politika finansiranja zdravstvenog osiguranja i zdravstvene zaštite u

Ibrahim Toti 1

POLITIKA FINANSIRANJA ZDRAVSTVENOG OSIGURANJA I ZDRAVSTVENE ZAŠTITE U SJEDINJENIM AMERI KIM DRŽAVAMA

Porez je naknada koju pla amo da bismo živeli u organizovanom društvu, s tim što on nikom

ne daje pravo da poreskog obveznika razori ve da ga održi u životu.

(FRANKLIN DELANO RUZVELT)

Apstrakt: Zdravlje ljudi u svakoj državi zavisi od vladine o cijelne politike i strategije, a zatim i od zdravstvene politike i rezultata u smi-slu realizovanih zdravstvenih ciljeva, programa i pravilnog rukovanja raspoloživim potencijalima. U ovom radu je zapravo a rmisana i uloga vlade Sjedinjenih Ameri kih Država jer je ona presudna u utvr ivanju programa i mera zdravstvene politike i u kontroli i vrednovanju realizo-vanih strateških ciljeva. Ciljevi se odnose na pove ani obuhvat gra ana zdravstvenim osiguranjem, na podizanje ukupnog zdravstvenog kvaliteta, angažovanje raspoloživih i nalaženje novih potencijala i na spre avanje uzlaznog toka zdravstvenih troškova. Pravovremena realizacija ciljeva postiže se uve anjem zdravstvenih vrednosti, studioznim analizama rezultata konkretnih zdravstvenih programa, racionalnom upotrebom angažovanih faktora i pripremom materijala za preduzimanje narednih akcija. Iako relevantan pokazatelj, visok kvalitet zdravlja ne uspeva da oslobodi gra ane Sjedinjenih Ameri kih Država stalnog i neubedljivog uveravanja, da za njegovo dostizanje najve e zasluge pripadaju osigu-rava ima i njihovom nesebi nom angažovanju. To nije i ne može biti ta no, a cilj ovog rada je da to i dokaže. Uveravanja te vrste zaklanjaju istinu budu i da kvalitet zdravlja svakog gra anina u najve oj meri zavisi od njegovog odnosa prema li nom i tu em zdravlju i od uticaja politi kih, društvenih, socijalnih, tehni kih i ekonomskih faktora. To je razlog zašto savremeni analiti ari smatraju da bi Sjedinjene Ameri ke Države trebalo da napuste lozo ju da sve vrednuju novcem, a naro ito život i zdravlje gra ana.

1 Državni univerzitet u Novom Pazaru, e-mail: [email protected]

32 MEDICINSKI GLASNIK / str. 31-45

Što se ti e velike nepokrivenosti gra ana zdravstvenim osiguranjem ona ne bi predstavljala poseban problem, me utim, on je tim ve i što se njegovo rešavanje ne želi na pravi na in. Nejednakost u tretmanu zdravstvenih osiguranika zbog njihovog pripadanja pojedinim, posebno vulnerabilnim kategorijama, ne bi predstavljala problem kada bi postojalo ve e raspoloženje da se ljudi an masse jednako vrednuju. Sjedinjene Ameri ke Države su dugo godina bile jedina visokorazvijena, industrij-ska država koja nije obezbe ivala uslove u kojima bi svi gra ani imali zdravstvenu zaštitu (državno osiguranje ili neku vrstu privatnog osigura-nja). Dublja analiza ovog i njemu sli nih problema pokazuje da kriti ari aktuelne zdravstvene politike po inju sami sebi da smetaju. Naime, njih brine injenica da u zdravstvu Sjedinjenih Ameri kih Država starija i bolesnija populacija obilato koristi sredstva zaposlenih (i dobrostoje ih) slojeva stanovništva što, po njihovom mišljenju, uzrokuje nepravilnu raspodelu budžetskih sredstava. Ako je tako (stvari su u redu ili O. K.), ali se postavlja pitanje, emu onda toliko brige i imperativnih želja za pove anim životnim vekom njihovog gra anina?

Klju ne re i: zdravstvena zaštita, nansiranje, programi nansiranja, troškovi, strategije

UVOD

U Sjedinjenim Ameri kim Državama veliki broj problema, pa i onih u zdrav-stvenoj delatnosti, rešava se merama skalne politike, s tim što se ni mnoga rešenja ne smeju smatrati uvek izvodljivim. To su odgovorno shvatile politi ke strukture i po ele su ozbiljnije da se bave bitnim pitanjima, a najpre pitanjima skalne politike i njenog uticaja na funkcionisanje zdravstvenog sektora. Rasprave idu u pravcu da se poslodavci isklju e iz poreske obaveze kako bi sponzorisali zdravstvenu zaštitu i pomogli nansiranje troškova nastalih usled ve eg zdravstvenog obuhvata. Pro-nicljivom i veštom analiti aru ne može proma i signal da su troškovi zdravstvene zaštite i u Sjedinjenim Ameri kim Državama univerzalan i svojevrstan problem. Na primer, u 1990. godini, iznosili su 714 milijardi $ US, da bi 2008. dostigli 2,3 biliona $ US, što je pove anje preko tri puta. Podse anja radi, 1980. iznosili su „samo“ 253 milijarde $ US, ili osam puta manje nego u 2008. godini. Evidentno je da je porast troškova postao glavni politi ki prioritet, pa se vlada, poslodavci i potroša i gr evito bore da zaustave, obuzdaju ili da uspore njihovu ekspanziju. Zdravstvena politika u Sjedinjenim Ameri kim Državama ako ima jasan cilj, a trebalo bi da ima, mora makar da ponudi odgovor na pitanja, koji su glavni pokreta i rasta zdravstvene potrošnje, kako se efektno suzbija njena ekspanzija, koja je uloga vlade u njenom rastu i kako se najlakše sprovode mere štednje? Pitanja e, po svemu sude i, duže vreme ostati bez pravog odgovora, budu i da je na tlu Sjedinjenih Ameri kih Država posejano

33POLITIKA FINANSIRANJA ZDRAVSTVENOG OSIGURANJA I ZDRAVSTVENE ZAŠTITE U SAD

seme iz koga je nikla aktuelna ekonomska kriza. Zato je sve izvesnije da e nezado-voljstvo severnoameri kih gra ana još više rasti, prvo, zbog nedovoljnog kvaliteta zdravstvene zaštite, a drugo, zbog korporativne pohlepe, visoke stope nezaposlenosti, zaplene njihovih ku a i drugih nepokretnosti od strane nezasitih banaka namera enih na njihovu imovinu.

I pored toga, sigurno je da e u Sjedinjenim Ameri kim Državama primat u sistemu zdravstvene zaštite i dalje imati tržišni model koji pruža kvalitet jedino ako se usluge skupo plate, iako ni tada nema dovoljno garancija da e kvalitet zdravstvene zaštite biti u skladu sa izdvajanjima. Zato se sumnja u zdravstvene reforme, jer preovladavaju mišljenja (u mnoga treba verovati) da one do sada nisu suštinski sprovo ene niti su imale zna aj kada je u pitanju kvalitet zdravstvenog osiguranja. Niko ne spori da e tržište i dalje biti moderator svih odnosa i zbivanja i da e preko 15 miliona gra ana Sjedinjenih Ameri kih Država biti bez ijednog vida zdravstvenog osiguranja. Da bi ameri ki gra anin dobio priliku da bude osiguran, treba da priloži lekarska uverenja o svim vrstama oboljenja (ili da ih nema), da bi mu osiguravaju e društvo ponudilo ugovor o osiguranju i odredilo visinu premije koju treba da upla uje. U ameri koj praksi ve i broj osiguravaju ih društava ne želi da zaklju i bilo koju vrstu ugovora o zdravstvenom osiguranju sa licima koja prema njihovim kriterijumima imaju status rizi nih klijenata, a to nijedna reforma nikada ne može u initi u interesu gra ana. Model privatnog zdrav-stvenog osiguranja u Sjedinjenim Ameri kim Državama je doskora karakterisao mali obuhvat stanovništva, odnosno veliki broj neosiguranih lica i nansiranje zdravstvenih usluga iz fondova privatnog osiguranja. Sredstva fondova formiraju se od upla enih premija kupaca-mušterija, bez obzira da li ih upla uju poslodavci u ime svojih zaposlenih ili sami gra ani.

Mnogo je elitista koji smatraju da i od ameri ke zdravstvene politike i zdrav-stvenog sistema postoje bolje ure eni, racionalniji i ekonomi niji sistemi u kojima se ljudsko zdravlje humanije uva i realnije vrednuje. Ovo je sugestija itaocu da ne o ekuje kao dokaz stvarnosti ni veliku glori kaciju niti izražen odijum, budu i da su Sjedinjene Ameri ke Države prostor u kome je zdravstvena sigurnost gra ana vr-hunsko dostignu e. Ovaj aspekt ne bi smeo da bude zanemaren, iako on kriti arima, koji su zaboravili da suprotstavljanje relevantnim injenicama predstavlja avanturu neizgra enog duha, ne zna i puno.

Mnogi od njih esto iznose podatke da zdravstveni sistem u Sjedinjenim Ame-ri kim Državama ostvaruje slabije rezultate od drugih isto tako razvijenih zdrav-stvenih sistema, ali ne predlažu adekvatna rešenja, a postoje a jednostavno smatraju katastofalnim. Me utim, olako prelaze preko injenice da se ipak njena zdravstvena politika sprovodi besprekorno, da zdravstvena služba vrhunski funkcioniše i da je u ameri kom zdravstvu angažovan najstru niji i najprofesionalniji zdravstveni i drugi kadar na svetu.


