Manipal College of Pharmaceutical Sciences

Manipal Academy of Higher Education, Manipal

Navigating the Comparison of Complex

Landscape of Health Insurance in United States
and India

A project work report submitted to Manipal Academy of Higher Education

In partial fulfillment of the requirements for the degree of

Bachelor of Pharmacy
May 2024
by
Arjita Nanda
Reg. No. - 200601108
Manipal College of Pharmaceutical Sciences
Manipal Academy of Higher Education, Manipal

Trisha Das
Reg. No. - 200601178
Manipal College of Pharmaceutical Sciences
Manipal Academy of Higher Education, Manipal

Under the guidance of

Dr D Sreedhar
Additional Professor and Head, Department of Pharmaceutical Regulatory
Affairs and Management, Manipal College of Pharmaceutical Sciences,
Manipal Academy of Higher Education, Manipal

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2
3
INTRODUCTION

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1. Introduction
In the event of medical necessity, health insurance provides people and families with a financial safety
net. It is the cornerstone of the American health care system. But the world of health insurance in the US
is full with laws, regulations, and seemingly endless possibilities. It may be frightening.
The fundamentals of health insurance in the US are covered in this extensive reference, including with
information on the Affordable Care Act (ACA), types of coverage, basic vocabulary, and advice on
selecting the best plan for your requirements.

Historical Background
Over the past century, the idea of health insurance has changed dramatically in the US. Early in the 20th
century, most Americans had to pay for their own medical treatment, which put them at risk of financial
difficulty in the case of illness or accident. The first health insurance plans did not start to show up until
the 1920s, and those that did were mostly provided by employers. When Medicare and Medicaid were
passed into law in 1965, it marked a significant turning point in the history of health insurance in the
United States by offering public insurance coverage to the underprivileged and elderly. These initiatives
represented a major advancement in providing vulnerable groups with greater access to healthcare.

India's health insurance journey began in the 1950s with limited schemes for government employees. In
the 1970s-80s, rural health development initiatives emerged, followed by the National Health Policy of
1983 emphasizing universal coverage. The late 2000s saw the launch of social health insurance schemes
like RSBY, with Ayushman Bharat PM-JAY in 2018 as a landmark, aiming to provide extensive
coverage to economically vulnerable households.

Key Terminology: Understanding key terminology is essential for making informed decisions about
health insurance. Some important terms to be familiar with include:
 Premium: The amount paid for health insurance coverage, typically monthly.
 Deductible: The amount that the policyholder must put up before the insurance provider starts to
pay for qualified costs is known as the deductible.
 Copayment: Generally made at the time of service, this is a set sum that the insured person pays
for services covered.
 Coinsurance: The amount, usually after the deductible is paid, that the insured person must
contribute toward covered costs.
 Out-of-Pocket Maximum: The highest amount an insured person must pay for services covered
in each month before the insurance company pays 100% of qualified costs.

Affordable Care Act (ACA) Plans: The Health Insurance Marketplaces, established after the
Affordable Care Act (ACA) was passed into law in 2010, allow individuals and families to compare and
buy health insurance plans that comply with the legislation, sometimes with the help of income-based
subsidies.
Among the ACA's most important provisions are:
 Prohibition of Insurance Denials: The ban on insurance denials states that an insurer cannot
refuse a policyholder due to a pre-existing medical condition.
 Essential Health Benefits: Preventive care, maternity care, mental health services, and
prescription medication is among the essential health benefits that must be included by all
ACA-compliant plans.
 Subsidies: Families and individuals with low to moderate incomes are eligible for
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financial assistance under the ACA to help defray the cost of out-of-pocket medical bills and
health insurance premiums.

Tips for Choosing Health Insurance.

 Plan: Selecting the best health insurance plan can be difficult, but there are a number of things to take
into account that will help you make the correct choice.
 Evaluate Your Needs: Consider the medical treatment you require, taking into account any current
ailments, prescription drugs, and expected medical costs
 Compare Plans: Examine the costs, features, and provider networks of several health insurance plans
to determine which one best suit your requirements and price range.
 Understand Costs: Pay attention to premiums, deductibles, copayments, coinsurance, and out-of-
pocket maximums to understand the full cost of coverage.
 Consider Network Coverage: Check whether your preferred doctors, hospitals, and other healthcare
providers are in-network with the health insurance plan you are considering to avoid unexpected out-
of-network costs.
 Utilize Available Resources: Utilize resources to evaluate plans and anticipate expenses, such
as internet tools, insurance brokers, and the Health Insurance Marketplace. For millions
of Americans, health insurance is essential for both access to healthcare and financial security.

Types of Health Insurance Coverage:

There are several types of health insurance coverage available in the United States, each with its
own features and requirements:

 Employer-Sponsored Health Insurance: As part of their benefits package, many Americans

obtain health insurance coverage from their employment. Usually, these plans are provided at a
group rate, with premiums split between the company and the employee.

 Individual Health Insurance: Those without access to employer-sponsored coverage can

purchase individual health insurance policies directly from insurance companies or via the
Health Insurance Marketplace, which was established by the Affordable Care Act.

 Medicare: Medicare is a government health insurance program primarily for those 65 years of age or
older, as well as some younger individuals with impairments and those suffering from end-stage renal
disease (ESRD).

 Medicaid: Medicaid is a combined federal-state program that offers health care to low-income
individuals, families with children, expecting mothers, the elderly, and persons with disabilities.

India offers various types of health insurance coverage to cater to diverse needs and demographics. Some
common types include:

 Individual Health Insurance: Policies designed to cover medical expenses for an individual,
providing financial protection against illnesses, accidents, and hospitalization.

