In the remaining part of this lecture, we'll review all the building blocks that make up the US health care system and the way in which those building blocks interact to produce outcomes particularly population health outcomes. There are six World Health Organization building blocks. These are leadership and governance, finance, service delivery, pharmaceuticals and medical products, information and workforce. In this segment of the lecture, we will review the leadership and governance building block. The World Health Organization defines leadership and governance building block in the following terms. The leadership and governance of Health Systems also called stewardship is arguably the most complex but most critical building block of any health system. It's about the role of government in health and its relationship to other activities that impact on health. This involves overseeing and guiding the whole health care system, private as well as public in order to protect the public interest. In this definition, the most significant part is the reference to the government guiding the whole system, private as well as public. And it is in this respect that will notice that the US health care system is somewhat different. The primary way in which the US government, state, federal, state and federal influence the health care system is through the establishment of arrangement to support system of insurance to provide access to health care for various sub-populations in the United States. There is Medicare for the aged, Medicaid covering the poor and disadvantaged. There is a system of direct private insurance for those who do not have the benefit of employer provided health insurance and there is employer provided health insurance. In addition, the federal government maintains particular health care systems for sub-populations particularly for veterans and for Native Americans. This slide shows a reflection of the piecemeal nature of health insurance in the United States and reflects the makeup of the system insurance as a whole. At the top is Medicare for the aged which covers around 42 million people. At the bottom of the graphic is Medicaid, which is for the poor and disadvantaged and that covers around 65 million people. The largest provider of health insurance is employer provided health insurance, which covers around 156 million people or some 49% of the population. Not shown in this graph are 27 million people, who are uninsured. The role of the US government in guiding the US health system and the complexity of understanding that role is dependent upon the relationship between the system of insurance and the system for providing health care in the United States. Doctors have a central role in providing access to healthcare. This is not just in access to primary care but it is doctors who provide access to hospitals and outpatient care. There is a very large system of hospitals in the United States. Predominantly, not for profit but including some for profit and some public hospitals. And there is a very large outpatient system of providers. Doctors, hospitals, and other health care providers form complex sets of relationships with various systems of insurance to provide health care for patients. And it is the interaction between the systems of insurance and the providers of health care which generate complexity within the health care system. Within this, government has two predominant roles. Firstly, it uses a system of finance insurance to regulate the provision of health care to improve both the quality of health care and quality outcomes for some sub-populations. Secondly and perhaps most importantly though, the government uses regulation to ensure that health care providers, payers, and patients interact in a framework of competitive markets. And it is this characteristic of the US health care system, which is most important. This relies on competition in order to regulate interactions between insurers, providers and patients. The loosely connected polycentric nature of the US health care system is partnered by similar characteristic in the US legal system. Professor Robert Kagan in the book of this name describe the US style of law is that of adversarial legalism. And I want focus on two aspects of adversarial legalism, which are covered in this slide. The first is that the US legal system includes more adversarial procedures for resolving political and and scientific disputes. It is clear that legal challenges to the constitutionality of the Affordable Care Act had a huge impact on the implementation of that act. The second feature of adversarial legalism may be found in the final sentence of the definition included on this slide. The second feature of law and government in the United States, it is more politically fragmented and relies on less closely coordinated decision making systems. This refers to interactions not just between the federal government and stakeholders, but between federal governments, state governments, and local governments. So there's a close interaction between on the one hand a legal system in which the authority is fragmented and hierarchical authority is relatively weak with a fragmented healthcare system with loosely connected parts. In module three, when we analyze the health care systems in England and Germany will see just how significant that difference is because in those countries, governments are able to rely on hierarchical legal systems to guide the whole of the health systems. So what can we say about the role of all of the leadership and governance building blocks in the health care system in the United States? The first is that federal and state governments account for 45% of total spending in the health care system. This is significant, but no government in the United States is responsible for the overall design of the system nor is any government responsible for guiding the system as a whole. Governments are directed and improving access to care and quality of the care for particular sub-populations but not for the population as a whole. In the remaining part of this lecture, we'll review each of the other World Health Organization building blocks. And analyze the interaction between those building blocks in the connection between the health care system on the one hand and population health outcomes on the other.
