punish insurance companies that violate the prohibition on the refusal to insure or that impose discriminatory premiums; cross-check that every citizen and resident has health coverage; manage access to Federal Health Insurance; manage access to PHI; make payments to institutions and health professionals for their activities; check the information system for medical and administrative data; manage approval of professionals and health institutions.

The objective of this programme is to support future generations. All seniors who are already enrolled in Medicare on the date of entry into force of the programme and all seniors below an income threshold would be transferred to the FHI; other seniors otherwise ineligible will pay for insurance coverage at their own expense (that is, seniors above the income threshold). The FHI will provide the standard coverage for health institutions and health professionals, which have a contract with the SHA. The FHI would reimburse: consultations; examinations and diagnostic tests; hospitalizations for surgery, medicine, obstetrics, at-home care or convalescent hospitals; drugs and devices.

Federal Health Insurance (FHI) The FHI programme would merge all government plans (Medicare, Medicaid, SCHIP and so on) into one insurance plan to streamline and achieve administrative savings and to enhance negotiating power in purchasing goods and services. The FHI is designed to support a number of demographic groups. People eligible to benet from this programme would include: all persons with an income below a set threshold regardless of age; all children from 0 to 18 years of age without distinction; all state-supported scholarship students; all students whose parents are enrolled in this programme; all members and veterans of the military; all persons with a disability below a threshold income; all pregnant women.

Public Health Insurance The second interesting reform is the creation of a separate public insurance programme to provide optional coverage for low-income people or for those who choose to buy low-cost insurance. This insurance could be purchased at a low cost and it would provide minimum coverage for persons who are enrolled. In exchange, these persons may have health care only through health institutions contracting with an SHA with regard to: consultations; examinations and diagnostic tests; hospitalizations. The purpose of this public insurance is not to compete with private insurance but to supplement it. In addition, this public insurance will be supplemented by private insurance policies according to the level chosen.

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Private insurance Private insurance companies would be required to provide: a standard coverage to all current and future clients; different contracts with complete transparency on the level of the health coverage;

a supplemental coverage to holders of PHI to complement their care. The rules of reform To allow a health system reform, it is important to enact a number of principles (Figure 7), which would result in: better transparency of the system;

Medical progress

Aging population

FEEDBACK -

FEEDBACK American way of life

Labor costs Health care cost control

Management costs

Drugs costs

PUBLIC INSURANCE

FEDERAL GOVERNMENT

PRIVATE INSURANCE COMPANIES

FEDERAL HEALTH AGENCY

FEEDBACK +

Monitoring compliance of obligation to have health coverage Monitoring compliance of obligation to sell policies without discrimination in coverage or premiums Establishment of good medical practice and pertinent acts Establishment of pricing actions and activities Administering prices for drugs and implantable medical devices Instituting therapeutic education and prevention

FEEDBACK +

Lower unemployment

Concurrent coverage

Specialized member contributions

Increased business transactions

Increased purchasing power

Decrease in the number of people without coverage. Objective: universal coverage

Figure 7:

Principles for a health-care cost control.

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improved management of the system; greater system exibility; more opportunities to control costs. The obligation to have health coverage Why mandate health coverage? The reform would not require residents to purchase any specic policy, but simply to have basic coverage. Every American would have a choice among the following options: contribute to a private insurance policy; contribute to public health insurance; benet from the FHI within the limits dened; be taxed and thereby benet from minimum coverage from public insurance. The obligation to sell policies without discrimination in coverage or premiums In French law, It is prohibited to deny a consumer the sale of a product or providing a service, without good reason. (Art. L. 122-1 of the Consumer Code) Included in this prohibition of discrimination are all activities of production, distribution and services, including those that are made by public gures, particularly in the context of delegation agreements public service. Using this as a model, the US law could extend the non-discrimination mandate for other services (housing, public services and so on) to the sale of insurance policies. Regarding discriminatory premiums, France also provides that, discrimination is sanctioned in general and in all forms by the penal code (Art. 225-1 to 225-4), whether for access to jobs, training and internships, or in the exercise of any economic activity especially when discrimination is to deny the supply of property or services or to make such

provision a condition based on one of the elements listed in Article 225-1 of the said Code. Discrimination is any distinction made between individuals for example because of their origin, sex, marital status, pregnancy, health, disability, genetic characteristics or age. Good medical practice and pertinent acts The objective of this idea is to apply evidence-based medicine to each health service and each health act. For example, a pregnant woman with a normal pregnancy without any associated co-morbidity should automatically receive as a benet: seven consultations; three ultrasounds, including one morphological ultrasound; various examinations (including cervical, vaginal sampling and measurement of foetal heartbeat); amniocentesis if the doctor considers it necessary; eight delivery training sessions. We must be aware that the practice of medicine differs from one doctor and hospital to another because of differences in medical education and the lack of standardized care. By setting good medical practice and pertinent act standards, we will meet the dual objectives of ensuring fairness of care and control of costs. The medical establishment should determine, with the help of expert conferences and consensus conferences, which best practices and relevant acts to support. Finally, a signicant point in health law, particularly with regard to therapeutic risks, is the tracking of good medical practices and relevant acts. This would reduce the threat of malpractice suits against health professionals or institutions. In addition, a reduction in the judicial