 Family Floater Health Insurance: Covers the entire family under a single policy, offering a
defined sum insured that can be utilized by any family member for medical expenses.
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 Group Health Insurance: Offered by employers or organizations to provide coverage to employees
or members, typically with lower premiums and broader coverage than individual policies.

 Senior Citizen Health Insurance: Specifically tailored for elderly individuals, providing coverage
for age-related ailments, pre-existing conditions, and other healthcare needs.

 Critical Illness Insurance: Offers coverage for specific critical illnesses such as cancer, heart attack,
stroke, etc., providing a lump sum amount upon diagnosis to cover treatment expenses.

 Maternity Health Insurance: Covers medical expenses related to pregnancy, childbirth, and
maternity care, including pre and postnatal care, delivery, and newborn care.

 Personal Accident Insurance: Provides financial protection in the event of accidental death,
disability, or injury, offering compensation for medical treatment and loss of income.

 Travel Health Insurance: Covers medical expenses incurred while traveling, including emergency
medical treatment, evacuation, and repatriation, both domestically and internationally.

 Disease-Specific Insurance: Policies focusing on specific diseases or medical conditions such as

diabetes, cancer, or HIV/AIDS, providing coverage for related treatments and medications.

These are just a few examples of the types of health insurance coverage available in India, with policies
often customizable to meet individual or family healthcare needs.

The landscape of health insurance in the United States is multifaceted, marked by a complex interplay
of public and private systems, diverse coverage options, and evolving policy frameworks. With a
population
of over 330 million, the US faces ongoing challenges in ensuring equitable access to healthcare services
while managing costs and addressing disparities in health outcomes. In contrast, the healthcare system
in India, with its population exceeding 1.3 billion, grapples with its own set of complexities, including
fragmented insurance coverage, inadequate infrastructure, and varying levels of healthcare.

As policymakers, healthcare providers, and stakeholders in both countries seek to address these
challenges, there is much to be gained from a comparative analysis of health insurance systems. By
examining the strengths and weaknesses of the American model and identifying strategies for
improvement, valuable lessons can be learned to improve India's healthcare system.

This study aims to explore the complexities of American health insurance and analyze key challenges
and opportunities and suggest strategies to improve the Indian healthcare system. Through an in-depth
look at data, policy frameworks and best practices, we aim to provide actionable insights that can lead to
meaningful reforms and improve access, affordability, and quality of healthcare in India. Building on
the experience and innovation of the United States, we aim to chart a path to a more inclusive, efficient
and equitable healthcare system for all Indian citizens.

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ABSTRACT

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2. Abstract

Introduction –
This abstract presents a comparative study of health insurance systems in the United States (US) and
proposes improvements for the healthcare system in India. The US health insurance landscape is
characterized by a complex mix of private and public insurance schemes, leading to high costs,
coverage gaps, and disparities in access to care. In contrast, India faces challenges such as inadequate
coverage, limited financial protection, and unequal access to quality healthcare services. By analyzing
key statistical indicators, including insurance coverage rates, healthcare expenditure, and health
outcomes, this study identifies several lessons from the US experience that can inform strategies to
strengthen the Indian healthcare system. Recommendations include expanding insurance coverage
through innovative financing mechanisms, enhancing primary care infrastructure, investing in
preventive care and public health initiatives, and promoting healthcare technology adoption to improve
efficiency and access. Implementing these
reforms could help address the longstanding healthcare challenges in India and move towards
achieving universal health coverage and better health outcomes for all citizens.

Methodology:
- Data collection: Utilization of publicly available datasets, including census data, health
expenditure reports, and insurance coverage surveys.
- Comparative analysis: Examination of key indicators such as insurance coverage rates, healthcare
expenditure per capita, out-of-pocket spending, and health outcomes.
- Qualitative assessment: Review of policy frameworks, regulatory mechanisms, and institutional
arrangements influencing health insurance in both countries.
Results:
- Analysis of health insurance coverage rates: Comparison of insured populations in the US and
India, including demographic characteristics and disparities.
- Evaluation of healthcare expenditure: Examination of per capita spending on healthcare and the
proportion of public vs. private financing.
- Assessment of health outcomes: Comparison of key health indicators such as life expectancy,
infant mortality rates, and disease burden.
- Identification of challenges: Highlighting common issues faced by both countries, including
affordability, accessibility, and quality of care.
Conclusion:
- Recap of key findings: Summary of comparative analysis highlighting lessons from the US
experience.
- Recommendations for policy action: Proposed strategies for enhancing the Indian healthcare
system based on identified challenges and opportunities.
- Call to action: Urging policymakers, healthcare providers, and stakeholders to priorities reforms
that promote equitable access to quality healthcare for all citizens.

This comprehensive review provides insights into the strengths and weaknesses of health insurance
systems in the US and India, offering actionable recommendations to drive improvements in the Indian
healthcare landscape.
Keywords: Health insurance, United States, India, Healthcare system, Comparative analysis,
Universal health coverage, public health, Healthcare financing, Health outcomes, Indian Healthcare
System
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OBJECTIVES OF THE STUDY

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 3. Objective of the study

This study is to provide a comprehensive comparative analysis of the health insurance systems in the
United States and India. The purpose of this analysis is:

 Estimate the coverage differences: Estimate the extent of coverage in both countries, including the
proportion of the population covered by different insurance systems and demographic differences
in coverage ratios.

 Analyzing health expenditures: Compare patterns of health expenditures, including total

expenditures, per capita expenditures, and the distribution of expenditures between public and private
sources.

