Welcome to the second module of Comparative Health Systems. In this module and module three, we will review the Health Care Systems in several High income countries, the United States, Germany and England. We begin with the United States because it is an outlier. It does not provide universal health coverage for its population, but it is a large extensive, well-funded system of health care. Our analysis of the US Health System also form an introduction to defining and describing each of the World Health Organization building blocks. It's useful before we begin this analysis to remind ourselves of the primary feature of comparative analysis. That is we are concerned about the interactions between the WHO building blocks that make up the US Healthcare System and with the outcomes produced by that system. And we're concerned with two kinds of outcomes. We're concerned with intermediate outcomes, which we would normally measure as access to care, cost of care and the quality of care and with ultimate outcomes, which are population health outcomes. Here in particular, we're concerned with the outcomes of whether or not the population or the health of the population as a whole is improved by the health system. In this module, we will deal with two characteristic features of the United States health system. The first is the relationship between health and social spending, we'll analyze that element in this segment of the lecture. In the remaining segments of the lecture, we'll review the interactions between the building blocks and how those interactions produce an unbounded polycentric system that includes many governments, many payers, many providers and many system. So let's begin with the analysis of the interaction between health and social spending. This is important because it's indicative of the counter intuitive relationship between the health care system and population health outcomes in the United States. I've termed this segment of the lecture the American Healthcare Paradox and in doing so I draw upon a book of that name by Elizabeth Bradley and Lauren Taylor. The starting point for their analysis of the US healthcare system and health care spending is it size. Consuming 17.9$% of GDP or roughly $3.5 trillion dollars, it reflects a very high commitment to health. From the perspective of economists, the amount that one is prepared to pay for a service or a good reflects its priority. Using this starting point in health in the United States is clearly a very high priority, but this is indicative of a problem because there is no direct relationship or no necessary direct relationship between the size of a health system and health outcomes produced by that system. When considering health outcomes, that is the health of individuals and populations, health care systems contribute a significant, but small part. The general measure is that healthcare contributes between 10 to 20% of ultimate health outcomes. Other social determinants of health include environmental, social, individual and genetic factors. So when we are considering the high level of spending on healthcare, it's useful to compare that spending with social spending as a whole. And here, we are defining social spending as the full bundle of spending which refers to improvements in a range of social criteria, including health, pensions, housing, income support, training and a broad array of other forms of spending. This graph shows the proportion of spending on health and other forms of social spending in the United States. The very high level of spending on health care makes up a very large proportion of total spending on health and social spending. In this graph, you can see the total health and social spending in the United States includes a proportionally equal amount of spending on health and on other forms of social spending. This proportion of spending on health care is much greater than in other high income countries. For example in France, health care spending is approximately 12% of GDP, other forms of social spending make up 25% of GDP. So what we can say is that there are very high levels of health care spending in the United States and that health care spending forms a larger proportion of total social spending. This graph adds another element to the picture. It measures total net social spending and the dark parts of the bar refer to mandatory spending and this directs us to a very important distinction the United States. The United States is very high spender on social spending. It is the second or third biggest spender on social spending. However, when you analyze the proportion of mandatory public spending as part of the total amount of social spending, you see the United States falls well below the OECD medium, that is mandatory public spending is comparatively low whereas total spending is very high. This difference is explained by the level of private social spending. Private social spending include spending on health care and pensions, which is either voluntary or mandatory, but which is paid for by individuals. The significant feature of private social spending is a beneficiaries or the benefits that people receive from private social spending are related to contributions. And the significance of this is a private social spending is generally less accessible to those on lower incomes. We can see this reflected in the graph of health care spending and the relevant feature of this graph is the orange bar, which is the amount of private health spending in the United States. The largest proportion of spending in health care is public spending, but private social spending is very high in comparison to other OECD countries. What we can infer from this is that while a high levels of health care spending indicate a higher priority for health, high levels of health care spending do not indicate a high priority for improving the health of the population as a whole. And this is reflected in the levels of social spending in the United States. Higher proportions of social spending in the United States tend to be concentrated on forms of social spending which benefit contributors and which are less accessible and less available to low-income recipients. In the remaining segments of this lecture, we will review the US health system as a whole. We'll review each of the building blocks that make up the US health care system and the interactions between those building blocks. We conclude by making some observations about the characteristics of this system in particular that it is an unbounded polycentric health system.