Cilj rada

Cilj rada je diskusija o stavu osigurava a da vlada Sjedinjenih Ameri kih Država u javnom sektoru obezbe uje izme u 60 i 65% sredstava za nansiranje zdravstvene potrošnje. Da se sredstva usmeravaju na nansiranje razli itih programa, me u kojima dominiraju Medikar (Medicare), Medikal (Medicall) i Medikaid (Medicade) programi, Program zdravstvenog osiguranja dece i Program Uprave za zdravstvenu zaštitu ratnih veterana. Zdravstvena politika još uvek najrazvijenije ekonomije na svetu zasnovana je na relevantnim pokazateljima koji pritiskaju vladu, ali i privatni sektor, da konci-piraju i usvajaju konkretne programe zdravstvene zaštite i zato se smatra politikom budu nosti. Ona se vrsto naslanja na dostignu a savremene medicinske nauke, na rigorozno kontrolisanje nansijskih tokova i na pravilnu primenu farmakoloških i tehno-ekonomskih procedura.

Zdravstvena politika i zdravstvena zaštita

Ukupna zdravstvena politika, ne samo u Sjedinjenim Ameri kim Državama nego i šire, mora biti shva ena kao svesna i odgovorna aktivnost, usmerena na postizanje speci nih ciljeva zdravstvene zaštite primenom adekvatnih instrumenata i efektnih mera, angažmanom stru nih egzekutora i racionalnim koriš enjem raspoloživih resursa. Uprkos širokom spektru mišljenja da je zbog toga re o komplikovanoj po-litici, treba ista i suprotno, jer stvari stoje sasvim druga ije. Pre bi se moglo govoriti o konkretnim zahtevima za sprovo enje precizno donešenih odluka, planova i akcija koje su zvani nici Svetske zdravstvene organizacije (SZO) promovisali kao viziju budu nosti, nego o komplikovanoj politici koja stvara dodatna optere enja. S obzi-rom na to da se radi o viziji, treba ista i da ona isti e prioritete i o ekivano u eš e razli itih grupa, obezbe uje konsenzus kod velikog broja pitanja i obaveštava ljude o mogu nostima za pristupanje svim oblicima zdravstvene zaštite. Dakle, zdravstvena politika nije svet za sebe, bez obzira što je jedan od najvitalnijih sastojaka globalne politike Sjedinjenih Ameri kih Država. Ona je, u skladu sa svojom prirodom i sadr-žinom, prostrana paleta koju strukturiraju druge, uže politike i/ili njihovi speci ni delovi. Bilo kako da je shva ena, teorijski ili prakti no, ona može biti sve osim lista taksativno navedenih želja, želja koje to esto i nisu, s obzirom na njihov pravi smisao. Ako su želje neostvarive ili teško ostvarive, a u mnogo slu ajeva jesu, onda takav pristup dodatno erodira kompletan koncept politike zdravstvene zaštite. Zbog toga je od velike važnosti da zdravstvena politika va bank pretpostavlja tehnologiju dode-ljivanja i uživanja prava na zdravstvenu zaštitu, veliki obuhvat stanovništva, proces neometanog nansiranja zdravstvene industrije i potrošnje, aktivno zadovoljavanje zdravstvenih potreba i korektnu farmaceutsku zaštitu.


Od zdravstvene politike u tako razvijenoj državi, centru grupe G 5 (poznata KVINTA), što Sjedinjene Ameri ke Države jesu, s pravom treba o ekivati da svoju aktivnu funkciju obavlja u cilju o uvanja javnog zdravlja i promoviše programe koji sadrže na ine i principe vo enja kvalitetnog života gra ana. Na primer, neka to bude sprovo enje aktivnosti u borbi protiv uživanja duvana, alkohola i razaraju ih opijata, sa ravnopravnim tretmanom razli itih korisnika zdravstvene zaštite. Neka to bude i kod procedura imunizacije, borbe protiv savremenih bolesti, pravilnog dojenja, o uvanja okoline i kod stvaranja uslova potrebnih za pravilan razvoj i negovanje biološkog i humanog kapitala. Tokom prve decenije XXI veka, delovanje zdravstvene politike na tlu Sjedinjenih Ameri kih Država bilo je tema razli itih debata, me u kojima je najintenzivnija ona koja je najmanje potrebna, politi ka. Zašto? Zato što se rezultati zdravstvene politike odnedavno vrednuju kroz politi ku prizmu, nezavisno od toga koliko je ona kao merni instrument zaista precizna. Politi ka ocena se svodi na pri-bližavanje ivici gapa (jaz) koji je posledica suženih mogu nosti nansiranja i narasle zdravstvene potrošnje, usled proširenog obima prava na zdravstvenu zaštitu i sve ve ih zahteva osiguranika.

U uslovima kakvi jesu, o ekuje se da sve probleme reši zdravstvena politika zbog ega uvek dobija nove, prema mnogim mišljenjima, znatno teže zadatke. Njena sudbina je borba sa nansijskim problemima, mukotrpna inicijativa u nalaženju na ina da se galopiraju a zdravstvena potrošnja, izazvana delovanjem razli itih inilaca, neometano nansira i kada su sredstva za te namene nedovoljna. A u kojoj meri su takvi pokušaji opravdani i kakvi se rezultati o ekuju, budu i da obzirom da velika ekonomska kriza od 2008. godine potresa svet i ne samo što ne jenjava, nego preti da znatnije ekspandira, lako se može zaklju iti. Tokom zadnjih decenija XX veka, porast zdravstvene potrošnje u Sjedinjenim Ameri kim Državama, kao i u ve ini drugih industrijski razvijenih država sveta, postao je glavni problem zdravstvene politike. Ali nije re samo o borbi sa nansijskim problemima (lista je mnogo šira), radi se i o drugim prepoznatljivim manjkavostima ije prisustvo devastira njenu vrednost i ote-žava realizaciju ciljeva. Zdravstvena zaštita je velikim delom i zbog toga postala pred-met živih, na momente oštrih rasprava koje esto izlaze iz okvira u tivog ponašanja. Mnogi u esnici u raspravama o njoj imaju jedan jedini cilj, osporavanje odre enog koncepta i dezavuisanje postignutih rezultata. Programe, mere i ciljeve zdravstvene politike svi vrednuju razli ito, a ustaljena praksa je, da se kriti ki osvr u na obim prava na zdravstvenu zaštitu, pristupe, pravi nost, e kasnost, cene, izbor, ekvivalentne vrednosti i uopšte na njen ukupni kvalitet. Kriti ki nastrojeni analiti ari smatraju da je u mnogo emu ona nedosledna, i zbog njenih nejasno a aktuelni ameri ki sistem zdravstvene zaštite, osim što posr e, znatno zaostaje za drugim razvijenim sistemima u svetu, naro ito za kanadskim. Zato, smatraju oni, njen koncept ne uliva nadu da se mogu o ekivati bolji uslovi u kojima bi funkcionisala kvalitetnija zdravstvena zaštita.

vrsto su uvereni da mnoge projekcije i namere nisu u skladu sa realnim potrebama


i zadacima. Prema njihovom mišljenju ovako koncipirana zdravstvena politika nema odgovaraju i kapacitet koji bi predstavljao adekvatnu logistiku zdravstvenoj zaštiti ija je obaveza da bude ekvivalent utrošenim nansijskim sredstvima. Imaju i u vidu

da je Kongres Sjedinjenih ameri kih država tesnom ve inom (219:212) izglasao novi Zakon o obaveznom zdravstvenom osiguranju što je kruna zdravstvenih reformi pred-sednika Baraka Hoseina Obame, mnogim gra anima Sjedinjenih ameri kih država zdravstveno osiguranje postalo je pristupa nije i primenjiva e se na osobe slabijeg imovinskog stanja.

Da bi ciljevi zdravstvene politike u Sjedinjenim Ameri kim Državama bili real-no postavljeni i realizovani, njihovi protagonisti, kao malo koji u drugim državama, moraju biti svesni da je neophodan multidisciplinaran pristup iniocima (doprinos medicinskih, socijalnih, ekonomskih i institucionalnih) koji deluju u okviru nacio-nalnog zdravstvenog sistema i da oni nemaju alternativu. Kada je re o pomenutim faktorima za sprovo enje efektne zdravstvene politike, važno je precizno utvrditi koji od njih jasnije od ostalih determiniše obim zdravstvene potrošnje. Promoteri zdravstvene politike nekada mogu zanemariti premisu koliko njihova država treba da izdvaja za zdravstvenu zaštitu. Mada ih to ne osloba a obaveze da aproksima-tivno operišu sa fondovima nansijskih sredstva koja su uslov za funkcionisanje zdravstvenog sistema i kako da raspolažu sa spektrom razli itih varijabli, od kojih zavise pomenuti fondovi. Njihova obaveza u okviru zdravstvene politike odre ena je poznavanjem strukture bolesti, sklonostima ka obolevanju, a zatim razlikovanjem uticaja socijalnih, privrednih i geografskih uslova, kao i procenjivanjem o ekivanog trajanja životnog veka populacije.

Zdravstveni programi i nansiranje

Zdravstveno osiguranje, odnosno pokrivenost populacije jednim od njegovih oblika predstavlja goru i problem u Sjedinjenim Ameri kim Državama. To je razlog zašto Federalna vlada preduzima ozbiljne korake ka utvr ivanju i realizaciji programa koji bi pove ali obuhvat gra ana zdravstvenim osiguranjem. Prema zvani nim izvešta-jima, neosigurani stanovnici, njih oko 38% živi u doma instvima koja na nivou godine ostvaruju prihode od 50,75 ili više hiljada $ US. Svakako najzna ajniji poduhvat je preko Medikar (Medicare), Medikal (Medicall) i Medikajd (Medicaid) programa, koji su uprili eni za korisnike zdravstvene zaštite. Medikar je savezni program zdravstve-nog osiguranja koncipiran sa ciljem da obuhvati osobe od 65 godina života i starije i mla e osobe ali sa invaliditetom, koji su najve i potroša i zdravstvenog osiguranja. Ve ina ljudi su Medikar-korisnici po odlasku u penziju zato što su uživaoci prava na socijalno osiguranje ili su korisnici neke vrste davanja po osnovu invalidskog osiguranja. Oni koji su korisnici dodatnih prihoda, na primer, nansijske podrške za izbeglice ili hraniteljske pomo i, automatski sti u pravo na zaštitu u okviru Medical-


programa, s tim što to pravo imaju i neki korisnici Medikar-programa (stare osobe, slepi, invalidi, trudnice, roditelji ispod 21 godine i šti enici stara kih domova).