 Identify policy frameworks: Review health insurance regulatory frameworks, policy initiatives
and institutional arrangements in both countries to understand the factors that influence coverage and
health care delivery.

 Highlight Challenges and Opportunities: Identify common challenges faced by both countries,
such as affordability, access and quality of care, and explore opportunities for policy action and
system improvements.

 Inform Policy Recommendations: Synthesize findings to provide evidence-based recommendations

to improve India's healthcare system.

Building on America's experience, you can advance reforms to achieve universal health care and
improve health outcomes for all citizens by meeting these conditions.

The purpose of this study is to promote informed decision-making and policy processes that ultimately
lead to improved access, affordability, and quality of health care in both the United States and India.

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 RESEARCH
METHODOLOGY

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4. Research Methodology

The study began with the formation of a suitable research question using the PICO method. Following
this, a relevant search strategy was devised and employed using Boolean operators such as “OR” and
“AND” for both U.S. and India respectively. The final search results for both these countries were
compiled and the duplicate copies of the article present in any of the results were removed. Following
this, article selection was carried out using certain inclusion and exclusion criteria. The inclusion
criteria included all age groups of people, in all regions of India and U.S. according to the MeSH entry
terms as the second criteria. The selected studies were required to have been published in the last three
years (2021-2024) from start of study and must be in English to eliminate language barrier. Finally, the
studies were required to be human in nature. We meticulously curated our study to encompass only
articles directly relevant to our research, which exclusively featured content from the USA and India
while deliberately excluding mentions of other countries. Additionally, we ensured that the articles
selected were written in English and published after 2021, thus effectively sidestepping any irrelevant
material that could potentially skew our analysis.

For this review, we conducted our searches by using PubMed database, and got final search results of
articles as 1580 for U.S. and 328 articles for India were selected after using relevant search strategy.
The results were exported with the citations and other relevant information, and compiled into an
Excel sheet, with the duplicates being promptly removed before combining two final search results of
respective countries. After conducting screening based on title and abstract reading, 216 articles were
chosen. Out of these, the articles containing information conforming to the study objectives were
selected on discussion with the co-author containing information that does not have high load and
conclusions were derived from these selected studies in the limited time for conducting this study.

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RESULTS

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 5. Results
On reviewing various studies and gathering data upon careful evaluation of selected studies (that have high
content readability and does not contain article load); data analysis was carried out and is being reported as
follows.

5.1 The various U.S. Health Insurance programs and its implications

5.1.1 Overview of unaffordability outcomes in Medicare.

Delayed Care Problems Paying Medical Bills Either Difficulty or Both

Age Group (%) (%) (%)
Older Enrolees 8.3 7.4 12.2
Under 65 Years 25.2 29.8 38.0
Community-Dwelling Medicare
Enrolees 10.9 10.8 16.2

So, in this study examining the prevalence of unaffordability outcomes in Medicare [1], among older
participants, 8.3% (95% CI, 7.4%-9.1%) postponed care owing to cost, and 7.4% (95% CI, 6.6%-8.2%)
reported difficulty paying medical bills. Although the numbers were comparable, there was little overlap
between the two outcomes: only 3.4% (95% CI, 2.9%–3.9%) experienced both types of unaffordability. As
a result, a significant number of older registrants had either form or both: 12.2% (95% CI, 11.1%–13.3%).

Among individuals under 65 years old, 25.2% (95% CI, 21.8%-28.6%) delayed care, 29.8% (95% CI,
25.6%-34.1%) faced payment issues, and 38.0% (95% CI, 33.4%-42.7%) encountered either or both
problems [1]. For Medicare enrollees living in communities, rates were 10.9% (95% CI, 9.9%-11.9%) for
delayed care, 10.8% (95% CI, 9.8%-11.9%) for payment problems, and 16.2% (95% CI, 14.8%-17.6%) for
either or both issues [1]. Many enrollees experiencing payment difficulties also dealt with collection agency
contact, paying bills over time, or both, with rates of 5.0% (95% CI, 4.4%-5.6%) among those aged 65 or
older, 24.1% (95% CI, 19.9%-28.3%) among those under 65, and 7.9% (95% CI, 7.0%-8.9%) overall.

Additionally, the logistic regression multivariate model analysis found:

The likelihood of having difficulty paying medical expenses was 3.4 times higher among near-poor
participants (incomes $15,000-$25,000) than among those with incomes more than $50,000 [1].
Cost-related delays in care were 2.5 times more likely among near-poor enrollees [1].
Race (white vs. black), marital status (single or married), and number of chronic diseases all had a
substantial impact on difficulty paying medical expenditures among older participants.

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This bar chart illustrates the percentage of Medicare enrollees facing affordability issues, showing a
significant difference between older enrollees (12.2%) and those younger than 65 years (38.0%)

Several factors were found to be significantly associated with difficulty paying medical bills among
older enrolees, but not with delaying care due to cost; these factors included being in white versus
black race, being single or married, and having no conditions versus having two or more
chronic conditions.

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 5.1.2. Impact of Affordable Care Act on income inequality -

In another study to evaluate if the Affordable Care Act (ACA) has reduced income inequality in the U.S. [2] with
the expansion of its health benefits, we compared income inequality based on three factors mentioned below.

Between- Within-
Group Group
Inequality Inequality
Reduction Reduction
Aspect (%) (%) Notable Changes in Expansion States
Larger reductions observed in Medicaid expansion
states, significant declines within each racial/ethnic
group, especially among American Indians/Alaska
Race/Ethnicity 8.5 94 Natives, Hispanics, and Black non-Hispanics.
Larger reductions observed in expansion states across
most age categories, particularly significant for the
Age 5.3 At least 10 youngest age group (23.5% decrease).
Larger reductions observed in expansion states,
Educational particularly significant for those with a high school
Attainment 9.3 N/A education.

