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Medical Care System in USA vs India.pptx
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- 2. Scheme • US HealthcareSystem Structure • What is Insurance? • Principles of Insurance • History of Health Insurance • Health Insurance Models • Medicare • Medicare vs Medicaid • Recent reforms in U.S Healthcare Policy • USA vs India
- 3. US Healthcare SystemStructure
- 5. Status of HealthcareSystem of USA
- 6. Insurance •A mechanism ofrisk transfer and sharing by pooling of risks and funds among a group of individuals who are exposed to similar kinds of risks for the benefit of those who suffer loss on account of the risk.
- 8. Ancient Indian Insurance Practices Insurancein India has a rich and ancient history, deeply rooted in the principles of resource pooling and redistribution during times of calamity. The concept finds mention in the writings of Manu (Manusmrithi), Yagnavalkya (Dharmasastra), and Kautilya (Arthasastra), which laid the foundation for practices resembling modern-day insurance. Manusmrithi • Manusmrithi, one of the earliest texts on law and ethics, discusses the idea of collective responsibility and resource pooling. • It emphasizes the importance of community support during disasters such as fires, floods, epidemics, and famines. • These practices were likely precursors to modern insurance, where risks are shared among a group.
- 9. Ancient Indian Insurance Practices Dharmasastra •Yagnavalkya's Dharmasastra expands on the principles of social welfare and mutual aid. • It highlights the need for financial security and protection against unforeseen events, advocating for systems that ensure stability for individuals and families. Arthasastra • Kautilya's Arthasastra, a treatise on economics and governance, provides insights into risk management in trade and commerce. • It mentions marine trade loans and carriers' contracts, which are early forms of insurance for merchants and traders. • These contracts ensured compensation for losses incurred during transportation, laying the groundwork for commercial insurance.
- 10. 1.Pooling of Resources:Communities would pool resources to support members in times of need. 2.Redistribution: Funds were redistributed to those affected by calamities, ensuring social and economic stability. 3.Trade Protection: Merchants and traders used agreements to safeguard against losses during transportation. These ancient practices reflect the philosophy of mutual aid and social responsibility, which continues to influence modern insurance systems. Key Features of Ancient Indian Insurance Practices
- 11. History of HealthInsurance • The concept of health insurance was first proposed in 1694 by Hugh the Elder Chamberlen, a member of the Peter Chamberlen family. This idea laid the groundwork for modern health insurance systems, although it was not implemented in its entirety at the time. • The first formal health insurance system was introduced in Germany under Chancellor Otto von Bismarck in the 1880s. This system was part of Bismarck's broader social insurance program, which included health, accident, and disability insurance. It marked the beginning of organized health insurance globally and served as a model for many other countries.
- 12. Health Insurance Models Health insurance systems aroundthe world are generally categorized into four major models, each with unique funding mechanisms and delivery structures. 1. Beveridge Model 2. Bismarck Model 3. National Health Insurance Model 4. Out-of-Pocket Model
- 13. Beveridge Model Healthcareis provided and financed by the government through tax payments, similar to public services like the police or libraries. • Key Features: • No direct medical bills for patients. • Government owns most hospitals and employs healthcare providers. • Focuses on universal access and cost control. • Examples: United Kingdom (NHS), Spain, New Zealand, Cuba.
- 14. Bismarck Model Adecentralized system where healthcare is funded through insurance systems, often called "sickness funds," jointly financed by employers and employees. • Key Features: • Insurance is mandatory and non-profit. • Providers are private, but the system is tightly regulated. • Examples: Germany, France, Japan, Switzerland.
- 15. National Health InsuranceModel Combines elements of the Beveridge and Bismarck models. Healthcare is funded by the government through taxes, but services are delivered by private providers. • Key Features: • Single-payer system reduces administrative costs. • Universal coverage for all citizens. • Examples: Canada, South Korea, Taiwan
- 16. Out-of-Pocket Model Individualspay directly for healthcare services without insurance or government assistance. • Key Features: • Common in countries without a structured healthcare system. • Access to care depends on personal financial resources. • Examples: Many developing countries.