Prakti no, gra ani Sjedinjenih Ameri kih Država istovremeno mogu biti korisnici oba programa, jer njihovi provajderi imaju identi ne interese, tesno sara uju i nastale troškove zdravstvene zaštite pla aju prema utvr enom redosledu. Medikar-program pla a prvi a Medikal drugi. Prilikom koriš enja zdravstvenih usluga moraju se uvek pokazati obe legitimacije o osiguranju radi identi kacije i kategorizacije usluga i redosleda u pla anju. Medikar-program pokriva etiri dela (ili oblasti) zdravstvenog osiguranja, tako da se korisnicima pruža prilika da u skladu sa nansijskim mogu -nostima biraju deo:

1. A, koji obezbe uje bolesni ke usluge i bolesni ku negu pod odre enim uslo-vima;

2. B, koji obezbe uje vanbolni ke medicinske koristi i laboratorijske takse;3. C, koji predvi a prednosti kroz razne zdravstvene planove koje pacijenti mogu

dobijati u bolnicama i van njih u skaldu sa izabranim programom i4. D, koji obezbe uje pokrivenost troškova zdravstvene zaštite, propisanih

farmakoloških procedura i lekova na izdati recept.

Delovi A i B Medikar-programa pokrivaju rashode samo za neophodne medi-cinske usluge, uklju uju i zaštitu mentalnog zdravlja, ali ne i rashode za usluge u stomatologiji. Medikar-program je u kompetenciji Federalne vlade, koja ima mandat da na osnovu relevantnih postulata koncipira i sprovodi zdravstvenu politiku. Njegovi korisnici imaju široka prava na informacije i savete u vezi sa na inom osiguranja, obimom i kvalitetom zdravstvene zaštite, zastupanjem i/ili pružanjem stru ne pomo i u rešavanju problema. U skladu sa iznetim, korisnici imaju mogu nost da ulože žalbu na štetne odluke, na primer u vezi sa pla anjem ili nepoštovanjem odredbi iz utvr enih zdravstvenih planova koje su odabrali na osnovu ponu enih smernica. U slu aju da neki korisnici Medikajd-programa iz nekog razloga koriste zdravstveno osiguranje u Medikar-programu i da, pored uplata premija, ne mogu snositi svoje zdravstvene troškove, Medikajd-program može stati iza njih i uplatiti pripadaju e premije. Medi-kajd-program obuhvata osobe koje nisu u stanju da sebi priušte pravo na zdravstvenu zaštitu jer ne ostvaruju nansijske prihode ili ih ne ostvaruju u dovoljnoj meri. Ovom programu je ina e svojstveno da esto ini ustupke pojedinim kategorijama osigu-ranika (trudnice, deca, siromašni) i da im omogu ava koriš enje odre enog obima zdravstvene zaštite, ali samo u za to odre enim klinikama i/ili bolnicama.

Ukoliko korisnik pod odre enim okolnostima (gubitak zaposlenja, skra eno radno angažovanje, duže odsustvo i sl.) izgubi pravo na osiguranje Medikajd-program ne prestaje sa uplatom bene cija i pokrivanjem zdravstvenih troškova u njegovu korist. Medikajd-program može platiti korisniku zdravstvene usluge i u slu aju kada


on to ne može da u ini zbog starosne dobi, loših nansijskih okolnosti, nezavidne porodi ne situacije ili zbog promene na ina na koji organizuje život. Na drugoj strani, ako su korisnici u mogu nosti da štede, Medikajd-program im nudi i takvu soluciju. Oni pla aju svoje premije, a Medikar-program pla a premije i odbitne stavke. Osobe obuhva ene Medikajd-programom imaju apsolutno pravo na svoju privatnost, tako da se informacije o njihovom zdravlju, privatnim aktivnostima, bra nom i imovinskom statusu mogu dobiti i koristiti isklju ivo uz njihov pristanak ili ako je to krajnje nužno, na primer radi sudskih sporova.

Finansiranje zdravstvene zaštite ameri kih gra ana je neobi no važno pitanje. U ingerenciji Federalne vlade je da ure uje zdravstveni sistem iji je osnovni cilj obezbe-ivanje i distribucija nansijskih sredstava za pokrivanje troškova zdravstvene zaštite.

Iako ne raspolaže ni sa jednim oblikom zdravstvenog osiguranja koji bi apsolutno obuhvatio sve gra ane Sjedinjenih Ameri kih Država, vlada svojom zdravstvenom politikom fokusira problem nansiranja zdravstvenih usluga na osnovu ekonomskog rizika koji preti da ekspandira zbog njihovog niskog zdravstvenog stepena. S obzirom na to da 84,7% gra ana Sjedinjenih Ameri kih Država ima neki vid zdravstvenog osiguranja (preko poslodavca, supružnika ili roditelja), Federalna vlada za njihovo nansiranje koristi model:

1. opšteg oporezivanja na nivou države, okruga ili opština;2. socijalno-zdravstvenog osiguranja;3. dobrovoljnog/privatnog zdravstvenog osiguranja;4. direktnog pla anja usluga ili isplata iz sopstvenog džepa i 5. doniranja od strane raznih dobrotvora.

Me utim, u mnogim federalnim državama se, pored navedenih modela, prime-njuju njihove kombinacije, odnosno model miks- nansiranja. U takvim slu ajevima na in distribuiranja sredstava na odre ene nosioce troškova varira od jedne do druge federalne države, a neretko se varijacije tokom vremena mogu sresti i unutar svake od njih. U zdravstvenoj politici svake federalne države, ali u skladu sa njenom jurisdikcijom, kreira se tehnika nansiranja. Jurisdikcija upu uje na relevantne pro-pise i njihovu striktnu primenu i podsti e vladu i privatni sektor da donose odluke koje se ti u zdravstvene politike i usvajanja speci nih programa, mera, tehnike i nivoa nansiranja. Na primer, socijalno-zdravstveno osiguranje podrazumeva model u kome cela populacija ima pravo na pokri e zdravstvene zaštite, pri emu su i obuhvat i na in pružanja zdravstvenih usluga zakonom regulisani. U takvim okolnostima osiguranici bi kao najbolji oblik zaštite njihovog zdravlja doživljavali univerzalnu zdravstvenu zaštitu, koja bi ih oslobodila pla anja premija osiguranja i/ili li nog u eš a u zdravstvenim troškovima. Time je istaknut zna aj opredeljenosti za preventivnu zdravstvenu zaštitu koja, gledano na duže vreme, sužava prostor


raznim bolestima, smanjuje zdravstvene troškove i umnogome spre ava ekspanziju zdravstvene potrošnje.

U zdravstvenom sistemu Sjedinjenih Ameri kih Država posebno pitanje je odnos jvnog i privatnog (dobrovoljno) nansiranja zdravstvene zaštite. Postoje tvrdnje da javno nansiranje zdravstvene zaštite unapre uje kvalitet i e kasnost li nim kontak-tom zdravstvene zaštite jer javna (državna) potrošnja ima suštinski zna aj kada je u pitanju pristupa nost i održivost zdravstvenih usluga i programa. Javno nansirana zdravstvena zaštita (državna), koja je uzgred besplatna, poslovi no prouzrokuje za-htevnije medicinske procedure i usluge, što ima za posledicu porast ukupnih zdrav-stvenih troškova. Dodeljena javna sredstava, bilo da su ograni ena ili ne, ne lišavaju neosigurane gra ane obaveze da iz sopstvenog džepa pla aju troškove za koriš ene zdravstvene usluge. Primedba je da bi javna sredstva mogla biti racionalnije upotre-bljena, na primer kod pružanja usluga iz delokruga hitne pomo i, pri emu status ili nansijska sposobnost osiguranika pri pla anju takvog tretmana ne bi bio naro ito bitan. Na drugoj strani, privatni sistemi, odnosno osiguravaju e kompanije smanju-ju rasipništvo i birokratiju uklanjanjem nepotrebnih izvršilaca-provajder poslova, smanjenim ekanjima na specijalisti ke usluge i ve im mogu nostima upotrebe savremene tehnologije u zdravstvenim procedurama. Paralelno sa tim, smanjuje se obimna dokumentacija koju profesionalci, ugovara i osiguranja obra uju i na taj na-in pove avaju koncentrisanost na potrebe osiguranika. To su argumenti za one koji

veruju da privatno nansiranje poseduje organizovaniju zaštitu i time podiže kvalitet zdravlja na viši nivo i za one koji imaju dilemu na koji na in privatno nansirana zdravstvena zaštita postiže bolje rezultate i ve u efektivnost. Osim toga, privatno nansiranje zdravstvene zaštite i efektno upravljanje resursima ( nansijska sredstva) spre ava Federalnu vladu da pove ava poreske stope i da sa pove anim porezima podmiruje troškove zdravstvene zaštite. To je ujedno i najbolji na in da se izbegnu kon ikti me u vladinim agencijama i da se osujeti porast birokratskog uticaja.