These results indicate that the Affordable Care Act (ACA) contributed to reducing income inequality based
on race/ethnicity, age, and educational attainment, with larger reductions often observed in Medicaid
expansion states.
According to estimations based on racial/ethnicity and income disparity, the ACA decreased between-group
inequality by 8.5% overall, with expansion states experiencing higher reductions (10.2%) than non-
expansion states (6.1%) [2]. Within each racial/ethnic group, inequality decreased dramatically because
of the ACA, with bigger drops observed in states that expanded Medicaid. Regarding within-group
disparity, Black non-Hispanics, American Indians/Alaska Natives, and Hispanics usually had the biggest
declines. Only around 6% of the overall disparity was attributable to between-group income inequality, such
as the variations in income between the five racial/ethnic groups; in contrast, almost 94% of the total
inequality was attributable to within-group inequality [2].

The ACA reduced between-group inequality overall by 5.3% based on age and income disparity, with
significant decreases in expansion states (8.1%) and no change in non-expansion states [2]. Every age group
had a minimum 10% decrease in within-group inequality nationally, with bigger declines observed in
expansion states for the majority of the categories. Under the ACA, within-group disparity decreased most
in states of expansion for the lowest age group (23.5%). On the other hand, young individuals were less
impacted by within-group inequality in non-expansion states, whereas those aged 55–64 had the most
decrease (15.8%) [2].

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Between-group disparity accounted for more than a fifth of overall inequality based on income inequality
and educational attainment, which is a much bigger percentage than the 9.3% drop in between-group
educational attainment inequality for race/ethnicity and age during the Affordable Care Act [2]. Every
educational attainment group saw a fall in within-group inequality, with expansion states experiencing
greater declines. The people with a high school education had the biggest decreases in within-group
inequality for both expansion and non-expansion states, as did those with some college education and those
with less education than a high school diploma [2].

The bar chart displays the impact of the Affordable Care Act (ACA) on reducing income inequality, broken
down by race/ethnicity, age, and educational attainment. It highlights the greater reductions observed in states
that expanded Medicaid compared to those that did not. Expansion states saw reductions across all categories,
while non-expansion states showed little to no change, particularly in the categories of age and education

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 5.1.3 Impact of affordable care act on insurance coverage and discrimination rates.

- In this study to report the insurance-based discrimination rates for nonelderly adults with private, public, or
no insurance in a period of ACA and relevant threats to this Act the following data were derived.

Uninsured Rate Public Insurance Enrolment Private Insurance Coverage Insurance-Based

Year (%) (%) (%) Discrimination (%)
2013 10.7 17.7 N/A N/A
2015 3.6 23.1 73.3 7.7
2017 7.7 23.1 69.6 11.0

These results suggest that while the full implementation of the ACA led to a significant decrease in the
uninsured rate and an increase in public insurance enrollment, there was also a corresponding decrease
in private insurance coverage. Additionally, there was an increase in reports of insurance-based
discrimination, particularly in 2017, coinciding with the doubling of the uninsured rate and significant
drops in private insurance coverage.

 Between 2013 and 2015, the uninsured rate significantly decreased (from 10.7% to 3.6%, respectively)
as a result of the full implementation of the ACA, while public insurance enrolment increased in tandem
(17.7% to 23.1%) [3]. The majority of persons had access to private insurance; yet, however, between
2015 and 2017, the percentage of adults with private insurance fell from 73.3% to 69.6%, while the
percentage of adults without insurance rose from 3.6% to 7.7% [3].

 In 2017, the percentage of non-elderly individuals reporting insurance-based discrimination grew from
7.7% in 2015 to 11.0% in 2017, the year of the twofold decline in the uninsured rate and the sharp
decline in private insurance [3]. Between 2011 and 2019, reports of insurance-based discrimination by
insurance type was consistent, ranging from 18.4% to 24.0% for individuals with publicly insured
insurance and 24.7% to 28.1% for persons without insurance, in contrast to 3.0% to 5.4% for adults with
private insurance [3]. Regarding access measures, less than 20% of individuals stated they did not have a
regular source of care, less than 13% said they were not confident they would receive the treatment they
needed, and less than 37% said they had forgone care throughout the course of the research [3].

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This plot illustrates several key trends between 2013 and 2017 related to U.S. health insurance :

 Uninsured Rate (%): We see a significant drop from 10.7% in 2013 to 3.6% in 2015, followed
by an increase to 7.7% in 2017, showing fluctuations in the uninsured population possibly tied to
policy changes [3].
 Public Insurance Enrollment (%): There is an increase from 17.7% in 2013 to 23.1% in 2015,
which then stabilizes through 2017, reflecting the expansion of public insurance coverage [3].
 Discrimination Rate (%): Reports of insurance-based discrimination rose from 7.7% in 2015 to
11.0% in 2017, aligning with the increase in uninsured rates and changes in insurance type
coverage [3].

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5.1.4 Insights from the U.S. Health Insurance Programs:

 Affordability Issues in Medicare:

 A notable percentage of Medicare enrollees experience affordability issues, with older

enrollees (12.2%) and younger enrollees (38.0%) facing different rates of financial barriers
in healthcare access [3].
 The odds of experiencing payment difficulties are significantly higher among the near-poor
compared to higher-income groups.

