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- 2. The overall situation of the health insurance system in the Republic of Kazakhstan
- 3. Health care insurance in the US
- 3.1 Public health programs in the US
жас ғалыМдаРдың зеРттеулеРі исследования Молодых уЧеных younG scientists’ reseArch s. yevdokimov The effectiveness of Public Sector in the USA at the Federal level
ÌÅÌËÅÊÅÒÒІÊ ãîñóäàðñòâåííîå óïðàâëåíèå è ãîñóäàðñòâåííàÿ ñëóæáà 120
121 In addition, in order to avoid duplication of government I think the authority of making a functional analysis of government agencies should also be transmitted to the Audit Committee. These actions will give the Audit Committee the ability to: - make effective and comprehensive evaluation of government agencies by analyzing their functions and authority, as well as the allocation of budgetary funds; - ensure sufficient independence of the evaluation; - ensure objectivity. 2. Reforming the Agency for Civil Service Affairs Because the system of public administration includes the system of public service as well as analyzing the specifics of the public sector in the US and Kazakhstan, I think it is could be possible to concentrate the functions of modernization and development of public services in one agency; both in Kazakhstan and the US. Because the function on the development of public administration and public service are interrelated, I think it is possible in Kazakhstan to combine them in one agency, the Agency for Civil Service Affairs. These actions will allow the Government to ensure comprehensiveness and consistency in implementing public policy for improving efficiency in the public sector. In the US, I suggest that instead of having several specialized agencies for civil service, the government create one agency for improving the management and development in public service. These actions should help the Government to avoid the possibility of duplication of functions and increase the efficiency of the public service system. 3. Improving strategic planning One of the measures to improve the efficiency of public administration is to improve strategic planning. In this regard, I consider it possible in a system of state planning and evaluation government agencies efficiency to implement the principle of building logical models. Doing so will help the Government with short-, intermediate- and long-term outcomes and to make better decisions about resources and activities. Many groups design logical models for a funding or program cycle, a fiscal year, or a timeframe in which they believe they can achieve some meaningful results. The logical model structure is intended for program planning so Government should define the parameters of programs clearly and every government agency can also use logical models for strategic planning. Government can use logic model in evaluation of government agencies. However, Government evaluation efforts will be more effective if it starts with a logical model. Going through the logic model process will help ensure that government evaluation will yield relevant, useful information» [11]. 4. Improving transparency of public sector and increasing citizens participation It should be noted that the US’s system of federalism and the election of several agency heads have some advantages in improving the efficiency and transparency of the public sector. In this connection, I believe that it is possible that some of the components of this system could be implemented in Kazakhstan, as follows: – ensuring transparency of government agencies; – increasing citizens participation in decision making. These recommendations will improve public confidence in the public sector and ensure the further development of democratic principles in Kazakhstan.
The above recommendations will go far to help Kazakhstan. In addition, to improving the efficiency of the public sector, the Government also needs to focus on main directions such as: a) Develop an effective Government and public agencies; b) Modernize and simplify of administrative procedures; c) Improve the quality and availability of public services; d) Improve the quality of public sector’ staff; e) Make policy based on final outcomes; f) Developing and implementing accurate and strait forward indicators for the state agencies; g) Develop an integrated system of monitoring and evaluation of the public sector in order to improve its effectiveness. Together, these changes can help Kazakhstan fulfill its responsibility as a democratic government to keep careful watch over its own exercise of power.
1 United Sates of America // https://www.cia.gov/library/publications/the-world-factbook/geos/us.html 2 Constitution of the USA // http://www.house.gov/house/Constitution/Constitution.html. 3 Session of congress pursuant to house concurrent resolution 10 to receive a message from the President of the USA // http://capitolwords.org/date/2011/01/25/H457-6_joint-session-of-congress-pursuant-to-house- concur/.