Troškovi zdravstvene zaštite u Sjedinjenim Ameri kim Državama

Troškovi zdravstvene zaštite u Sjedinjenim Ameri kim Državama, u odnosu na privredne potencijale,

ekonomsku snagu i ostvareni bruto doma i proizvod (BDP), premašuju iste u svim drugim državama u svetu. Ukupna ameri ka zdravstvena potrošnja pokazuje tendenciju da u narednim godinama naraste do alarmantnih visina. Svaki $ US potrošen na zdravstvenu zaštitu u Sjedinjenim Ameri kim Državama može

pojedina no da se posmatra i valorizuje. Tako 31% odlazi na bolni ku negu, 21% za lekare koji pružaju klini ke usluge, 10% za pla anje lekova, 4% pokrivaju stomatološke usluge, 6% smeštaj i negu u domovima, 3% odlazi za ku nu negu, 3% na maloprodajne proizvode, 3% za vladine javne zdravstvene aktivnosti, 7% podmi-


ruje administrativne troškove, 7% otpada na investicije, a preostalih 6% pokrivaju ostale profesionalne usluge. U toku 2009. godine, Sjedinjene Ameri ke Države (lo-kalne vlade, korporacije i pojedinci) su za pružanje zdravstvene zaštite potrošili 2,5 triliona $ US ili 8.047 $ US po osobi, ili 17,3% od bruto doma eg proizvoda (BDP), a u 2010. izdvojeno je17,9% iz bruto doma eg proizvoda (BDP), ili 8.362 $ US po osiguraniku.

Zaklju ak je da troškovi zdravstvenog osiguranja rastu brže i od zarada i od in- acije i da je više od polovine rasta zdravstvene potrošnje, koja je obeležila poslednje decenije XX i prvu deceniju XXI veka, posledica tehnološkog progresa, promena u osiguranju i u zdravstvenim materijalnim i humanim resursima. Zdravstvena potroš-nja je rasla u skladu sa prihodima koje su odre ene kategorije gra ana ostvarivale u uslovima osiguranja, koje su diktirali provajderi i u skladu sa zaradama zdravstvenih stru njaka. Osim toga, porast potrošnje je i posledica obilne upotrebe farmaceutskih proizvoda, što je karakteristi no za bolesne i starije osobe. To je ozbiljan signal za štednjom, me utim, njeni zagovornici tvrde da je ona mogu a samo u sprovo enju mera i procedura kod preventivne zdravstvene zaštite i da se u drugim vidovima ne mogu o ekivati zna ajniji rezultati. Iako je rezultat serioznih istraživanja, da je štednja mogu a isklju ivo u preventivnoj zdravstvenoj zaštiti, to ne zna i da ona smanjuje nivo zdravstvene potrošnje ili da makar generiše zna ajnije uštede na duže vreme.

Kada je preventivna zdravstvena zaštita u pitanju, mora se uzeti u obzir da e pružanje zdravstvenih usluga osobama u poznim godinama života zna ajno doprineti porastu troškova. Tako e porast troškova zdravstvene zaštite (naro ito u prevenciji) kompanije koje pla aju njihove razli ite vrste za svoje zaposlene dovesti u nezavi-dan položaj, a ameri ki zdravstveni sistem kao ekonomski organizam e pojesti kao pantlji ara. Ovi zaklju ci su izvedeni nakon izražene želje Sjedinjenih Ameri kih Država da za pokrivanje zdravstvene potrošnje iz svog bruto doma eg proizvoda (BDP) izdvoje više od 18%, i nakon izveštaja da privatno zdravstveno osiguranje Sjedinjenih ameri kih država sa 35% u eš a u ukupnim zdravstvenim troškovima ima daleko najve i udeo me u državama Organizacije za ekonomsku saradnju i razvoj (Organization for Economic Cooperation and Development – OECD).

Prema podacima iz 2004. godine, u kojoj je zdravstvena potrošnja imala umeren tok, privatno zdravstveno osiguranje li nim sredstvima nansiralo je 36% osigura-nika, Federalna vlada Sjedinjenih Ameri kih Država nansirala je 34%, nansiranje iz sopstvenog džepa iznosilo je 15%, iz budžeta državnih i lokalnih samouprava nansirano je 11%, dok su drugi privatni fondovi nansirali oko 4% zdravstvene po-trošnje. I pored toga sve su eš e primedbe korisnika zdravstvenih usluga i uplatioca premija da je zdravstveni sistem u Sjedinjenim Ameri kim Državama na dobrom putu da doslovno prekopira neke evropske ili latinoameri ke zdravstvene sisteme, što ne ostavlja prostora za optimizam. Poslednjih godina prisutna je praksa da se javljaju naduvani ra uni, ponekad i po deset puta ve i nego što iznosi stvarna vrednost pru-


žene/koriš ene zdravstvene usluge, što izaziva podozrenje i odudara od utvr enih pravila. Osim toga, neefektan a uz to još i nekorektan i nepošten zdravstveni sistem ne treba nijednom ameri kom gra aninu, bez obzira da li je ili nije bio žrtva pla anja vešta kim putem uve anih zdravstvenih troškova.

Nezavisno od injenice da zdravstveni sistem u Sjedinjenim Ameri kim Drža-vama obuhvata nekoliko hiljada razli itih nosilaca zdravstvenog osiguranja, njihov broj se ne može ta no utvrditi. ak je vrlo teško i aproksimativno navesti koliko osiguravaju ih društava u njima trenutno egzistira. Ali je zato potpuno izvesno da zdravstveni sistem u Sjedinjenim Amer kim Državama ima zna ajne administrativ-ne troškove, neuporedivo ve e od kanadskog ili nekog od evropskih zdravstvenih sistema (Velika Britanija, Nema ka, Francuska). Ubedljivo zvu e podaci iz studije Harvardske medicinske škole i kanadskog Instituta za zdravstveni informacioni sistem, da na administrativne troškove godišnje odlazi oko 31% ameri kog zdravstvenog $ US, ili preko hiljadu $ US po osiguraniku. Ovaj iznos zdravstveno-administrativnih troškova je skoro dvostuko ve i od svih koji se mogu sresti u najrazvijenijim zdrav-stvenim sistemima u svetu. Zbog ove, a i zbog drugih okolnosti mnogo je primedbi da je sistem zdravstvene zaštite u Sjedinjenim Ameri kim Državama „nefunkciona-lan” i da pacijenta, kao glavnog u esnika nepravedno uklanja iz zbivanja koja se ti u utvr ivanja politike nansiranja. U narednoj tabeli prezentirani su podaci iz nekoliko država Organizacije za ekonomsku saradnju i razvoj (Organization for Economic Cooperation and Development – OECD) o izdvajanjima za zdravstvenu zaštitu po stanovniku i njihovom procentualnom u eš u u bruto doma em proizvodu (BDP) za 2009. i 2010. godinu.

Tabela 1. Potrošnja po glavi osiguranika u nekim državama Organizacije za ekonomsku saradnju i razvoj (Organization for Economic Cooperation and Development – OECD) i izdvajanja iz bruto doma eg proizvoda (BDP) za 2009. i 2010. godinu.

Red. broj

DržavaOECD

2009* 2010**

Potrošnja po osiguraniku % izBDP

Potrošnja po osiguraniku

% izBDP

1 Sjedinjene Ameri ke Države 7.960 17,4 8.362 17,9

2 Norveška 5.352 9,6 5.426 9,53 Švajcarska 5.144 11,4 5.394 11,54 Holandija 4.914 12,0 5.038 11,95 Luksemburg 4.808 7,8 6.743 7,86 Kanada 4.363 11,4 4.404 11,37 Danska 4.348 11,5 4.537 11,4


Red. broj

DržavaOECD

2009* 2010**

Potrošnja po osiguraniku % izBDP

Potrošnja po osiguraniku

% izBDP

9 Francuska 3.978 11,8 4.021 11,910 Australija 4.453 8,7 3.441 8,711 Velika Britanija 3.487 9,8 3.480 9,612 Japan 2.878 8,5 3.209 9,513 Novi Zeland 2.983 10,3 3.022 10,114 Južna Koreja 1.879 6,9 2.035 7,115 Meksiko 918 6,4 916 6,2

*Izvor: Izrada autora prema podacima OECD Health Division (June 30, 2011). “OECD Health Data 2011 – Frequently Requested Data”. Paris: OECD.

**Izvor: Izrada autora prema podacima The World Bank, World Development Indicators 2012.

Svi koji žele i za to imaju mogu nosti mogu kupiti privatno zdravstveno osi-guranje na nivou grupe (na primer, rma pokriva osiguranje svojih radnika) ili kao individualna mušterija kod odre enog osigurava a-provajdera (kompanija, agencija, diler, broker). Individualno kupljeno zdravstveno osiguranje prema nomenklaturi zdravstvenih usluga sli no je osiguranju koje obezbe uju poslodavci. Oni daju zna-ajan doprinos pokrivanju troškova zdravstvene zaštite i pla aju prose no oko 85%

od premije osiguranja za svoje zaposlene i oko 75% od premije za one ije osiguranje zavisi od zaposlenih, dok preostali deo premije pla aju zaposleni. Kod zdravstvenog osiguranja koje poslodavci pla aju svojim radnicima prime en je pad pokrivenosti sa 68%, u 2000, na 61% u 2009. godini. Ekonomska kriza koja je 2008. pogodila Sjedinjene Ameri ke Države i po domino efektu ostali deo sveta, prouzrokovala je visok stepen nesigurnosti, siromaštva, porasta cena zdravstvenih usluga i armiju ne-osiguranih lica-radnika koji su izgubili posao. Samo u martu 2009, oko 270 hiljada radnika, zbog gubitka posla, izgubilo je pravo na zdravstveno osiguranje, dok je 2010. godinu skoro 50 miliona ljudi, ili preko 16% ukupnog stanovništva, do ekalo bez zdravstvenog osiguranja.