 . Impact of the Affordable Care Act (ACA):

 The ACA has had a positive impact on reducing income inequality, especially in states that
expanded Medicaid. This reduction varies by race/ethnicity, age, and educational attainment,
showing the largest declines in states that participated in the Medicaid expansion.

 Insurance-based Discrimination:

 Following the ACA implementation, there was a significant reduction in the uninsured rate
and an increase in public insurance enrollment. Despite these changes, about 10% of nonelderly
adults reported facing insurance-based discrimination, with rates varying slightly across different
types of insurance [3].

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 5.2 The Indian Health Insurance programs and its implications.

5.2.1 Publicly Funded Health Insurance (PFHI):

 Enrollment in PFHI is associated with a lower out-of-pocket expenditure and better protection
against catastrophic health expenditures for the elderly.
 Hospitalization rates and out-of-pocket expenditures show disparities between those enrolled in
PFHI and those who are not.

Parameter PFHI Enrolled (%) Not Enrolled (%)

Overall Hospitalization Rate (%) 8.8 6.8
Mean OOPE for Hospitalization in Private
Sector Lower for PFHI Enrolled Higher for non-enrolled
Median OOPE for Hospitalization in Private Similar for PFHI Enrolled and Non- Similar for PFHI Enrolled and Non-
Hospitals Enrolled Enrolled

 These findings imply that among the elderly, hospitalization rates were greater for those enrolled
in publicly supported health insurance (PFHI) than for those not enrolled in PFHI [4]. Furthermore,
compared to the public sector, the mean out-of-pocket expense (OOPE) for inpatient treatment in the
private sector was around six times higher [4]. The median OOPE for hospitalization in private hospitals
was nearly comparable for both groups, even though the mean OOPE for using private hospitals was
lower for PFHI-enrolled persons than for non-enrolled individuals.

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This pie chart illustrates the percentage of the elderly covered by PFHI compared to those not
covered. It shows that 18.13% of the elderly are enrolled in PFHI.
In a longitudinal ageing study evaluating the role of publicly funded health insurance (PFHI) in
financially protecting the elderly from health expenditure [4], the following results were derived.
Using multivariate logistic regression analysis, it was possible to determine the relationship between
PFHI enrolment and CHE25 and CHE40 (CHE stands for catastrophic health expenditure).
Propensity Score Matching (PSM) model was used to investigate the impact of PFHI enrolment on
out-of-pocket spending (OOPE), CHE25, and CHE40 to add robustness [4].
18.13% of senior citizens qualified for PFHI coverage. At 2.58%, the percentage of people with
alternative health insurance was rather low [4].

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The bar chart above displays the hospitalization rates by insurance enrollment status. It illustrates that
individuals enrolled in the Publicly Funded Health Insurance (PFHI) have a slightly higher
hospitalization rate compared to the overall population, and significantly higher compared to those not
enrolled in PFHI.

Among the elderly, the total hospitalization rate was 7.1% (6.5%–7.6%) [4]. Hospitalization rates
among PHFI enrolled patients ranged from 8.8% (8.2%-9.4%) to 6.8% (6.2%-7.5%) among non-PFHI
enrolled patients [4].

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This bar chart illustrates that the mean OOPE is significantly lower for PFHI-enrolled individuals
compared to non-enrolled, indicated by a higher arbitrary scale value. The median OOPE shows nearly
equal amounts for both groups, indicated by a low scale value.

The mean OOPE in the private sector for using hospitalized care was almost six times more than in the
public sector [4]. When it came to using private hospitals, the PFHI-enrolled persons had a lower mean
OOPE than the non-enrolled individuals. Nonetheless, the PFHI-enrolled and non-enrolled persons'
median OOPE for hospitalization in private hospitals was nearly comparable [4].

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 5.2.2 Costs of Healthcare Services:

The study provided detailed cost analyses of healthcare services at different levels (sub-center and primary
health center) in four Indian states, highlighting significant variations in costs depending on the type of
healthcare facility and region [5].

This table provides an overview of the population served, services provided, and costs associated with
healthcare provision at both the sub center (SC) and primary health center (PHC) levels across the four
selected states of India.

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 Parameter Sub Center (SC) Primary Health Center (PHC)
Average Population Served 5753 (460 - 10,140) 25,612 (2623 - 47,313)
Outpatient Consultations (Annual) 716 23,083
Antenatal Coverage (ANC) Sessions (Annual) 379 N/A
Inpatient Care (Annual) N/A 252
Mean Annual Cost (INR Million) 0.69 (0.58 - 0.89) 5.1 (2.01 - 7.4)
Mean Annual Cost (USD) $11,392 ($9474 - $14,680) $83,837 ($33,095 - $122,283)
Cost Breakdown (%)
- Salaries 74 63
- Drugs/Consumables 14 23
- Space 5 4
- Equipment/Furniture 2 3
Unit Cost (INR)
- ANC Visit ₹221 (₹173 - ₹276) N/A
- Postnatal Care Visit ₹333 (₹244 - ₹461) N/A
- Outpatient Consultation N/A ₹121 (₹91 - ₹155)
- Inpatient Care (per bed day) N/A ₹1168 (₹955 - ₹1468)
Unit Cost (USD)
- ANC Visit $3.64 ($2.85 - $4.53) N/A
- Postnatal Care Visit $5.47 ($4.01 - $7.56) N/A
- Outpatient Consultation N/A $1.99 ($1.50 - $2.55)
- Inpatient Care (per bed day) N/A $19.23 ($15.70 - $24.16)

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The bar chart above shows the average population served by Sub Centers (SCs) and Primary Health
Centers (PHCs), highlighting the significantly larger population served by PHCs compared to SCs .
Throughout the four States, the average population served by the SCs and PHCs was 5753
(460–10,140) and 25,612 (2623–47,313), respectively [5].