- 17. Health Insurance Modelin USA The U.S. uses a mix of these models: •Beveridge Model: Veterans Health Administration. •Bismarck Model: Employer-sponsored insurance. •National Health Insurance Model: Medicare.
- 18. Medicare Medicare is afederal health insurance program primarily for: • People aged 65 and older • Certain younger people with disabilities • Individuals with End-Stage Renal Disease (ESRD) or ALS • It is administered by the Centers for Medicare & Medicaid Services (CMS). • Medicare has set standards for costs and coverage. This means a person’s Medicare coverage will be the same no matter what state they live in.
- 19. Year Event 1965 Medicare wasestablished under Title XVIII of the Social Security Act during President Lyndon B. Johnson’s administration. 1972 Expanded to cover people under 65 with long-term disabilities or ESRD. 1997 Creation of Medicare+Choice (later Medicare Advantage) under the Balanced Budget Act. 2003 Medicare Part D (prescription drug coverage) added by the Medicare Modernization Act. 2010 Affordable Care Act (ACA) introduced cost-saving and quality improvement reforms in Medicare.
- 20. Part Coverage Part A Inpatienthospital stays, skilled nursing facility, hospice, and home health care. Part B Outpatient care, doctor services, preventive services, and some home health care. Part C (Medicare Advantage) Private insurance alternatives covering Parts A & B and often Part D, with additional benefits. Part D Prescription drug coverage through private plans. Medicare
- 21. • Medicare-related billsare paid from two trust funds held by the U.S. Treasury. • Different sources (including payroll taxes and funds that Congress authorizes) fund the trust funds. • People with Medicare pay part of the costs through things like monthly premiums for medical and drug coverage, deductibles and coinsurance. Medicare
- 22. Key Policies andFeatures • Fee-for-service (FFS) model for traditional Medicare (Parts A & B). • Diagnosis-Related Groups (DRGs) for hospital payments. • Value-Based Purchasing (VBP) programs incentivize quality care. • Accountable Care Organizations (ACOs) aim to improve care coordination and reduce costs. • MACRA (2015) replaced the Sustainable Growth Rate with a merit-based payment system for providers. Medicare
- 23. • Covers over65 million beneficiaries (as of 2024). • Budget: ~$900 billion/year. • Major challenges: • Rising costs due to aging population. • Fraud and abuse in billing. • Variation in access and outcomes. • Trends: • Growing shift from FFS to Medicare Advantage (now covering ~50% of beneficiaries). • Focus on preventive care, digital health, and interoperability. Present Status of Medicare
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- 25. Medicaid • Medicaid isa joint federal and state program that helps cover medical costs for some people with limited income and resources. • Each state runs its own program. This means eligibility requirements and benefits can vary from state to state. • Medicaid offers benefits that Medicare doesn’t normally cover, like nursing home care and personal care services. • People with Medicaid usually don’t pay anything for covered medical expenses but may owe a small co- payment for some items or services.