Politi ka dimenzija zdravstvenog osiguranja – slu aj OBAMACARE

„Ne želimo da porezi na neto zaradu porodica ameri ke srednje klase budu po-ve ani... svi mi želimo dalji ekonomski razvoj, svi mi želimo povratak na svoja radna mesta i stalno insistiramo na novim zapošljavanjima“, ve iti je stav predvodnika Re-publikanske stranke. Oni su 40 puta pokušavali da spre e usvajanje budžeta za 2013.


godinu, zbog neslaganja sa politikom nansiranja obaveznog zdravstvenog osiguranja, poznatog kao “Obamacare”. Time je i zvani no po ela nansijska blokada Federalne vlade 1. oktobra 2013. godine, jer u više asovnoj politi koj drami u Senatu i u Pred-stavni kom domu Kongresa Sjedinjenih Ameri kih Država pripadnici Demokratske stranke i Republikanske stranke nisu uspeli da se dogovore ili da na u zajedni ko, odgovaraju e rešenje za nansiranje države za teku u nansijsku godinu. Nastali nesporazum je doveo do prekida niza državnih i budžetski nansiranih aktivnosti, ime je automatski blokirano funkcionisanje ameri ke Federalne vlade. Istraživa ka

kompanija IHS tvrdila je da e nansijska blokada vlade dnevno koštati ekonomiju Sjedinjenih Ameri kih Država najmanje 300 miliona $ US. U slu aju jednonedeljne blokade vlade, prognozirani privredni rast od 2,2% za poslednji kvartal smanjio bi se za 0,2%, a tronedeljna blokada vlade umanjila bi ameri ki bruto doma i proizvod (BDP) izme u 0,9% i 1,4%. Da pomenuta blokada predstavlja ozbiljnu pretnju glo-balnoj ekonomiji složila se je i direktorka Me unarodnog monetarnog fonda (MMF), Kristin Lagard, obra aju i studentima Univerziteta Džordž Vašington. Blokada je ozbiljna i loša, a ako se ne na e rešenje za ameri ki suvereni dug, to bi moglo ozbiljno da ugrozi ne samo njenu, ve itavu globalnu ekonomiju, zbog ega bi taj problem morao biti rešen što pre. Zbog blokade na prinudne odmore trebalo je da ode više od 825 hiljada zaposlenih u saveznoj administraciji.

Zvu i nestvarno ali je istina., da nekoliko desetina poslanika poseduje toliku mo da su prakti no itav sistem držali za svog taoca, samo zato što su na zdravstvenu reformu gledali kao na bolan i preskup potez predsednika Baraka Hoseina Obame, koji je želeo da u zdravstveni sistem dodatno uvrsti preko 40 miliona novih osigu-ranika. Takav obuhvat zahtevao je ogromne izdatke pa su Republikanci želeli da taj novac uštede i da blokiraju sprovo enje neophodne zdravstvene reforme. Me utim, zdravstvena reforma je zakon i ustavno je priznata od strane Vrhovnog suda Sjedi-njenih Ameri kih Država i postala je klju ni deo politike Baraka Hoseina Obame. Da je kojim slu ajem spre ena od strane Republikanaca, to bi sigurno izazvalo veliku politi ku a i zdravstvenu pometnju. Na kraju, kada je reforma ipak sprovedena sva nastojanja Republikanaca li ila su na najobi nije ma evanje sa vetrom. Veliki broj predstavnika Republikanske stranke zatražio je odlaganje primene “Obamacare”, a zatim i smanjenje nadležnosti Agencije za zaštitu životne okoline, što su pripadnici Demokratske stranke odbili, zalažu i se za „ istu” odluku koja se odnosi samo na prag zaduživanja.

Republikanci nisu propustili priliku da podsete na politiku od pre više od trideset godina koju vezuju za Ronalda Regana, koji je na svojoj prvoj inauguraciji izjavio da „vlada nije rešenje za naše probleme, vlada je problem”, ime je, kažu oni, i prakti -no po ela demontaža koncepcije ekonomskog sistema koji je stvoren posle „Velike depresije” iz tridesetih godina prošlog veka. Nju je trebalo da zameni „nevidljiva ruka” slobodnog tržišta, me utim, dogodilo se da je produktivnost nastavila da raste,


ali su prihodi srednje klase stagnirali ili su se realno ak i smanjivali. Uprkos svim otporima administracija Sjedinjenih Ameri kih Država je nastavila sa radom i po ela je sprovo enje klju nog elementa reforme zdravstvene zaštite. Sada je gra anin Sjedinjenih ameri kih država dobio priliku da na posebnim tržištima kupuje polisu zdravstvenog osiguranja, a za ljude s nižim primanjima zakon je predvideo odre ene vrste subvencija.

Zaklju ak

U svetu postoji veliki respekt prema trenutno vode oj politi koj, vojnoj i eko-nomskoj sili i, gledano kroz prizmu znatiželje, ona predstavlja izazov radi nalaženja makar i najmanje slabosti u bilo kojoj sferi njenih državnih aktivnosti. Eventualne slabosti trebale bi da posluže kao argument da su stubovi uverenja da u Sjedinjenim Ameri kim Državama zaista sve besprekorno funkcioniše prili no uzdrmani i da stre-me urušavanju. Zbog toga udi podatak da je u Sjedinjenim Ameri kim Državama do samog isteka 2009. godine skoro 50 miliona gra ana (ili 16,7% stanovništva) bilo izvan svih oblika zdravstvenog osiguranja i da su ukupni javni zdravstveni rashodi zauzeli vrlo visoku tre u poziciju na svetu. Time je obelodanjeno da Sjedinjene Ameri ke Države za zdravstvenu zaštitu na godišnjem nivou izdvajaju više sredstava po osigu-raniku (8.362$ US) nego bilo koja druga država na svetu. Naro ito su visoki troškovi kod pružanja direktnih medicinskih usluga, kod upotrebe farmaceutskih proizvoda i u glomaznom administriranju. Oni su uzrok u estalih bankrota osiguravaju ih društava i fondova zdravstvenog osiguranja, ali i pove anom broju neosiguranih gra ana.

U Sjedinjenim Ameri kim Državama situacija je da pojedini privatnici, na jednoj strani, dobijaju poreske olakšice za zdravstveno osiguranje ili ga mogu kupiti uz dodatne poreske olakšice a, na drugoj, ve ina potroša a na pojedina nom tržištu ne dobija nikakve povoljnosti jer i premije zna ajno variraju zavisno od dijagnoze, bolesti ili od starosti. Danas udruženja Plavi krst (Blue Cross) i Plavi štit (Blue

Shield) u kombinaciji, direktno ili indirektno, obezbe uju zdravstveno osiguranje za više od 100 miliona gra ana Sjedinjenih Ameri kih Država. U svojoj operativ-nosti i ove osiguravaju e kompanije postale su sli ne komercijalnim kompanijama za zdravstveno osiguranje. To se smatra normalnim zato što je tržište zdravstvenog osiguranja postalo teren velike koncentracije kapitala i konkurencije, tako da su vode i osigurava i od 1990. do 2000. godine izvršili preko 400 fuzija. Uo i 2005. godine, kompanije Vellpoint i United Health imale su lanstvo ije je osiguranje iznosilo oko 67 miliona $ US i zajedno ine preko 36% nacionalnog tržišta u komercijalnom zdravstvenom osiguranju.

Ina e, u Sjedinjenim Ameri kim Državama termin zdravstveno osiguranje koristi se za opisivanje programa koji je donešen da pomogne u pla anju troškova zdravstvene zaštite. Nebitno je da li se radi o privatnom ili kupljenom osiguranju ili o socijalnom


osiguranju, odnosno socijalnom programu koji je nansirala Federalna vlada. U teh-ni kom smislu, ovaj termin se koristi da opiše bilo koji oblik zdravstvenog osiguranja koji obezbe uje pokrivanje troškova pruženih/koriš enih zdravstvenih usluga. Pored toga, on objašnjava obuhvatnost zdravstvene zaštite privatnim zdravstvenim osigura-njem i programe socijalnog osiguranja u kojima je predvi eno pokrivanje zdravstvenih troškova koji nastaju usled zbrinjavanja stare i iznemogle populacije i osoba sa težim oblicima oboljenja (Medicare). Ono podrazumeva socijalne programe koji predvi aju pokrivanje troškova koji su nastali ili e nastati usled zbrinjavanja osoba sa niskom materijalnom osnovom i osoba koje nisu u stanju da sebi i lanovima svoje porodice obezbede zdravstveno osiguranje (Medicaide).

Analiti ari, kriti ki nastrojeni i oni koji to nisu, nemaju odgovor na pitanje zašto se njihovo stanovništvo, uprkos tolikom izdvajanju za njegovu zdravstvenu zaštitu prema dužini životnog veka nalazi tek na 42, mestu na svetu. Ako se u tome Sjedi-njene Ameri ke Države upore uju sa drugim industrijalizovanim državama (Japan, Francuska, Nema ka, Velika Britanija), onda su daleko iza njih, ak su daleko i iza država koje nisu tako razvijene, na primer ile, koji zauzima 35. ili Kuba 37. mesto. Stanovnici Sjedinjenih Ameri kih Država ne mogu da zamisle da se najduže na sve-tu živi u maloj Andori ili Makauu i da je u njima prose an životni vek stanovništva poodavno premašio 83,5 godina.

Ibrahim Toti 1

POLICY FINANCING HEALTH INSURANCE AND HEALTH CARE IN THE UNITED STATES

Tax the fees you pay to have lived in organized society, with what he does not give

anyone the right to taxpayer destroy but to pre-serve life.