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nding of malpractice owing to medical error should have a positive effect on the insurance providers liability. A therapeutic risk is simply the risk of negative effects that are not necessarily attributable to any professional error. Pricing actions and activities The idea would be to implement the common classication of medical procedures CCAM, being used in France, for example, in the US health-care system. The interest of this proposition, as we shall see, is to anticipate by xing the basic price for each health-care act. This classication is a nomenclature to encode gestures charged by doctors, technical gestures initially, and subsequently clinical intellectual acts like you can see several samples in Table 6. This classication is used to establish: in private practice and hospitals, the fees of technical acts carried out during consultations; in private clinics, the fees for procedures performed; in public and private hospitals, the DRGs and pricing of hospital stays provided health insurance as part of the pricing to activity (T2A). Example code: DZQJ010 Name: Ultrasound Doppler transthoracic Doppler ultrasonography of the oesophagus through the heart and intra-thoracic vessels with intravenous

ultrasound; contrast agent does not cross the lung. Price for activity: $214 303. Admission to reimbursement: Yes. Supplement charges rm: No. Travel costs: Yes. The pricing of activity constitutes a mode of funding aimed at getting a unique framework for the billing of all medical acts. The resources for each health institution are calculated based on an estimate of activities for the next year (the price of each activity being xed by the specic mechanism around disease and hospitalization called GHM and GHS). The medicalization of information systems would help public and private health institutions assess their care activities. Each patient within this system could be classied to a homogeneous patient group categorization (GHM), and then classied according to a homogeneous stay group (GHS). The GHM are identied by an alpha-numeric code combined with a medical label (ex: 08M04W GHM fractured hip and basin with CMA). Thereafter, each GHM is associated with its nancial counterpart dened by the Health Insurance. As we can see in the Tables 7 and 8, the global cost for treating the same pathology is prohibitive in the United States as contrasted to the French cost. In specic situations, a larger amount may be proposed in relation to GHM. This is particularly true

Table 6: Other examples of fees and reimbursements Act Generalist consultation Specialist consultation Psychiatrist consultation Cardiologist consultation Filling a cavity Root canal Teeth cleaning Prescription medicine 30 Advil 200 mg Fee $ 31.57 $ 35.88 $ 53.10 $ 70.32 $ 27.6769.17 $ 134.88 $ 41.50 Variable $ 3.60 % reimbursed 70 70 70 70 70 70 70 35100 60

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Table 7: Sample of GHS in France GHM 08M04W GHS Fractures of the hip and pelvis with CMA GHS price $7029.29 Length of stay 14 days

Rates V10 applicable in 20062007. http://www.atih.sante.fr.

Table 8: Sample of DRGs in the United States DRGs 8236 Fractures of hip and pelvis $16 311
http://hcupnet.ahrq.gov/HCUPnet.jsp.

Expenses (mean)

Length of stay 4.3 days

in the case of payment of additional days for long stays. In reverse, a lump sum or daily cost can be assigned to particularly short stays. Finally, in the case of highly specialized units such as intensive care, a supplemental fee is added to the basic GHS. Administering prices for drugs and implantable medical devices As we saw previously, generally the all-inclusive rate is a single reimbursement by GHS for health insurance. The expensive cost of medicines and implantable medical devices has prompted the Ministry of Health in France to be exible with this rule in order to ensure equal access to the most innovative care. Thus, cancer treatments, coagulation factors and medicines for orphaned diseases are fully reimbursed by health insurance. This reimbursing is possible only if medicines and devices have administered prices. How to evaluate the price of a drug? In France, after obtaining authorization to market a medicinal product, if the product manufacturer wants that its speciality be refunded by social security, he les an application to the High Authority of Health for a review by the Transparency Commission. This Commission makes a scientic opinion on the medical service rendered

by this medication and his interest compared to therapies already on the market, and thus the selling price of reimbursable medicines is not free. A patent in the United States is limited to 20 years of protection from the day of ling the application. However, for a new molecule, 10 years are necessary for research and testing before health authorities authorize its availability to patients. The medicinal product would therefore, in fact, be protected by the patent for only 10 years after its availability for purchase. When intellectual property rights have expired, it is said that the invention falls into the public domain and the original drug can be legally copied into generic drugs. How to establish a drug price in the United States? First, as in France, to compensate the exceptionally long duration of pharmaceutical research and development, the United States should implement a supplementary protection certicate to extend the duration of patent protection for up to 5 additional years. On average then, a newly patented drug could be commercially protected for approximately 15 years. Second, taxes levied in the phase of research, design and authorization just before the marketing could be considered a tax credit for businesses during marketing.