- 26. Feature Medicare Medicaid TypeInsurance program Assistance program Eligibility Primarily for people 65+ and some younger individuals with disabilities Covers low-income individuals of all ages Administrat ion Federal program State-run program following federal guidelines Coverage Hospital stays, outpatient services, preventive care, and optional prescription drug coverage Hospital stays, doctor visits, nursing home care, and additional benefits like dental and vision (varies by state)
- 27. Feature Medicare Medicaid Enrollment Mustenroll via Social Security Must enroll via state agency Cost Includes premiums, deductibles, and copays Generally low or no cost, with minimal copays for some services Dual Eligibility Some individuals qualify for both programs Medicaid may help cover Medicare premiums and out-of-pocket costs
- 28. 1. Financial Sustainability •Fundedby payroll taxes, premiums, and federal revenues. •Medicare Trust Fund for Part A is projected to be depleted by 2031. 2. Coverage Gaps •Does not cover long-term care, dental, vision, or hearing (except in Advantage plans). •High out-of-pocket costs despite being insurance Failures and Drawbacks of Medicare
- 29. 3. Complexity andFragmentation •Multiple parts and private plans cause confusion among beneficiaries. •Difficulties in navigating prior authorizations, coverage rules, etc. 4. Inefficiencies and Fraud •Billing fraud, unnecessary services, and defensive medicine increase costs. •Administrative burden for providers. Failures and Drawbacks of Medicare
- 30. The U.S.healthcare system has undergone several policy changes and reforms in 2025, focusing on • Cost reduction • Accessibility • Transparency Efforts to balance affordability, accessibility, and efficiency in the U.S. Recent Reforms in U.S. Healthcare Policy
- 31. Recent Reforms inU.S. Healthcare Policy
- 32. Recent Reforms inU.S. Healthcare Policy
- 33. Recent Reforms inU.S. Healthcare Policy
- 34. Recent Reforms inU.S. Healthcare Policy
- 35. Recent Reforms inU.S. Healthcare Policy
- 36. Recent Reforms inU.S. Healthcare Policy
- 37. Critical Review ofMedicare System (USA)
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- 39. Feature USA (Medicare & Medicaid) India Type Insurance(Medicare) & Assistance (Medicaid) Mixed system (public & private) Eligibility Medicare: 65+ & disabled; Medicaid: low-income individuals Universal healthcare initiatives, but mostly out-of-pocket expenses Administratio n Medicare: Federal; Medicaid: State-run Public healthcare funded by government; private sector dominates Coverage Comprehensive (hospital, outpatient, drugs, Public hospitals provide basic care, private
- 40. Feature USA (Medicare & Medicaid) India Cost Medicare:Premiums & copays; Medicaid: Free or low-cost Public healthcare is low- cost, private healthcare is expensive Insurance System Government-backed programs Limited insurance penetration, mostly out- of-pocket payments, PMJAY (Ayushman Bharat) for poor + private insurance Challenges High costs, insurance gaps, administrative Unequal access, rural healthcare shortages,
- 43. Key Indicators Indicator India(2022) USA (2022) Explanation GGHE % GGE 4.5% 24.7% General Government Health Expenditure as % of General Government Expenditure – the share of the national budget spent on health. Indicates government priority. GGHE % GDP 1.3% 9.1% General Government Health Expenditure as % of GDP – how much of the country's economy is used for public health. Reflects economic commitment. OOPS % CHE 46% 11.1% Out-of-Pocket Spending as % of Current Health Expenditure – direct payments by individuals. High values suggest a financial burden on patients. Primary Health Care as % of Current Health Expenditure – the proportion of spending on
- 44. Health Expenditure Indicator IndiaUSA Explanation Budget Priority (GGHE- D%GGE) 4.5% 24.7% Health’s share of total government budget. Public Spending as % GDP (GGHE-D%GDP) 1.3% 9.1% Economic weight of public health spending. Total Health Spending (CHE per capita USD) $79.5 $12,434.4 How much is spent per person per year on health. Huge gap shows disparities in capacity and access.
- 45. Revenue Sources Source TypeIndia USA Description Domestic public % of CHE 39.1% 55.2% Share of health funding from internal public resources like taxes. External % of CHE 1.2% - Foreign aid or donor funding (only significant for lower-income countries). Comes from household spending, private
- 46. Revenue Sources India: •Public funding:Mostly from the General Budget. •Private sector: Large chunk is Out-of-Pocket Spending (OOPS) – a financial risk for individuals. •Very minimal external donor funding (1.2%). USA: •Public sector includes both General Budget and Mandatory Social Insurance (like Medicare/Medicaid). •Private sector: Includes insurance and some OOPS (much lower % than India). •Heavy reliance on insurance-
- 47. References • Evolution ofInsurance - IRDAI. (n.d.). IRDAI. https://irdai.gov.in/evolution-of-insurance • https://aspe.hhs.gov/ Office of Assistant Secretary for Planning and Evaluation • Health Policy Challenges for 2025 and Beyond Lanhee J. Chen, JD, PhD1 JAMA Health Forum. 2025;6(1):e250184. doi:10.1001/jamahealthforum.2025.0184 • Health Financing and Economics https://www.who.int/teams/health-financing-and-economics/he alth-financing/hfpm-background-indicators
Editor's Notes
- #4 CHIP – children health Insurance Program
- #5 Deposit Insurance. CBO increased its projections of outlays for deposit insurance by $33 billion for 2023 and lowered such projections by $28 billion over the following decade. The increase for 2023 stems from two sources: payments made by the Federal Deposit Insurance Corporation when it invoked a systemic risk exception in March of this year in response to two bank failures; and an increased likelihood of losses from additional bank failures.19 The decrease in outlays for the 2024–2033 period stems from CBO’s expectation that over the next decade, the FDIC will recover much of the amounts it spent to resolve bank failures in 2023 by liquidating the banks’ assets and collecting higher premi ums over the next several years.