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The bar chart above illustrates the annual service counts at Sub Centers (SCs) and Primary Health Centers
(PHCs), including outpatient consultations and antenatal coverage sessions for SCs, and outpatient and
inpatient services for PHCs. Regarding service delivery, 379 Antenatal Coverage (ANC) sessions were
provided annually at the designated SCs, and 716 patients had outpatient consultations. Likewise, PHCs
provided inpatient care to 252 patients and outpatient consultation to 23,083 individuals each year.

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The mean annual cost of healthcare provisioning at Sub Centers (SCs) and Primary Health Centers
(PHCs) in several states is shown in this bar chart, which also clearly illustrates how expenses vary
depending on the location and kind of institution.
Healthcare services were provided at an average yearly cost of ₹ 0.58 million (USD 9474) in TN and ₹
0.89 million (USD 14,680) in HP [5]. With the highest cost in Kerala at $7,4 million (US$ 122,283)
and the lowest in Odisha at ₹ 2.01 million (USD 33,095), the average annual cost at PHC was ₹ 5.1
million (US$ 83,837) [5].

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The pie charts above display the breakdown of costs at Sub Centers (SCs) and Primary Health Centers
(PHCs). The largest portion of costs in both SCs and PHCs is allocated to salaries, followed by
drugs/consumables, space, and equipment/furniture. Salary costs accounted for around 3/4 (74%) of the
expenditure at the SC level and 2/3 (63%) at the PHC level. Additional factors influencing expenses were
medications/consumables (14 and 23%), space (5 and 4%) and furnishings/equipment (2 and 3%).

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The line graph above presents the unit costs for various types of healthcare services (ANC, postnatal
care, outpatient consultations, and inpatient care) across different states in India. The costs show
significant variation based on the type of service and the state, with particularly high costs in Himachal
Pradesh for certain services. An ANC's per visit cost at the subcentre level was ₹ 221 (173-276) at unit
cost; this cost ranged from ₹ 108 (64-162) in Kerala to ₹ 534 (272-771) in Himachal Pradesh [5]. In a
similar vein, the
unit cost of a postnatal care visit was ₹ 333 (244-461) in Himachal Pradesh and ₹ 172 (121-229) in
Kerala [5]. The cost of an outpatient consultation at PHCs was ₹ 121 (91-155), with the highest value
being ₹ 158 (100-233) in Himachal Pradesh and the lowest being ₹ 71 (44-109) in Tamil Nadu [5].
Inpatient care costs per bed day ranged from ₹ 107 (88-128) in Tamil Nadu to ₹ 5107 in Himachal
Pradesh [5]. The average
cost per bed day was ₹ 1168 (955-1468).

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5.2.3 The Transformation of the Indian health care system -
With 1.4 billion inhabitants, India's healthcare system is a complex and diversified network of public
and private sectors that offers a wide range of healthcare services.

The system continues to confront various obstacles even after undergoing substantial modifications
throughout time. These issues include a lack of financing for public health, a fragmented health system,
restricted health insurance, inequities between urban and rural areas, a lack of health staff, and
inadequate infrastructure. The rising number of non-communicable illnesses in India is posing a serious
threat to the country's healthcare system. A number of initiatives have been introduced by the Indian
government to enhance the healthcare system

The National Health Mission increases access to medical supplies and equipment. It also encourages
community involvement in service delivery and decision-making related to health care.
Ayushman Bharat is a health insurance programme that pays secondary and tertiary hospital care up to
INR 5 million per family annually [7].

Numerous innovations in healthcare have also been introduced into India's healthcare system, ranging
from creative ways to administer treatment to low-cost medical gadgets.

The nation's healthcare regulations are changing to guarantee patient security, encourage high-quality
treatment, and keep prices under control. A wide range of public and private healthcare providers with
differing levels of quality and regulation define India's healthcare system. diverse populations have
diverse health outcomes as a result of socioeconomic inequality and regional differences in access to
healthcare, and poorer groups and those living in rural places frequently have more problems in getting
access to high-quality healthcare. Two percent of India's total income went toward spending by the
government.

GDP in the healthcare sector is expected to reach above 2.5 percent of GDP by 2025, up from 2.2
percent in the fiscal year 2022. The Ministry of Health and Family Welfare Union Budget has been
allotted around INR 860 billion by the Indian government for the fiscal year 2022 [7].

The primary forces behind the improvement of India's healthcare system are Ayushman Bharat, Medical
Tourism, and the National Health Mission.

The National Urban Health Mission (NUHM) and the National Rural Health Mission (NRHM) are part
of the National Health Mission (NHM), which was established in 2013. By renovating current facilities,
constructing new ones, and expanding the availability of medical supplies and equipment, NHM intends
to bolster primary health infrastructure and services [7]. By educating and hiring more medical
professionals, nurses, and first responders, particularly in rural regions, this program also seeks to
enhance the human resources in the healthcare industry.
NHM also aims to enhance the health of expectant mothers, newborns, and children by increasing
access to essential services including immunization programs, skilled deliveries, and prenatal care.
Finally, it uses focused interventions and public health initiatives to address both communicable and
33
non-communicable illnesses. A budget over INR 290 billion has been allocated to the National
Health Mission for 2024 [7].