4 Address by the President of the Republic of Kazakhstan Nursultan Nazarbayev to the People of Kazakhstan 01/27/2012 // http://www.akorda.kz/ru/speeches/addresses_of_the_president_of_kazakhstan/ poslanie_prezidenta_respubliki_kazahstan_na_nazarbaev 5 Government Accountability Office (GAO) // http://en.wikipedia.org/wiki/Government_Accountability_ Office Government Accountability Office (GAO) // http://www.gao.gov/about/index.html 6 Provisions on the Accounts Committee for control over execution of the republican budget // http://www. esep.kz/first2.php?lang=eng&mid=91 7 Novikov A. V. The legal form of organization the public service in the USA. – М., 1979. 8 2012 Annual Report: Opportunities to Reduce Duplication, Overlap and Fragmentation, Achieve Savings, and Enhance Revenue. Report to Congressional Addressees. United States Government Accountability Office // http://www.gao.gov/assets/590/588818.pdf 9 The Public Service Production Process: A Framework for Analyzing Police Services Elinor Ostrom, Roger B. Parks, Indiana University Gordon P. Whitaker, University of North Carolina-Chapel Hill and Stephen L. Percy, Indiana University. 10 Logic Model Workbook. Transforming evaluation of social change. Innovationnetwork, inc. 1625 K Street, NW, 11th Floor / Washington, DC 20006 Telephone: 202-728-0727 • Facsimile: 202-728-0136 // http:// www.innonet.org/client_docs/File/logic_model_workbook.pdf.
In article the analysis of system of medical insurance in the USA is given, possibilities for inculcation of the American system in the Republic of Kazakhstan are considered. Keywords: system, medical insurance, organization, budget, hospital. аңдатпа Мақалада АҚШ-тағы медициналық сақтандыру жүйесіне талдау жасалды, Қазақстан Республикасына американдық жүйені енгізу мүмкіндігі қарастырылуда.
В статье дан анализ системы медицинского страхования в США, рассматриваются возможности для внедрения американской системы в Республике Казахстан.
In message to the people of Kazakhstan, the Head of the State noted that a healthy lifestyle and the principle of shared responsibility for their health should be the main focus of the public policy in the area of community health, and daily life of the population [1]. жас ғалыМдаРдың зеРттеулеРі исследования Молодых уЧеных younG scientists’ reseArch d. satenov The analysis of the health insurance system in the US, as an opportunity for implementing it in Kazakhstan
ÌÅÌËÅÊÅÒÒІÊ ãîñóäàðñòâåííîå óïðàâëåíèå è ãîñóäàðñòâåííàÿ ñëóæáà 122
123 Medical insurance, is a part of this policy area, It plays a role in improving the economic interest of many people by preserving their own health. Today, Kazakhstan`s policy in this area needs to be revised. The current structure, a state-based system, can no longer guarantee the level of service that Kazakhstan`s citizen deserve and require. Looking at the current system both in Kazakhstan and in the US reveals both principles and concrete examples of what needs to be done in Kazakhstan.
There are three basic organizational – economic options for basic structure of national health care systems: the state as the source of budget, private health care – system, (based on either voluntary medical insurance payments or direct payment for medical care), or a compulsory the health care system, based on mandated insurance coverage. Until now, Kazakhstan has had a state budget insurance system. However, in spite of annual growth in funding, funding for the full provision for the guaranteed volume of free medical assistance is not sufficient. Therefore, Kazakhstan must today consider – transition to a private insurance health care model. Medical insurance can afford to increase substantially the resource allocation for Public health.