(FRANKLIN DELANO ROOSEVELT)

Abstract: Human Health in each country depends on the government’s of cial policy and strategy, and then of health policy and the results in terms of implemented health goals, programs and proper handling of the available resources. This paper is actually af rmed the role of the United States of America because it is crucial in determining the programs and measures of health policy and control and evaluation of realized strategic objectives. The objectives related to increased coverage of citizens with health insurance, raising the overall quality of health care, employing the available and nding new resources and to prevent upward ow of medical expenses. Timely implementation of the goals can be achieved by increasing the value of health, a detailed analysis of the results of speci c health programs, rational use of the factors involved and the preparation of materials for taking the next action. Although a relevant indicator, high-quality health fails to free the citizens of the United States a permanent and unconvincing assurances that in reaching its greatest credit goes to insurers and their unsel sh effort. It is not and can not be true, and the goal of this work is to prove it. Assurances of its kind covering the truth because the quality of the health of every citizen in the largely depends on his attitude towards personal and other people’s health and the impact of political, social, social, technical and economic factors. This is why contemporary analysts believe that the United States should leave philosophy to all valued money, and especially the life and health of citizens.

As for large-coverage of citizens with health insurance probably not be a particular problem, however, it is even greater as the settlement of the dispute does not want to in the right way. Inequality in health treatment

1 State University of Novi Pazar, e-mail: [email protected]

47POLICY FINANCING HEALTH INSURANCE AND HEALTH CARE IN THE UNITED STATES

insured because they belong to individual, particularly on vulnerable would not be a problem if there were greater willingness to masse people an equally valued. United States of America have long remained only a highly developed, industrial country that is not secured by the conditions in which all citizens have health care (state insurance or some kind of private insurance). A deeper analysis of this and similar problems it shows that critics of the current health policies are beginning to themselves to bother. In fact, they are concerned that the health of the United States older and sicker populations extensively using compensation of employees (and wealthy) layers of the population which, in their opinion causes irregular distribution of budget funds. If so (things are ne or OK), but the question is, why is there so much concern and imperative desire for an increased life expectancy of their citizens?

Key words: health care, nance, funding programs, costs, strategies

INTRODUCTION

In the United States a large number of problems, including those in the health industry can be solved by scal policy measures with what even many solutions may not always be considered feasible. They are responsible understand the political struc-ture and began seriously to deal with important issues, and rst issues of scal policy and its impact on the functioning of the health sector. Discussions are going in the direction to employers to exclude from tax liability to sponsored health care and help nance the costs incurred due to higher health coverage. Insightful and skillful analyst can miss a signal, that the cost of health care in the United States and universal kind of problem. For example, in 1990, amounted to $ 714 billion US, to 2008, reaching $ 2.3 billion US, an increase of over three times. Podes anja works in 1980, amounted to “only” $ 253 billion US, or eight times less than in 2008. It is evident that the in-crease in costs has become a major political priority, and the government, employers and consumers frantically struggling to stop, restrain or to slow their expansion. He-alth policy in the United States if there is a clear goal, and should have, must at least answer the following questions, which are the main drivers of growth in health care spending, how to effectively suppress its expansion, which is the government’s role in its growth and how easiest to implement austerity measures? Questions will most likely remain for a long time without a proper response, given that the soil of the United States sowed the seeds from which the nickel current economic crisis. Therefore, it is apparent that the dissatisfaction with the North American citizens continue to grow rst, due to the insuf cient quality of health care and secondly, because of corporate greed, high unemployment rates, the seizure of their homes and other property by the insatiable banks intents on their property.


Nevertheless it is certain that in the United States receive health care system continues to have a market model that provides quality only if it is expensive to pay, although even then there are not enough guarantees that the quality of health care to be in line with allocations. Therefore, it is suspected in the health care reform because the prevailing opinion (to many to be believed), that they have not fundamentally enforced or had importance when it comes to quality health insurance. No one dis-putes that the market will continue to be the moderator of the relationship and the events and that over 15 million citizens of the United States to be without any vision of health insurance. To be an American citizen given the opportunity to be insured must attach medical certi cates of all kinds of diseases (or that they are not), that the insurance company offered him a contract of insurance and determine the premium that should be paid. In American practice, a larger number of insurance companies do not want to enter into any type of health insurance agreements with individuals according to their criteria, have the status of high-risk clients, and that no reform can never be done in the interest of citizens. The model of private health insurance in the United States until recently characterized by low coverage of the population and a large number of uninsured persons and nancing of health services from the private insurance funds. Funds of funds are formed by premiums paid customers-customers regardless of whether they are paid by employers on behalf of their employees or citizens themselves.

A lot of elitists who think that the US health policy and health systems are better equipped, more rational and economical system in which human health and humane kept realistic values. This is a hint to the reader not to expect as the eviden-ce of neither great nor glori cation expressed odium, as the United States space in which the health security of citizens crowning achievement. This aspect should not be ignored even though he critics have forgotten that opposing the relevant facts is the only undeveloped spirit, does not mean much. Many of these often present the information to the health care system in theUnited States realized lower results than others also developed health systems, but does not propose adequate solutions and existing simply considered catastrophic. However, lightly over the fact that though her health policy implemented awlessly, that the health service and excellent work that is involved in the American health care the most quali ed and most professional medical and other staff in the world.

Health programs and the nancing of health insurance or coverage of the po-pulation as one of its forms is a burning issue in the United States. That is why the federal government is taking serious steps towards the formulation and implementation of programs to increase the coverage of citizens with health insurance. According to of cial reports, uninsured residents, about 38% live in households where at the level of the realized revenue of 50, 75 or thousands of US $. Certainly the most challenging task is over Medicare, Medicall and Medicaid programs were organized for health


care consumers. Medicare the federal health insurance program designed in order to include persons 65 years of age and older and younger people with disabilities or who are the largest consumers of health $ US. Most people are Medicar-users at retirement because of rights to social security or the bene ciaries of some kind contributions related to the disability insurance. Those users additional income, for example, nancial support for refugees and help foster, automatically acquire the right to protection under the Medical program, except that it applies also to some users Medicare program (the elderly, the blind, the disabled, pregnant women, Parents under 21 years and residents of rest homes).

Aim

Objective is a discussion about the position of the insurer, the government of the United States in the public sector provides between 60 and 65% of funds for -nancing of health care spending. If the funds were directed to fund various programs predominantly Medicare, Medicall and Medicade programs, the health insurance program for children and Program Administration for health care of war veterans. Health policy is still the most developed economy in the world, based on relevant indicators that pressure on the government but also the private sector, to conceive and adopt concrete programs for health care, and therefore is considered to be the policy of the future. It is rmly resting on the achievements of modern medical science, the rigorous control of nancial ows and the proper application of pharmaceutical and techno-economic procedures.

Health policy and health care

Total health policy not only in the United States but also abroad, must be shav e-na as conscious and responsible activity aimed at achieving speci c goals of health care by applying adequate instruments and effective measures, the involvement of professional executors and rational use of available resources. Despite the wide range of opinions that is because word on the complicated politics, it should be noted the opposite, because things are quite different. Before we could talk about the speci c requirements for the implementation of precise decisions taken, plans and actions that of cials of the World Health Organization (WHO) to promote a vision of the future, but a complicated policy that creates an additional burden. Given that it is a vision, it should be noted that it highlights the priorities and expected participation of different groups, provides a consensus among a large number of questions and informs people about the possibilities for accessing all forms of health care. Therefore, health policy is not a world for themselves, regardless of what is one of the most vital components


of the global policy of the United States. It is in keeping with its nature and content, large palette structure a second, narrower policies and / or their speci c parts. Either way it is understood in theory or in practice, it can be anything other than enumerated list of desires, desires that often and not, with respect to their true meaning. If wishes were unattainable or hard to follow, and in many cases they are, then this approach is further eroding the concept of complete health care policy. It is therefore of great importance to health policy your bank assumes technology assignment and enjoyment of the right to health care, a large coverage of the population, the smooth process of nancing the healthcare industry and consumption, actively meeting the health needs and the correct pharmaceutical care.

Of health policy in such a developed country, the center of the group G 5 (known KVINTA) as United States of America are, with the right to expect that its active fun-ction is performed in order to preserve public health and promote programs that include methods and principles of management of quality of life of citizens. For example, let it be the implementation of activities in the ght against the consumption of tobacco, alcohol and opiates devastating, with equal treatment of different users of health care. Let it be with immunization procedures, the ght against modern diseases, proper breastfeeding, environmental conservation, and by creating the conditions necessary for the proper development and cultivation of biological and human capital. During the rst decade of the XXI century, health policy action on the soil of the United States was the subject of various debates, among which the most intense one that is at least necessary, political. Why? Because the results of health policy recently evaluated thro-ugh a political prism, regardless of how it is as a measuring instrument really precise. Political mark comes down to the edge of the convergence gap as a consequence of reduced scope of nancing and increased health spending, due to the expanded scope of rights to health care and the increasing demands of the insured.

In terms of the way they are, it is expected that all the problems solved health policy for which they receive new, according to most sources more dif cult tasks. Its fate is to ght nancial problems, painstaking initiative in nding ways to runaway health spending caused by the action of various factors undisturbed funded and when funds are insuf cient for that purpose. And to what extent such attempts are legitimate, and what results are expected since the Great Depression of the 2008 earthquake in the world and not only not subsiding, but threatens to signi cantly expand, we can conclude. During the last decades of the twentieth century, the growth of health care spending in the United States, as in most other industrialized nations of the world, has become a major problem of health policy. But it was not only the struggle with nancial problems (the list is much wider), it is about the other distinctive shortcomings whose presence devastates its value and makes it dif cult to realize the goals.