Launched in 2018, Ayushman Bharat is yet another significant health effort. Via Health and Welfare
Centers (HWC) and the Pradhan Mantri Jan Arogya Yojana, this program offers health and financial
security to India's most vulnerable citizens (PMJAY). There were around 117 thousand Ayushman
Bharat Health and Wellness Centers (AB-HWC) in India as of December 2022 [7].

In India, the transition to digital healthcare is transforming the way medical treatment is provided,
particularly in rural regions. The quality and effectiveness of healthcare services, as well as the
prevention and management of non-communicable illnesses, are being improved via the use of
telemedicine, digital health information, and mobile health applications.

In 2018, the percentage of Indians with health insurance was around 35%; this is a modest increase
over the previous year, when it was approximately 33% [7]. About 514 million Indians were enrolled
in health insurance programs in FY 2021, and the country's government-sponsored health insurance
program payouts totaled about INR 43 billion [7].

India has a plethora of innovative health care examples, ranging from low-cost medical gadgets to
creative healthcare delivery strategies. Long-term, these advances may result in lower costs and
better health outcomes. The goal of India's healthcare regulatory framework is to manage costs,
advance quality services, and guarantee patient safety.

The Indian Government is actively streamlining regulatory frameworks to ensure healthcare

providers maintain high standards of care. Recognizing the pivotal role of India and its private
healthcare sector on achieving universal healthcare, efforts are underway to simplify the processes.

Its private health sector offers quality treatment at competitive rates, attracting international patients
seeking cost effective care. Significant advancements in infrastructure, technology and specialty
service have been witnessed. Modern hospitals, clinics and diagnostic centers equipped with state-of-
the-art medical technology are now commonplace. Digital innovations like electronic medical
records and telemedicine have transformed patient care.

Enhanced health insurance coverage has facilitated easier access to private healthcare, with insurance
companies collaborating with private facilities. Public-private partnerships have been encouraged to
broaden healthcare access.

India has emerged as a leading medical tourism destination, drawing patients globally. The industry
thrives on factors like cost -effectiveness, skilled medical professionals, advanced technology,
diverse specialties, and alternative medicine options. Their proficiency in English and ease of travel
further contribute to its appeal.

34
DISCUSSION

35
 6. Discussion

Based on the above statistics and insights into both the US and Indian healthcare systems, we realized
that -Indian and US healthcare systems are completely different.
In India, healthcare is provided by both the public and private sectors, with the public sector being
the main healthcare provider.

Public Financed Health Insurance (PFHI) provides financial protection to the elderly against
healthcare expenses.
Overall hospitalization 7.1%. of the elderly. Among PFHI enrollees, the hospitalization rate was
8.8%.
while it was 6.8% of those not covered by the PFHI. The private sector also plays an important role
in providing health care, especially in urban areas.

Health care is generally cheaper in India than in the United States, but quality can vary widely. In the
United States, healthcare is primarily provided by the private sector, but the public sector plays a
smaller role. The United States has a complex and expensive health care system with both public and
private insurance options and out-of-pocket costs. The quality of healthcare in the United States is
generally high, but the cost can be a barrier for many people. Overall, the main difference between
the Indian and American healthcare systems is the balance between public and private healthcare and
the cost and availability of healthcare.

The Indian healthcare system has come a long way; there is no doubt about it. However, there is still
a long way to go according to international standards. Here are some striking differences between the
US and Indian healthcare systems.

 Insurance and Financing- The US relies on Medicare and Medicaid and commercial health
insurance. Until 2018, all Americans were required to purchase valid health insurance. India
uses government-subsidized programs and out-of-pocket costs.
In terms of health insurance, more than 91.4% of Americans are covered. The low level of health
insurance coverage in India can be attributed to a lack of knowledge and awareness. About 25% of
people in India have health insurance
 Type of insurance-There are several types of health insurance in the US. Many insurance
policies cover all patient medical expenses. It includes OPD, doctors and cosmetic treatments. Fees
are comparatively higher in the USA than in India. Insurance penetration in India is
gradually increasing. However, there is still a long way to go. In India, health insurance plans
usually cover pre-hospital and post-hospital expenses. Most of the insurance companies do
not provide OPD or doctor consultation, leaving a huge medical burden on the patients.
 Availability and affordability- The US offers better access to advanced health care services and
infrastructure. However, the biggest challenges related to access to health services are affordability
and lack of staff. Healthcare in the US is very expensive.
Access and affordability of high-quality healthcare are major challenges in India. Although the
country has free public medical services, the quality of treatment must meet international standards.
In addition, quality care is not provided in remote areas. Also, healthcare costs in private medical
centers are very high, but still lower than in the United States.

36
 Health Infrastructure-The United States has state-of-the-art infrastructure services in healthcare.
In the United States, healthcare is a private sector. The government only subsidizes treatment or
funds those who are unemployed or unable to purchase health insurance. However, many health
centers in India is run by government and private institutions. Improving healthcare and health
insurance policies in both India and the US requires comprehensive strategies that address access,
affordability, quality of care, and equity. Here is a detailed look at measures that can be taken:

 Expand Access to Healthcare: India and the US can improve access to healthcare by expanding
coverage to uninsured and underinsured populations. In India, this can be achieved through the
continued implementation of initiatives like Ayushman Bharat, ensuring that vulnerable populations
have access to quality healthcare services. In the US, expanding Medicaid coverage and increasing
subsidies for low-income individuals to purchase insurance through the Affordable Care Act
(ACA) exchanges can help reduce the uninsured rate.

 Enhance Primary Care Infrastructure: Both countries can invest in strengthening primary
care infrastructure, including clinics, community health centers, and telemedicine services. By
ensuring access to primary care providers, individuals can receive timely and preventive care,
reducing the need for costly hospitalizations and emergency room visits.

