(This article is about political movements affecting the delivery of health care and health care systems. For more information about movements to improve health, see Health reform.)

Health care reform is a general rubric used for discussing major policy creation or changes --for the most part, governmental policy --that affects healthcare delivery in a given place. Health care reform typically attempts to:

Broaden the population covered by private or public health insurance

Expand the array of health care providers consumers may choose among

Improve the access to health care specialists

Improve the quality of health care

Decrease the cost of health care

The Netherlands

The Netherlands has introduced a new system of health care insurance based on risk equalization through a risk equalization pool. In this way, a compulsory insurance package is available to all citizens at affordable cost without the need for the insured to be assessed for risk by the insurance company. Indeed health insurers are now willing to take on high risk individuals because they receive compensation for the higher risks.

A video which explains how the new Dutch health care system works is available at http://www.minvws.nl/en/themes/health-insurance-system/the-new-health-care-system-in-the-Netherlands-video/. (Warning: The video has a soundtrack in both English and Dutch. Be prepared to click the T symbol in the playback control to see substitles in English).

United Kingdom

Health care was reformed in 1948 with the creation of the National Health Service or NHS. It was originally established as part of a wider reform of social services and funded by a system of National Insurance, though receipt of health care was never contingent upon making contributions towards the National Insurance fund. Private health care was not abolished but had to compete with the NHS. About 15% of all spending on health in the UK is still privately funded but this includes the patient contributions towards NHS provided prescription drugs, so private sector health care in the UK is quite small. As part of a wider reform of social provision it was originally thought that the focus would be as much about the prevention of ill-health than it was about curing disease. The NHS for example would distribute baby formula milk fortified with vitamins and minerals in an effort to improve the health of children born in the post war years as well as other supplements such as cod liver oil and malt. Many of the common childhood diseases such as measels, mumps, chicken pox were mostly eradicated with a national program of vaccinations.

The NHS has been through several reforms since 1948 although it is probably fairer to say that the system has been through phases of evolutionary change. The conservative Thatcher administrations attempted to bring competition into the NHS by developing a supplier/buyer role between hospitals as suppliers and health authorities as buyers. This necessitated the detailed costing of activities, something which the NHS had never had to do in such detail, and some felt was unnecessary. The Labour Party typically opposed these reforms, although after the party became New Labour, the Blair government retained elements of competition and even extended it, allowing private health care providers to bid for NHS work. Some treatment and diagnostic centres are now run by private enterprise and funded under contract. However, the extent of this privatisation of NHS work is still very very small, though remains controversial. The adminsitration committed more money to the NHS raising it to almost the same level of funding as the European average and as a result, there has been a large expansion and mordernisation programme and waiting times are now much more acceptable than they once were.

The government of Gordon Brown has announced several new reforms for care in England. One is to take the NHS back more towards health prevention by tackling issues that are known to cause long term ill health. The biggest of these is obesity and related diseases such as diabetes and cardio-vascular disease. The second reform is to make the NHS a more personal service, and it is negotiating with doctors to give more services at times more convenient to the patient, such as in the evenings and at weekends. This personal service idea would introduce regular health check-ups so that the population is screened more regularly. Doctors will give more advice on ill-health prevention (for example encouraging and assisting patients to control their weight, diet, exercise more, cease smoking etc.) and so tackle problems before they become more serious. Waiting times, which have already fallen considerably under Blair (median wait time is about 6 weeks for elective non-urgent surgery) are also in focus. The NHS will from December 2008, ensure that no person waits longer than 18 weeks from the date that a patient is referred to the hospital to the time of the operation or treatment. This 18 week periodthereforeincludes the time to arrange a first appointment, the time for any investigations or tests to determine the cause of the problem and how it should be treated.

United States

The United States is the only wealthy, industrialized nation that does not provide universal health care. Health care reform was a major concern of the Bill Clinton administration headed up by First Lady Hillary Clinton; however, the Clinton health care plan was not enacted into law. More recently, President George W. Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act which included a prescription drug plan for elderly and disabled Americans. U.S. efforts to achieve universal coverage began with Theodore Roosevelt and continue to today.

In comparison with other developed nations, the United States spends significantly more on health care. When the health care expenditures per capita and GDP per capita for developed countries are graphed, a nearly linear relationship is revealed, with the United States the clear outlier.

Reforming or restructuring the private health insurance market is often suggested as a means for achieving health care reform in the U.S. Insurance market reform has the potential to increase the number of Americans with insurance, but is unlikely to significantly reduce the rate of growth in health care spending. If not implemented on a systematic basis with appropriate safeguards, market reform has the potential to cause more problems than it solves. Since most Americans with private coverage receive it through employer-sponsored plans, many have suggested employer "pay or play" requirements as a way to increase coverage levels. However, research suggests that current pay or play proposals are limited in their ability to increase coverage among the working poor. These proposals typically exclude small firms, do not distinguish between individuals who have access to other forms of coverage and those who do not, and increase the overall compensation costs to emplooyers.

Premium subsidies to help individuals purchase their own health insurance have also been suggested as a way to increase coverage rates. Research confirms that consumers in the individual health insurance market are sensitive to price. Estimates of the demand elasticity in this market vary, but typically fall in the range of -0.3 to -0.1. It appears that price sensitivity varies among population subgroups, and is typically higher for younger individuals and lower income individuals. However, research also suggests that subsidies alone are unlikely to solve the uninsured problem in the U.S.

A report published by the Commonwealth Fund in December of 2007 examined 15 federal policy options and concluded that, taken together, they had the potential to reduce future increases in health care spending by $1.5 trillion over the next 10 years. These options included increased use of health information technology, research and incentives to improve medical decision making, reduced tobacco use and obesity, reforming the payment of providers to encourage efficiency, limiting the tax federal exemption for health insurance premiums, and reforming several market changes such as resetting the benchmark rates for Medicare Advantage plans and allowing the Department of Health and Human Services to negotiate drug prices. The authors based their modeling on the effect of combining these changes with the implementation of universal coverage. The authors conclude that there are no magic bullets for controlling health care costs, and that a multifaceted approach will be needed to achieve meaningful progress.

A fundamental problem in evaluating reform proposals is the difficulting estimating their cost and potential impact. Because proposals often differ in many important details, it is difficult to give meaningful side-by-side cost comparisons. The empirical data and theory underlying cost estimates in this area are limited and subject to debate, increasing the variation between estimates and limiting their accuracy.

Elsewhere

As evidenced by the large variety of different health care systems seen across the world, there are several different pathways that a country could take when thinking about reform. Germany for instance, makes use of sickness funds, which citizens are obliged to join but are able to opt out if they have a very high income (Belien 87). The Netherlands uses a similar system but the financial threshold for opting out is lower (Belien 89). The Swiss, on the other hand use more of a privately based health insurance system where citizens are risk-rated by age and sex, among other factors (Belien 90). The United States government provides health care to just over 25% of its citizens through various agencies, but otherwise does not employ a system. The free market provides the balance of health care services, typically centered around modestly regulated private insurance methods.