Today the amount that voluntary medical insurance pays toward financing health services is very small, only two per cent. This is due to the fact that in Kazakhstan voluntary medical insurance has not yet gained popularity, as one would like to. If this type of insurance were more active it would be a substantial benefit not only for set hospitals but also in the social sphere, because the voluntary medical insurance means or implies cost sharing for their own health, a person pays and insures oneself, cares about one’s state and health. Therefore, the better voluntary insurance will be developed the more responsibility the person will take for their own health. Since Soviet times people have kept in mind the notion that medical care should be free [2]. In addition, health insurance is one of the levers to increase the economic interest and responsibility of the health and medical workers for the final outcome of their activities, as well as development of competition between health care organizations. 3. Health care insurance in the US One can say with confidence, that the private health insurance system is the most widely available source of funding in the US. Because I am recommending transition to a similar structure in Kazakhstan, this section will examine in detail the US system. Health care in the USA is one of the largest industries in the American economy, where the vast resources are concentrated. Medical industry comprises one-seventh of the entire national economy, where more than 10 million people are employed. The activity of the state in health care provides multilateral impact on American society. Policy in the sphere of Health care affects substantial interests practically all sectors, groups and classes of society, and is located in the center of political life in the country. The United States spends on health care (per capita) 2 – 3 times more compared to other industrialized countries of the West. And while millions of Americans do not have health insurance, it means, no guaranteed access to health care services. In the US the country with a well-established market relations, health care is, on the one hand, common industry in capitalist economy with all the features, characterized it, on the other hand, represents a particular socio-economic sphere-oriented modern economy. This special feature is that the market mechanisms are built into the strong elements of state regulation, enabling and guiding development of the social sectors of the economy. There is a tendency to expand and enhance the distributive functions of the state. Key feature of health care in the US is the legal immunity of patient. The legislative acts, providing mechanisms for protection of his rights, led to the establishment of such conditions in which arbitrariness in respect to human health, the part of both health services providers, and the state are almost excluded. This mechanism is organically integrated into the system paradigm of a democratic society [3]. However, in health, as it may, in any other socio-political sphere, there are enough problems, that lead to a certain fragility and relative instability in this area. One of the most important causes of social insufficiency of the American health care (the absence of universal access to the Health care services, and etc.) lies in that there are many sources of payment for medical care, that create chaos and duplicate each other. Of course, in the other western countries medical services are also paid by “third party” (mainly by the government) but these countries do not have a claim on the market nature of the sphere. Most civilized countries have universal (“the global”) budget in Health Care and well- coordinated system of health insurance funded by a single contributor. In the US there is no “global” budget, and there is no sufficient coordination among parts of the system. Instead, there is a chaotic system of contributors – insurers and Medical services providers, which operate independently from each other and usually seeking different purposes. In general this system contribute to increased cost of health care services and, as a consequence, their unavailability. In the US there are three hospitals: public, private-for-profit (commercial), private-non-for-profit. Private profitable, or commercial hospitals are conventional чprivate enterprises with their specific features. They form their capital in the individual, group and stock basis. Public hospitals are funded by the federal and state authorities i.e. completely from taxpayers’ money. They serve as a general rule, public servants, war veterans, persons with disabilities, persons, suffering from mental diseases, and tuberculosis. “Non-for-profit” private hospitals are created by local municipal bodies with public funds, private individuals, as well as various organizations and charities. These hospitals are private corporations, their initial capital is generated on a subscription basis of founders, and, as commercial organizations, they provide services for a fee. “Non-for-profit” status is widely used in the United States by various foundations, organizations, agencies and firms, since it gives them an opportunity to avoid paying taxes. The definition of “non- commercial”, “Non-for-profit” does not mean that these hospitals provide medical care for free. Medical institutions of that type in many ways are similar to commercial corporations of hospitals. They establish the organizations for health maintenance and organizations of preferred provider, rehabilitation centers for individuals suffering from alcoholism and drug addiction, manage other hospitals, invest capital in real estate, receive profit. Between commercial and “non-for-profit” hospitals there is a fundamental difference: instead of paying shareholders dividends “non-for-profit” system