Health care is in large part because of that became a subject of lively, at times heated debates that often go beyond polite behavior. Many participants in the dis-


cussions on it have only one goal, to challenge the concepts and disavowal of the achieved results. Programs, measures and objectives of the health policy all are valued differently, but common practice is to be critical of the scope of rights to health care, access, equity, ef ciency, cost, choice of equivalent value, and in general to its overall quality. Critical analysts believe that in many ways it is inconsistent and because of its vagueness current US health care system, except that stumbles and falls signi cantly behind other developed systems in the world, especially in Canada. Therefore, they say, its concept is not hopeful that they can expect better conditions in which to fun-ction better health care. Are rmly convinced that many projections and intentions are not in line with the real needs and tasks. In their opinion thus conceived health policy lacks capacity which would constitute an adequate logistics to health care with the responsibility to be the equivalent of funds spent. Considering that the Congress of the United States of America a narrow majority (219: 212) passed a new law on compulsory health insurance which is the crown of healthcare reform President Barack Hossein Obama, many citizens of the United States health insurance has become more accessible and shall apply to low-income people condition.

To aim of health policies in the United States were set realistic and realized their protagonists as few in other countries should be aware that the necessary multidisci-plinary approach factors (contribution to medical, social, economic and institutional) operating within the national health system and that they have no alternative. With regard to the aforementioned factors for the implementation of effective health policy, it is important to establish which of them 4 more clearly than the other determines the scope of health care spending. Promoters health policy can sometimes ignore the premise, as far as their state should set aside for health care. Although it is not released from the obligation to approximate the operating funds of the nancial re-sources that are a precondition for the functioning of the health system and how to dispose of a range of emerging variables in uencing the aforementioned funds. Their commitments in the framework of health policy is determined by the knowledge of the structure of disease, the tendency to get sick, and then differentiating the impact of social, economic and geographical conditions as well as evaluating the expected lifespan of the population.

Health programs and funding

Health insurance or coverage of the population as one of its forms is a burning issue in the United States. That is why the federal government is taking serious steps towards the formulation and implementation of programs to increase the coverage of citizens with health insurance. According to of cial reports, uninsured residents, about 38% live in households where at the level of the realized revenue of 50, 75 or thousands of US $. Certainly the most challenging task is over Medicare, Medicall and


Medicaid programs were organized for health care consumers. Medicare the federal health insurance program designed in order to include persons 65 years of age and older and younger people with disabilities or who are the largest consumers of health $ US. Most people are Medicare-users at retirement because of rights to social security or the bene ciaries of some kind contributions related to the disability insurance. Those users additional income, for example, nancial support for refugees and help foster, automatically acquire the right to protection under the Medicall program, except that it applies also to some users Medicare program (the elderly, the blind, the disabled, pregnant women, parents under 21 years and residents of rest homes).

Practically, the citizens of the United States at the same time can be the bene -ciaries of both programs, because their providers have identical interests, cooperate closely and resulting health care costs are paid according to the established order. Medicare program due on the rst and second Medicall. When using health services must always show both legitimaceije insurance for identi cation and categorization of services and the order of payment. Medicare program covers four sections (or areas) of health insurance, so that gives users the opportunity to comply with the nancial capabilities of selected part:

1. A, which provides hospital services and hospital care under certain condi-tions;

2. B, which provides outpatient medical bene ts and laboratory fees;3. C, that provides the advantages of the various health plans that patients can

receive in hospitals and elsewhere in accordance with the selected program and

4. D, which provides coverage of costs zdravstne protection prescribed pharma-cological procedures and drugs on a prescription.

Parts A and B Medikar-progrm cover expenses for necessary medical services, including mental health care, but not the expenses for services in dentistry. Medicare program is in the competence of the Federal Government mandated that under the relevant postulates conceived and implemented health policy. Its users have broad rights to information and advice on how to ensure, 5 volume and quality of health care, advocacy and / or the provision of expert assistance in solving problems. In line with the users have the ability to appeal adverse decisions, for example, in relation to the payment or non-compliance with the provisions of the established health plans that are selected on the basis of proposed guidelines. In the event that some users Medicaid program for some reason use health insurance in Medikar-program in addition to the premium payments can not cover their health care costs, Medicaid program can stand behind them and pay the corresponding premium. Medicaid program includes people who are not able to afford the right to health care because they do not generate nan-


cial revenues or do not exercise enough. This program is usually characteristic that often makes concessions to certain categories of insured persons (pregnant women, children, the poor) and that enables them to use a certain volume of health care, but only in dedicated clinics and / or hospitals.

If the user under certain circumstances (loss of employment, reduced working engagement, extended leave, etc.) Lose the right to security Medicaid program does not end with the payment of bene ts and coverage of medical expenses in his favor. Medicaid program can pay to health services even if he can not do so because of age, poor nancial circumstances, unenviable family situation or changing the way life is organized. Across the Roof, where users are able to save Medicaid program offers them and that solution. They pay their premiums, and Medikar program pays the premiums and deductibles. Persons covered Medicaid program have an absolute right to his privacy, so that information about their health, private activities, marital and property status can be obtained and used only with their consent or, if absolutely necessary, for example, for legal disputes.

Financing health care of American citizens is extremely important question. The competence of theFederal Government to regulate the health care system whose main goal is the provision and distribution of funds to cover the cost of health care. Although not available with any form of health insurance that would absolutely co-ver all citizens of the United States, its government health policy focuses problem of nancing health services on the basis of economic risk that threatens to expand due to their low level of health. Given that 84.7% of the citizens of the United States have some form of health insurance (through an employer, spouse or parent) Federal government for their funding model used:

1. general taxation at the state, district or municipality; 2. of social health insurance; 3. voluntary / private health insurance; 4. direct payment or payment services from their own pockets and5. donations from various benefactors.

However, in many federal states in addition to the above models are applied a combination thereof, and the model mix- nancing. In such cases, the method of distributing funds to speci c cost centers varies from one federal state, and often the variations over time can meet and within each of them. The health policy of each federal state, but in accordance with its jurisdiction created the technique of nancing. Jurisdiction refers to the relevant regulations and their strict application and encoura-ges the government and the private sector to make decisions concerning health policy and adoption of speci c programs, measures, techniques and the level of funding. For example, the social health insurance implies a model in which the entire population is


entitled to health care coverage, with being the scope and manner of providing health services regulated by law. In such circumstances, the insured would be the best form of protection of their health experienced universal health care, which would free them to pay insurance premiums and / or personal participation in health care costs. This has highlighted the importance of commitment to preventive health care, which, in a long time, decrease various diseases, reduce health care costs and greatly restricts the expansion of health care spending.

The health care system of the United States in particular question the relation-ship jvnog and private (voluntary) health care nancing system. There are allegations that public funding of health care improves the quality and ef ciency of health care personal contact because public (government) expenditure is essential when it comes to affordability and sustainability of health services and programs. Publicly funded health care (state), which is free by the way, proverbially cause demanding medical procedures and services, which results in an increase in total health expenditure. Allo-cated public funds, whether limited or not, do not deprive citizens uninsured liabilities from their own pockets to pay the costs of health care services used. The objection is that public funds could be rationally used, for example, the provision of services within the scope of emergency where the status or nancial ability of the insured upon payment of such treatment would not be particularly signi cant. On the other hand private systems or insurance companies reduce waste and eliminating unnecessary bu-reaucracy perpetrators-provider business, reduced waiting times for specialist services and greater possibilities for the use of modern technology in medical procedures. In parallel reduces the voluminous documentation to professionals, contractors insurance process and thus increase the concentration on the needs of the insured. These are the arguments of those who believe that private funding has organized protection and thus increases the quality of health at a higher level and for those who have a dilemma, how privately funded health care achieves better results and higher ef ciency. In addition, private nancing of health care and effective management of resources (funding), prevents the federal government to increase tax rates and with increased taxes cover the costs of health care. It is also the best way to avoid con icts between government agencies and to prevent an increase in bureaucratic in uence.

Health care costs in the United States

Health care costs in the United States, compared to economic resources, econo-mic strength and gross domestic product (GDP), exceeding the same in all the other countries in the world. Total US health

spending has a tendency to grow in the coming years to an alarming height. Each US $ spent on health care in the United States, can be viewed individually and valorized. Thus, 31% goes to hospital care, 21% for physicians who provide clinical


services, 10% for drugs, 4% cover dental services, 6% of the accommodation and care homes, 3% goes for home care, 3% on retail products, 3% of the government’s public health activities, 7% settled administrative costs, 7% of their investment, and the remaining 6% covering other professional services. In 2009, United States (local governments, corporations and individuals) for the provision of health care spent 2.5 trillions US $ or US $ 8,047 per person or 17.3% of gross domestic product (GDP), and in 2010 . year, allocated je17,9% of gross domestic product (GDP), or US $ 8,362 per insured.

The conclusion is that health care costs are rising faster than wages and in ation, and that more than half of the growth in health care spending that marked the last decade of the twentieth and the rst decade of the twenty- rst century, a consequence of technological progress, changes in health insurance and the material and human resources. Health care spending grew in line with revenues that are certain categories of citizens to exercise the insurance terms dictated by the service providers in accor-dance with the salaries of health professionals. Besides an increase in consumption is a consequence of heavy use of pharmaceutical products which is typical for the sick and elderly. This is a serious signal for savings, however, its advocates argue that it is only possible in the implementation of measures and procedures in preventive health care and that in other respects can not expect signi cant results. Although the result of serious research, that the savings possible in preventive health care that does not mean that it reduces the level of healthcare spending, or at least generate signi cant savings in the long run.

When the preventive health care in question, must take into account that the pro-vision of health services for people in old age signi cantly contribute to rising costs. This will increase the cost of health care (particularly the prevention of) companies that pay their different types of its employees to bring in an untenable position, and the American health care system as an economic organism will eat a tapeworm. These conclusions are drawn after the expressed wishes of the United States to cover the health care spending of its gross domestic product (GDP) set aside more than 18%, and after a report that private health insurance the United States with a 35% share of total health expenditure has the greatest share among the countries of the Organization for Economic Cooperation and Development (Organization for Economic Cooperation and Development-OECD).