- #11 1818 – Advent of life insurance business in India. Oriental Insurance Company set up in Calcutta. It failed in 1834.
- #16 The U.S. uses a mix of these models: Beveridge Model: Veterans Health Administration. Bismarck Model: Employer-sponsored insurance. National Health Insurance Model: Medicare. Out-of-Pocket Model: Uninsured individuals.
- #17 The U.S. uses a mix of these models: Beveridge Model: Veterans Health Administration. Bismarck Model: Employer-sponsored insurance. National Health Insurance Model: Medicare. Out-of-Pocket Model: Uninsured individuals.
- #23 FFS (Free for Service)
- #31 1. Price Transparency Executive Order President Donald Trump signed an executive order aimed at improving price transparency in healthcare. The order requires hospitals and insurers to disclose real-time pricing for services, helping patients make informed decisions.
- #32 2. Medicare & Medicaid Payment Model Changes The Center for Medicare & Medicaid Innovation (CMMI) is streamlining alternative payment models, shifting towards value-based care rather than fee-for-service. This aims to improve efficiency and reduce costs for Medicare and Medicaid beneficiaries.
- #33 3. Affordable Care Act (ACA) Adjustments A proposed rule for ACA health insurance marketplaces suggests changes to enrollment and subsidy structures, potentially reducing the number of enrollees. The administration has also cut funding for the ACA Navigator program, which helps individuals find coverage.
- #34 4. Inflation Reduction Act (IRA) Impact The IRA introduced a $2,000 out-of-pocket cap for Medicare Part D enrollees with high prescription drug spending. This reform aims to reduce financial burdens for seniors and individuals with chronic conditions.
- #35 5. Medicaid Flexibility & Rural Healthcare Support The administration is exploring greater flexibility in Medicaid policies, allowing states to customize coverage based on local needs. There is also a push to increase funding for rural healthcare providers to improve access in underserved areas.
- #36 6. Tax Policy & Healthcare Costs The expiration of tax provisions in the Tax Cuts and Jobs Act (TCJA) is expected to increase health-related tax expenditures by over $51 billion. Lawmakers are considering expanding deductions for out-of-pocket healthcare expenses and enhancing health savings accounts (HSAs). These reforms reflect ongoing efforts to balance affordability, accessibility, and efficiency in the U.S. healthcare system.
- #37 Strengths Provides universal coverage to a vulnerable population. Promotes evidence-based medicine, preventive services. Innovates with value-based purchasing and Accountable Care Orgs. Weaknesses Complexity in administration; high overhead costs. Coverage limitations: No dental/vision, long-term care. High costs and unsustainability without structural reform. Unequal access to care among ethnic and socio-economic groups. Opportunities Expand telehealth and home care services. Improve integration with social services and Medicaid. Reform drug pricing and provider payments. Threats Political gridlock could prevent reforms. Demographic pressures and rising chronic disease burden. Continued shift toward privatization via Medicare Advantage could erode the original single-payer intent.
- #43 General Government Health Expenditure as % of General Government Expenditure – the share of the national budget spent on health. Indicates government priority. General Government Health Expenditure as % of GDP – how much of the country's economy is used for public health. Reflects economic commitment.