of hospitals invest their profits into new or upgraded facilities, in the establishment of reserves for investment and funds to provide assistance to the poor, that is promoted by the State through concessional taxation. In other respects the difference between the two types of hospitals is erased. As well as commercial, “non-for-profit” hospitals develop an intensive marketing to attract secured patients (almost everywhere, for example, in these medical institutions the post of commercial director is introduced). “Non-for-profit” hospitals, as well as commercial, don’t invest so much money in the provision of assistance for poor people, as public medical institutions. American hospitals are characterized by short terms of hospitalization, since they provide intensive treatment of acute diseases, their further treatment is provided by the «home nursing care». In terms of medical care assistance can be divided into three types: home nursing care – highly skilled assistance of paramedical personnel, residential homes for older persons and the elderly with medical grade, homes and shelters for the elderly and the poor. The main person in health care system of the USA is a private legal practitioner – doctor. According to research conducted by University of California in San Francisco, about 80 % of all expenditures on health in one form or another is controlled by them. Many doctors are shareholders of commercial hospitals, sanatoriums, diagnostic laboratories, own shares of medical corporations. The reason for Profit in health care is not different from the desire to make a profit in the other sectors of the economy. In the United States for the past three decades there has been a growing tendency towards the specialization and extra specialization in medical professions. Historically the largest distribution in the USA received private medical insurance. The private insurance, the leading health insurance in the USA – covers the majority of the population, and the most widespread form of its are “plans” of insurance on the place of work. The policies of the state in relation to the private health insurance, providing for incentive taxation for the entrepreneurs, to a large extent has identified the development of this system. Private health insurance provides access to health care workers and employees in the private sector of economy. Private insurance for stationary treatment provides more than insurance medical assistance services, dentists and buying drugs. A private insurance contributes to a sufficiently broad access to
The analysis of the health insurance system in the US, as an opportunity for implementing it in Kazakhstan
ÌÅÌËÅÊÅÒÒІÊ ãîñóäàðñòâåííîå óïðàâëåíèå è ãîñóäàðñòâåííàÿ ñëóæáà 124
125 health care services of workers and employees in the private sector. Service providers and insurance companies, with almost monopoly to dictate prices for medical services, tend to get the “more” with patients, bills for their treatment to a large extent are paid by employers. The last ones search for forms and methods of medical insurance, making medical care cheaper. In the market of health insurance there is a tendency toward the wider dissemination of the insurance “Plans” that involve the tightening financial control over the medical treatment, require prior coordination for necessary treatment. In general the current USA system of private insurance does not guarantee the patient full coverage of the cost of all received medical services. Group private medical insurance, is strictly related to the working place, carries a threat of negative consequences for workers in the circumstances of loss, or change of working places. In addition, “voluntary” nature of the provision of health care benefits with corporate workers leaves out millions of Workers and Employees from access to health insurance. Therefore, the private insurance system, in terms of social needs of the society, is not enough. In this lies the main reason for objective necessity for the emergence and development of the state programs Medicare (highways) and the “Medicaid costs” (Medicaid or Medicare patients). The US, starting with the era of F. Roosevelt and especially after the Second World War, are actively developing their public activities in the social sphere. In the mid 1960s the State assumed the care of the medical facility providing a large part of the population in the country. Two major public health programs – Medicare and “Medicaid” costs absorb 60 % of the total public expenditures on health objectives. Costs to the health care is one of the most rapidly growing components of the Federal budget: in the mid 1990s these two, Medicare and “the Medicaid costs”, accounted for over $270 billion (18 % federal budget) – an amount equal to the cost; by the end of the 1990s these costs exceeded for the $300 billion. More than 20 % state and local authorities (county, municipal, School districts) have also been involved in the provision of medical services. Health care accounted for over a quarter of the federal budget, assigned to social security. Medical public programs cover a significant portion of the population, and their influence is not limited to outside of these programs. 95 percent of the workers’ pay a tax on social insurance, inc. earning the right of the public health program in old age. The State takes the responsibility for those spheres of health care which are either unprofitable for private medicine nor objectively need nationwide support. In the activities of the State in this area is clearly expressed the tendency to the interests of society as a whole, in the time as the activities of the main components medical care is aimed at obtaining maximum profits. In this lies one of the major controversies of American health care, arising elements of crisis in medical system.
