A1. Country to Compare
For citizens to enjoy optimal health, the delivery of quality healthcare is essential. Considering the role of nursing within the healthcare industry, it is essential for nurses to understand issues related to the delivery of quality healthcare such as financing, healthcare policies, and initiatives. With this knowledge, nurses are able to collaborate with patients and families to deliver healthcare that meets the patients’ needs. Consistently, this paper compares the U.S. healthcare system with Great Britain in areas of healthcare access, medication coverage, referral to a specialist, coverage for preexisting conditions, and financial implications for healthcare delivery.
In the United States, Medicaid and Children’s Health Insurance Program provides health coverage to millions of American children from low-income families below the age of 18. In particular, CHIP provides health care coverage to children from families that earn too much money and do not qualify for Medicaid (Healthcare.gov. n.d.a). Consistently, for parents who have health insurance plans that cover dependents, children can be added to this plan until they turn 26 years (Healthcare.gov. n.d.b). Medicare covers for retired people who do not have employer retiree insurance cover or private plan (Medicare.gov, n.d.). For the employed people in the United States, they may get affordable private health insurance or qualify for free low-cost Medicaid coverage. For one to qualify for Medicaid coverage, the household income and income determine the eligibility (Healthcare.gov, n.d. c). As compared to the United States health care coverage, in the United Kingdom, the government provides universal health coverage to everyone. According to the NHS Constitution for England, health coverage is available to everyone regardless of race, disability, age, sexual orientation, gender, and religious affiliation among others as outlined (Department of Health & Social Care, 2015). The UK health care system is committed to promoting equality in healthcare through universal health care coverage.
A2a. Coverage of Medications
In the United States, health insurance plans pay for certain prescription drugs. However, according to Healthcare.gov (n.d.d), some medications are not covered by insurance plans. Private insurer’s websites provide lists of prescription drugs that the plan cover. Some insurance companies often provide clients with a one-time refill for prescribed medicine after the first enroll although there are some exceptions. Medicare pays for prescription drugs and provides protection for people who pay high drug costs or experience unexpected prescription drugs. Medicare does not cover all costs and patients are required to pay part of the prescription drug cost (MedlinePlus, n.d.). On the other hand, the National Health Service in the United Kingdom pays for both inpatient and outpatient drugs. According to the Commonwealth Fund (n.d.), the NHS constitution asserts that patients have a right to drugs approved in technology appraisals by the National Institute of Health and Clinical Excellence. Additionally, it is important to note that outpatient prescription medicines are subject to copayment and only drugs prescribed in National Health Service hospitals are given free. Children below 15 years or aged between 16 and 18 years and are in school full-time, as well as older people aged 60 years and above, low-income people, and pregnant women among others as outlined by the NHS constitution, are exempt from copayments of prescription drugs.
A2b. Referral to See a Specialist
In the United States, some insurance coverage plans require patients to have a referral from a primary care doctor. According to the Commonwealth Fund (n.d.), this insurance plan also limits patients to the choice of specialists. Other plans allow broad and direct access to specialists. For patients under Medicaid coverage plans, access to specialists is a bit difficult for the beneficiaries and the uninsured. This is because some specialists refuse to accept Medicaid due to low reimbursement and limited safety-net programs. On the other hand, patients in the United Kingdom under NHS are entitled to specialist treatment (NHS, 2019). However, a GP recommendation is necessary because all medical records are held by the registered GP and he/she understands your medical history better than anyone else. Patients under NHS cannot self-refer to a specialist except for sexual health treatment or A&E treatment.
A2c. Coverage for Preexisting Conditions
In healthcare, preexisting conditions involve a health problem that has been in existence before the date of the new health coverage. Some of the preexisting conditions include diseases such as cancer, asthma, and diabetes among others. In the United States, marketplace insurance plans are expected to cover treatment for preexisting medical conditions without discrimination (Healthcare.gov, n.d.e). Insurance companies should not reject patents, charge more, or refuse to pay essential health benefits. Once a patient is enrolled, the insurance company cannot deny a patient coverage or increase the insurance rates due to the medical condition. For pregnant women, insurance companies should not reject a patient because she is pregnant. Childbirth is also covered under the insurance plan. Notable exceptions include grandfathered plans that do not cover pre-existing conditions. Instead, they are offered two options – purchase a marketplace plan outside the grandfathered plan or switch to a marketplace plan to cover them for the preexisting condition. On the other hand, in the United Kingdom, the NHS does not cover for a preexisting condition. According to Foubister, Thomson, Mossialos, and McGuire (2006), private insurers often underwrite their plans on a moratorium basis, which means that preexisting conditions are not covered until a specific time has elapsed. By doing this, providers keep their premiums low; the application process is easier, and faster. There is no permanent exclusion of preexisting conditions. Additionally, at this time the provider evaluates the amount of risk they are willing to undertake.