According to data from 2004, in which health spending had a moderate ow, private medical insurance personal funds nanced 36% of the insured, the Federal Government of the United States has funded 34% funding from their own pockets amounted to 15%, from the budgets of state and local government nanced 11%, while other private funds nanced the approximately 4% of health care spending. In spite of all the frequent complaints of users of health services and premium payer, that the health system in the United States on its way to literally mimic some European


or Latin American health systems that do not leave room for optimism. In recent years, there is a practice that appear in ated bills, sometimes ten times higher than the actual value provided / used health services which causes suspicion and matched by the rules. In addition ineffective and with it also incorrect and unfair health care system should not even an American citizen, regardless of whether or not the victim was paying arti cially increased medical expenses.

Despite the fact that the health system in the United States includes several thousand different health insurance carriers, their number can not be accurately de-termined. Even very hard and approximately

indicate how much insurance companies in them now exists. But it is absolutely certain that the healthcare system in the United States The American has signi cant administrative costs, much larger than Canada’s or any of the European health systems (UK, Germany, France). By far the sound data from the study Harvard Medical School and the Canadian Institute for Health Information System, that the administrative costs per year take about 31% of US healthcare $ US, or more than a thousand US $ per insured. This amount of health and administrative costs nearly twice as much as any that can be found in most developed health systems in the world. Because of this, and because of other circumstances, many complaints that the system 8 health care in the United States “dysfunctional” and that the patient, as the main participants unjustly removed from the events concerning the determination of funding policy. The following table presents data from several countries of the Organization for Economic Cooperation and Development (Organization for Economic Cooperation and Deve-lopment-OECD), the appropriations for health care per capita and their percentage share in the gross domestic product (GDP) for 2009 and for 2010. a year.

Table 1. Per capita consumption of the insured in some countries of the Organization for Economic Cooperation and Development (Organization for Economic Cooperation and Development-OECD) and allocations from the gross domestic product (GDP) for 2009 and for 2010.

Seriosnamber

Country OECD

2009* 2010**

Consumption per insured % of GDP Consumption per

insured% of GDP

1 United States 7.960 17,4 8.362 17,92 Norway 5.352 9,6 5.426 9,53 Swicerland 5.144 11,4 5.394 11,54 Netherlands 4.914 12,0 5.038 11,95 Luxembourg 4.808 7,8 6.743 7,86 Canada 4.363 11,4 4.404 11,3


7 Denmark 4.348 11,5 4.537 11,48 Germany 4.218 11,6 4.332 11,69 France 3.978 11,8 4.021 11,910 Australia 4.453 8,7 3.441 8,711 United Kingdom 3.487 9,8 3.480 9,612 Japan 2.878 8,5 3.209 9,513 New Zealand 2.983 10,3 3.022 10,114 South Korea 1.879 6,9 2.035 7,115 Mexico 918 6,4 916 6,2

* Source: Making the author according to the OECD Health Division (June 30, 2011).”The OECD Health Data 2011-Frequently Requested Data”. Paris: OECD.

** Source: Making the author according to the World Bank, World Development Indicators 2012th.

All who wish for it and have options can buy private health insurance at group level (for example, the company covers insurance of their workers) or as individual customers with speci c insurers-provider (company, agency, dealer, broker). Indivi-dually purchased health insurance according to the nomenclature of health services similar to insurance provided by the employer. They make a signi cant contributi-on to cover the cost of health care and pay an average of about 85% of insurance premiums for their employees, and about 75% of the premiums for those whose security depends on employees, while the remaining part of the premium paid by the employees. When health insurance that employers pay their workers have witnessed a decrease of coverage from 68% in 2000 to 61% in 2009. The economic crisis that struck in 2008 the United States and the domino effect of the rest of the world, has created a high degree of insecurity, poverty, rising prices of health services and the army of uninsured persons-workers who lost their jobs. Only in March 2009, about 270 thousand workers because of job loss, lost their right to health insurance and the year 2010, nearly 50 millions people, or over 16% of the total population, welcomed without health insurance.

The political dimension of health insurance-case Obamacare

“We do not want taxes to net earnings of US middle-class families are increased ... we all want to further economic development, we all want to return to their jobs and constantly insist on new employment,” the eternal leader of the attitude of the Republican Party. They are 40 times tried to prevent the adoption of the 2013 budget, due to disagreement with the policy of nancing of the compulsory health insurance,


known as “Obamacare”. This is the of cial start of the nancial blockade of the Fe-deral Government on October 1, 2013, because of the hours-long political drama in the Senate and in the House of Representatives of the Congress of the United States by members of the Democratic Party and the Republican Party have failed to reach an agreement or to nd common, appropriate solution for the nancing of state for the current nancial year. The resulting misunderstanding led to the interruption of a series of government and budget-funded activities which automatically block of functioning of the US Federal government. Research rm IHS argued that the nancial blockade of the government daily cost economy, and the United States at least $ 300 millions US. In the case of a week-long blockade of the government, the projected economic growth of 2.2% for the last quarter dropped to 0.2%, a three-week blockade of gover-nment would reduce the US gross domestic product (GDP) between 0.9% and 1.4%. In the said blockade represents a serious threat to the global economy and agreed to the director of the International Monetary Fund (IMF), Christine Lagarde, speaking to students of the University George Washington. The blockade is a serious and bad, and if you can not nd a solution for US sovereign debt, it could seriously jeopardize not only her, but the entire global economy which would make this problem had to be solved as soon as possible. Because of the blockade on forced leave should have gone more than 825,000 employees in the federal administration.

Sounds impossible but it is true that several dozen deputies has so much power that practically the entire system of holding hostage, just because they are on health reform seen as a painful and expensive move president Barack Hossein Obama, who wanted to include additional health system over 40 million new insured. Such coverage is required enormous expenditures and the Republicans wanted to save the money and to block the implementation of the necessary health care reform. However, the health reform law is constitutional and is recognized by the Supreme Court of the United States has become a key part of the policy of Barack Hossein Obama. Had he prevented by the Republicans, it would certainly cause a huge political uproar and health. In the end, when the reform is still carried out all efforts Republican makeup are the most ordinary fencing with the wind. A large number of representatives of the Republican Party requested the delay of “Obamacare”, then a reduction in the jurisdiction of the Agency for environmental protection as members of the Democratic Party, refused, arguing for a “clean” decision relating only to the threshold of borrowing.

The Republicans did not miss the opportunity to remind the policy of more than thirty years that relate to Ronald Reagan who was at his rst inauguration, said that the government is not the solution to our problem, government is the problem, “which they say practically began dismantling the concept of economic system that was created after the “Great Depression” of the thirties of the last century. She was supposed to replace the “invisible hand” of the free market, however, there was that productivity continued to grow, but the middle-class incomes stagnated or have even


decreased in real terms. Despite all the resistance to the US administration has conti-nued its work and began the implementation of a key element of health care reform. Now a citizen of the United States got the opportunity to special markets buys health insurance policy, and for people with lower incomes the law provides for certain types of subsidies

Conclusion

In the world there is a great respect for the current leading political, military and economic power, and through the lens of curiosity, it is a challenge to seeking even the slightest weakness in any sphere of its national activities. Possible weaknesses should be used as an argument, that the pillars of belief that in the United States really all works seamlessly pretty shaken up and strive collapse. Therefore surprising that in the United States until the end of 2009, almost 50 millions people (or 16.7% of the population) were out of all forms of health insurance, and that total public health expenditure took a very high third position in the world. This was disclosed to the United States for health care annually allocate more funds per insured ($ 8,362 US), than any other country in the world. In particular, the high cost of the provision of direct medical services, with the use of pharmaceutical products in bulky administra-tion. They are the cause of frequent bankruptcy of insurance companies and health insurance funds as well as increased number of uninsured citizens.

In the United States the situation is that some private companies on one side of any tax breaks for health insurance, or it can be purchased with additional tax relief and on the other, the majority of consumers in the individual market do not receives any bene ts because premiums vary considerably depending on the diagnosis, diseases or of age. Today, Blue Cross Association (Blue Cross) and Blue Shield (Blue Shield) in combination, directly or indirectly provide health insurance to more than 100 million citizens of the United States. In its operation, and the insurance companies have become similar to commercial companies for health insurance. It is considered normal because the health insurance market has become the eld of high concentrations of capital and competition, so that the leading insurers in 1990 and 2000, conducted over 400 fusion. On the eve of 2005, the company Wellpoint and United Health, had a membership whose insurance amount to approximately $ 67 millions and US together account for over 36% of the national market in the commercial health insurance.

Otherwise, in the United States the term health insurance is used to describe the program, which was enacted to help with the cost of health care. It is irrelevant whether it is a private or purchased insurance or social insurance or social program funded by the US federal government. In technical terms, this term is used to describe any form of health insurance that provides cover the costs of services / used health care


services. In addition, it explains the coverage of health care private health insurance and social insurance

programs, which provide coverage of medical expenses incurred due to dispo-sal of old and vulnerable populations and people with severe forms of the disease (Medicare). It includes social programs that provide for covering the costs incurred or to be incurred as a result of care of people with low material base and the people who are not able to themselves and their family members provide health insurance (Medicaid).

Analysts, critical and those that are not, do not answer the question, why in spite of their population with such allocation for the health care of the long life span of only 42 in the world. If in fact the United States compared with other industrialized countries (Japan, France, Germany, United Kingdom), then you are far behind them, even as far behind countries that are less developed, for example, Chile, which occupies 35 or 37 a place Cuba. Residents of the United States of America can not conceive that the longest in the world lives in a small Andorra or Macau and that in them the life expectancy of the population long ago exceeded 83.5 years.

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