In the US there are also many public health programs. The primary ones are Medicare and Medicaid. Only one program, Medicare, pays 20 % of the value of the American medical industry. (For 5700 medical institutions Medicare and Medicaid are the only source of income.) An average of more than 20 % of all doctors and more than 30 per cent of all hospital services are paid from sources of public programs, primarily Medicare and Medicaid. It is obvious that no one consumer or the buyer has as much influence on the medical market services as these public programs. Medicare is the largest health insurance program, and was introduced with an amendment to the social security act, and entered into force on 30 July 1965. It originally covered Americans of 65 age and older, and in 1972 it was expanded to the sick and infirm citizens of certain categories. Medicare is part of the social insurance system, for the citizens of the country pay the corresponding tax, and receive the right for appropriate services. Social tax is made by equal shares employers and employees in the amount of $7.65 per cent of the wage bill, of which 1.45 % is withdrawn for the Medicare program. Those persons who are not employed, and also the representatives of the small business pay social tax of $15.3 % of their income, of which 2.9 % is for the program. The program consists of two parts: part of a health insurance hospital and part B – additional insurance. The program (part of A) automatically applies to every American citizen of 65 age and older, who have the right to the enjoyment of a general federal program (further – GFP) – the main program for social insurance. Medical benefits for Medicare are also for the sick persons, suffering from chronic renal diseases, and patients located in the nursing homes and short-term (6 months or less) boarding for the sick and the infirm. Through the program they pay for immunosuppressant after organ transplantation for 12 months (annual cost of antibiotic suppressing the reaction of rejection amounts to an average of more than 5 thousand dollars by daily intake). The right for additional insurance (the part (B) persons of 65age and older, living in the country, and who are nationals of either the US or allied states, with a legitimate right for permanent residence, as well as the persons residing permanently in the country for five years prior to the inception of treatment for insurance for part B. Persons included in the part A enjoy automatic right adherence to the part B regardless of other requirements. Americans, who do not have enough seniority for possession the right for social security according to GFP can be insured on part A on a voluntary basis with monthly payments (monthly the amount of the contribution is subject to change from 1 January of each new year). When this is compulsory insurance for part B. In the early twenty-first century system of social insurance and the program Medicare encountered serious difficulties associated with demographic changes – an aging population and an increase in the proportion of Americans 65 years. Social insurance and the program Medicare provide benefits, the size of which exceeds previously made an investments. If in 1950 one recipient’s social security benefits were provided by 16 working people, in 1996, – three working people, to the 2030 if the current tendencies preserve, each pensioner will account for only two workers. In the late 1990s costs of the Medicare were equal 2.6 % of GNP, in 2030, they were, to an estimated 7.5 % of GNP. On average, in the period from 1999 to 2004, costs for the program Medicare increased to 31 % – with 201 billion to $264 billion. In 1995, the Medicare covered 37.6 million. pers., in 2010, the number of users of the service program amounted to 46.9 million people. It is estimated that, by 2020, the program will cover 61.3 million Americans. Medicaid is the second largest state program in the area of health and serves as the main source of medical care for the poor and the poorest in the US, was created simultaneously with the Medicare program in 1965. Medicaid is different from the Medicare by the two main characteristics. In the first place, it is the state charitable nature, since its recipients did not earn the right for ownership, i.e. did not pay tax, as is the case with the Medicare. Secondly, it is located in the legal and administrative management of state authorities, although jointly funded by the federal government and the governments of the states. It is the legislative assembly and governorship of each state that defines the specific category of low-income and working conditions, which are provided with medical benefits in the framework of the general federal regulations. In the late 1990s, the total cost of the Medicaid program were $177 billion..: the percentage of the federal government was equal to 101 billion dollars (57 %), and governments of the state – 76 billion (43 %). Starting from the 1990s, Medicaid costs, as a share of the structure in their overall cost, has increased from 10 to 19, 4 %, and in the federal government from 2.7 up to 5.6 %. In 1998 Medicaid, served nearly 33 million poor Americans. It is estimated that, cost of the program will grow an average of 7 percent per year in the period from 2000 to 2004. The practical solution of the problems in medical care using the poor is effectively in the hands of powerful structures at the state level. The expansion of Medicaid spending is associated with the need for the protection of mothers and children in the US. Medicaid covers the cost of the medical services provided to 25 % of American children. In 1997, a five-year program of children’s health insurance was established, and 24 billion dollars were assigned. States have the right to use the funds for the program children’s health insurance from the low- income families, whose income does not exceed 200 % of poverty level (about 34 thousand dollars in the year for a family of four pers.). Experts estimate that from 3 to 5 million of the total number of 10 million uninsured children in the country could be covered by health insurance in conditions for the full realization of this program. Many low-income children previously had been excluded from the Medicaid program, since they have both working parents. By the rules of each state assistance in the form of a benefits of this
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