A3. Finance Implications for Healthcare Delivery
Within the healthcare systems, financing is one of the critical components. Most health care measures are an attempt to address health care financing through allocation and utilization of services, provider pay incentives, and distribution of financial risks among others. In the United Kingdom, the National Health System has evolved to become one of the largest systems in the globe. The NHS is committed to creating a more responsive and patient-centered health care system. In particular, the health care delivery model in the United Kingdom is primarily a disease detection and treatment system. however, it is important to note that this particular health care delivery model has various financial implications for patients. Drawing upon an article by Montgomery et al. (2017), one of the financial implications is a disproportionate and sometimes inappropriate expenditure in end-stage illness in hospital settings. Ideally, the current UK health care model focuses on acute care and often neglects end-of-life disease management. The result is that patients do not get universal access to the end of life care, which would probably lead to better outcomes. Another financial implication is the denial of certain treatments. Currently, the UK health care system is in crisis and central funding is unable to match the current demand. Additionally, the current health care needs demand to balance healthcare interventions with treatment options to achieve cost-effectiveness. On the other hand, in the United States, affordable health care has become a national concern. In particular, Emanuel, Glickman, and Johnson (2017) note that with the rising health care costs the cost of prescription drugs is likely to increase. In addition, with the rising costs of health care, insurance premiums are likely to increase. As a result, patients are likely to be unable to afford the insurance premiums and in return affect their access to health care.
Drawing upon the above discussion, the health care system in the United States and the United Kingdom represent two sides of the extreme. On one side, while the U.S. healthcare system has the largest private sector, the United Kingdom has the largest public sector. In essence, private healthcare providers mainly deliver health care in the U.S. individuals often purchase marketplace health insurance, while others, especially the aged and unemployed/ low-income families get their health care coverage from Medicare and Medicaid. On the other hand, the United Kingdom is more government based on the largest health care insurance provider being the National Health Service. The NHS provides health care coverage for the significant majority in the United Kingdom and has fewer exceptions in coverage as compared to the U.S. system. The United Kingdom health care system is also low cost as compared to the U.S. healthcare system that is high cost.
Department of Health & Social Care. (2015). The NHS Constitution for England. Retrieved from https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england
Emanuel, E. J., Glickman, A., & Johnson, D. (2017). Measuring the Burden of Health Care Costs on US Families. Jama, 318(19), 1863-1864.
Foubister, T., Thomson, S., Mossialos, E., & McGuire, A. (2006). Private medical insurance in the United Kingdom. European Observatory on Health System and Policies. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0007/98422/Private_Medical_Insurance_UK.pdf
Healthcare.gov. (n.d. c). Health coverage options if you’re unemployed. Retrieved from https://www.healthcare.gov/unemployed/coverage/
Healthcare.gov. (n.d.a) “The children’s health insurance program (CHIP.” Healthcare.gov. Retrieved from https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/
Healthcare.gov. (n.d.a). How to get or stay on a parent’s plan. Retrieved from https://www.healthcare.gov/young-adults/children-under-26/
Healthcare.gov. (n.d.d). Getting prescription medications. Retrieved from https://www.healthcare.gov/using-marketplace-coverage/prescription-medications/
Healthcare.gov. (n.d.e). Coverage for pre-existing conditions. Retrieved from https://www.healthcare.gov/coverage/pre-existing-conditions/
Medicare.gov. (n.d.). Retiree insurance. Retrieved from https://www.medicare.gov/supplements-other-insurance/retiree-insurance
MedlinePlus. (n.d.). Medicare prescription drug coverage. Retrieved from https://medlineplus.gov/medicareprescriptiondrugcoverage.html
Montgomery, H. E., Haines, A., Marlow, N., Pearson, G., Mythen, M. G., Grocott, M. P. W., & Swanton, C. (2017). The future of UK healthcare: problems and potential solutions to a system in crisis. Annals of Oncology: Official Journal of the European Society for Medical Oncology, 28(8), 1751-1755.
NHS. (2019). Referrals for specialist care. Retrieved from https://www.nhs.uk/using-the-nhs/nhs-services/gps/referrals-for-specialist-care/
The Commonwealth Fund. (n.d.). International health care system profiles: what is covered? Retrieved from https://international.commonwealthfund.org/features/what_covered/
The Commonwealth Fund. (n.d.). The U.S. health care system. Retrieved from https://international.commonwealthfund.org/countries/united_states/
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