 Promote Preventive Care: Prioritizing preventive care measures such as screenings, vaccinations,
and health education programs can help identify and address health issues before they become
serious. India and the US can incentivize preventive care by providing coverage for preventive
services and promoting public health campaigns to raise awareness about healthy lifestyle choices.

 Control Healthcare Costs: Addressing rising healthcare costs is crucial to making healthcare
more affordable for individuals and governments. Both countries can explore measures to control
costs, such as negotiating drug prices, reducing administrative overhead, and promoting generic drug
usage. Additionally, implementing value-based care models that reward quality outcomes rather
than volume of services can help improve cost-effectiveness.

 Address Health Disparities: Health inequalities based on race, ethnicity, socioeconomic level, and
geography need to be addressed in both India and the US. Targeted interventions, including
community health programs, culturally competent care, and health equity initiatives, can help reduce
disparities and improve health outcomes for marginalized populations.

 Foster Innovation in Healthcare Delivery: Embracing innovation in healthcare delivery,

technology, and treatments can improve efficiency and quality of care. Both countries can invest in
research and development, promote telemedicine solutions, and encourage the adoption of digital
health technologies to enhance access to healthcare services, especially in rural and underserved
areas.

 Enhance Healthcare Coordination: Improving coordination and communication among

healthcare providers, insurers, and government agencies can streamline care delivery, reduce
duplication of services, and improve patient outcomes. Integrated care models, care coordination
programs, and health information exchanges can facilitate seamless transitions between healthcare
settings and improve care continuity.

37
 Promote Patient-Centered Care: Both India and the US can prioritize patient-centered care
approaches that empower individuals to actively participate in their healthcare decisions. This
includes promoting shared decision-making between patients and providers, respecting patient
preferences and values, and enhancing patient access to their health information.

 Invest in Health Information Technology (HIT): Investing in HIT infrastructure, including

electronic health records (EHRs), telehealth platforms, and health data analytics, can improve
care coordination, enhance clinical decision-making, and facilitate population health management.
Both countries can incentivize HIT adoption and interoperability to enable seamless exchange of
health information across healthcare settings.

 Ensure Regulatory Oversight and Accountability: Strengthening regulatory oversight and

accountability mechanisms are essential to safeguarding patient rights, ensuring quality of care,
and preventing fraud and abuse. India and the US can enforce rigorous quality standards,
implement transparent reporting requirements, and enhance monitoring and enforcement mechanisms
to maintain the integrity of their healthcare systems.

By implementing these comprehensive strategies, India and the US can work towards building more
efficient, equitable, and sustainable healthcare systems that prioritize the health and well-being of their
populations.

38
LIMITATIONS OF THE
STUDY

39
7. Limitations of the Study
 In most of these selected studies, the data received largely derived on the reporting of the patients
(in scenarios of interviews, forms or questionnaires conducted) to assess the care provided and the
extent to which health insurance is covered and could not be extrapolated from respective national
databases.
 Our study focuses broadly on the health insurance system in US and India, but the intricacies of
various programs in both these countries cannot be highlighted due to the high article load and lack of
time present to delve into these topics, which would require a higher knowledge of the working of
these systems which we do not currently possess.
 When patients change their insurance coverage from private to public and vice versa, would likely
be providing their past experiences to the provider instead of the current coverage they are insured by.
Due to the irregularity in the time reference, our study has been unable to point the instances in
which insurances in the US or India were at their best or worst for given parameters and respective
groups of population.
 In one study, the ability to establish causal associations (e.g. between insurance type, access
experiences at survey time and forgone care) was inhibited because of repeated cross-sectional studies
over the last 12 months.
 In a country like India where there are stark differences in health system characteristics,
infrastructure, wage rate and so on there remains a need to conduct a broader study to estimate the
average cost which can be representative at a national level. However, there is ample data on State-
specific cost information and for the time being these plays a more important value than the national
value in India.
 In some studies, related to the US, the Medicaid and Medicare disproportionately covers the elderly
citizens and/or the disabled which is another difference to be worked on in future research, as
excluding these major groups would certainly impact our findings on the
US healthcare insurance systems and their importance.

40
Conclusion

41
 8. Conclusion

The Study of Health Insurance in the United States provides valuable insight into the complexities and
challenges of the diverse health care environment. Despite significant progress, the US system
struggles with disparities in affordability, accessibility, and health outcomes, highlighting the need for
continued innovation and reform.

The comparative analysis reveals several strategies that can improve India's health care system and
ultimately promote progress toward universal health care and improve health outcomes for all citizens.
The main findings of the statistical review emphasize the importance of expanding insurance coverage
through innovative means. financial mechanisms, strengthening of primary health care infrastructure,
promotion of preventive treatment and introduction of technology-based solutions. By adopting a
holistic approach that addresses the root causes of health inequalities, India can make significant
progress towards its goal of universal health coverage.

In addition, the US experience highlights the critical importance of policy coherence, stakeholder
engagement and long-term investments in health infrastructure and human resources. As India
experiences rapid demographic and epidemiological change, proactive measures are needed to build a
resilient and responsive healthcare system that can meet the changing needs of its population.

Finally, building on the strengths and lessons learned from the United States. In the healthcare system,
India has an opportunity to chart a path to a more inclusive, efficient, and equitable healthcare system.
We can strive toward the shared objective of guaranteeing that everyone, regardless of socioeconomic
class or geography, has access to high-quality health care via cooperation and evidence-based
decision-making.

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References

43
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Thank you

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