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Therapeutic education and prevention Therapeutic education is dened as tertiary prevention for patients, and includes ongoing care and support. This is a specic branch of health education in which health professionals share some of their knowledge and expertise with patients. It is essentially a multidisciplinary approach where many health professionals, patient associations and ones family and friends can provide education when a patient expresses need. After all, the patient, him or herself, is also the bearer of knowledge and should not be ignored in improving the quality of health care. This type of health education is especially relevant in cases of chronic disease (that is, diabetes, asthma, chronic bronchitis and hypertension) in which patients and their families must be enabled to better administer preventative measures and treatments. The approach must remain focused on the patient and must consider all the dimensions of being human. Therapeutic education is here to help the patient and his entourage: understand the illness and treatment; cooperate with caregivers; live as healthily as possible; maintain or improve quality of life; support his or her health; acquire and maintain the necessary resources to optimally manage their lives.

Americans have employer-sponsored coverage in which private insurance companies compete and regulate the economy of the health-care market. But public programmes that cover 20 per cent of Americans continue to see an increasing number of beneciaries and soaring costs. The second challenge lies with entrenched interests. Health providers who share the market (that is, insurers, establishments and doctors) have no interest in adding a new player who would threaten the loss of market share and ultimately a decrease in their turnover. The third challenge is political. How to solve the problem between the progressive camp that calls for a health system more akin to European models and the conservative camp that wishes to remain anchored to the free-market foundations of America? The rst suggestion proposed in this article is that the current system cannot control health-care costs while expanding to universal coverage. The second suggestion is that the system must be modied by the addition of a new player. The third suggestion is that any change must happen with support from the people and their representatives, and therefore we must offer the public a clear explanation of their potential alternatives for change. The proposed reforms in this article are: The merger of existing public programmes under a single agency the FHA and the creation of two coverage programmes: FHI with standard coverage for a dened population; PHI with minimum coverage for people who want it. The establishment of a Federal Health Programme that aims to promote health through therapeutic education, early detection, prevention and public health. The establishment of a standard of good medical practices and pertinent acts could

CONCLUSION
This article proposed to introduce European models of health systems, and analyse the current US health-care system and the proposed reforms. The rst signicant challenge to the United States is the economic basis of its health system. Entrenched in market principles, the current system is resistant to change. It is true that 60 per cent of

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help practitioners make the right decisions and could dene a support identical for all technical and medical acts in the nation. The establishment of a number of new laws: mandating citizens be covered either by public or private insurance or pay additional taxes; mandating that insurance companies cover all people who want to subscribe to their coverage without discriminating in the cost of premiums; mandating that private insurance companies offer identical and standard coverage for all insured, and at least one supplementary coverage chosen by the consumer. Finally, different regulatory and costcontrol tools can be engaged to decrease insurance costs: a xed price for each GHM according to the applicable rules (minimum required time for a hospitalization of a GHM, and minimum required services and tests of a GHM); a xed price for consultation and health care outside of a hospital; the administration of drug prices and repayment of implantable medical devices. These new fees may or may not be applied to private insurance; if so, these fees should not serve to provide windfall prots for insurance companies at the

expense of hospitals but should lower contributions of Americans. The goal of this article is to propose a health-care solution that will cover the entire population, provide an uncomplicated health-care system and control health expenditures. A comprehensive economic model can demonstrate all outcomes.

REFERENCES
1 Greenwell, M. (2009) The last hope for hungry kid. Washington Post, 30 May. 2 Carrou, L. (2009) The heart of the American automobile has stopped beating-Le Monde Diplomatique. February. 3 Caudron, J. (2007) Care organization in the United States: The consecration of any private, http://www .legrandsoir.info, February. 4 Duhamel, G. (2002) Health system and U.S. health insurance, http://lesrapports.ladocumentationfrancaise. fr, April. 5 Sauviat, C. (2004) Health system in crisis Although privatized! Chronicle International IRES November 2004. 6 Rongre, J. and Tavolacci, M.P. (2009) Public Health Brief ECNs, 2nd edn, Ed Masson. 7 Hartmann, L. (2008) The United States and the health cost of U.S. health care system The stands of health no. 19. 8 Raim, L. (2009) Why Obama has to make concessions on its health reform LExpansion. Com, August. 9 Hartmann, L. (2008) The United States and health. The cost of U.S. health care system The stands of health no. 19. 10 Rylko-Bauer, B. and Farmer, P. (2002) Managed care or managed inequality? A call for critiques of market-based medicine. Medical Anthropology Quarterly. 16(4): 476502. 11 Lucas, J.M. (2007) U.S. health care system: Reserve prognosis without intervention. Economic outlook. 12 Marnor, T.R. (2009) The private in health The reform debate in the U.S. Does it raises false expectations? www.sharedhostproofhosting.com.

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