Comparative Health Systems

Why compare? We have problems and others have different

and perhaps better solutions What kind of comparison? Scientific enterprise Inefficiency, efficacy, inequity and cost Repair versus prevent

Criteria for comparison

Legitimation and Regulation Services and benefits Finances Eligibility Organization and administration Liabilities and benefits of parties to the

medical organization

Other modes of comparison

Outcomes Equity Disease versus prevention and public health

Mutual aid model

Communal risk and communal cure Minimize financial risk Emphasize prevention Power local and communal Team oriented care delivery Patient not educated except in prevention

State model

Strengthen state control Minimize cost, and disease prevalence Universal access Centered on governance and control Not patient or physician centered Primary care, basic care Financed by state taxes

Professional model

Professional core delegated the responsibility and the power to provide medical care, finance it and decide who gets it

Best care, compassionate care Professional associations control Less primary care, more specialized care Private finance, risk pooling if able Expensive, secret and less equity

Corporatist model

Medicine as industry, buyers and sellers Minimize conflict Cost versus provider interests at issue Institution is the corporate body of medicine Negotiated between unequal negotiators Finance depends on the intervention of the

state Inequity and cost high

Canada

National system with central finance and regional control of allocation

Cost controls Indirect care availability controls 12.5% of GNP instead of 20.3% in U.S. 8.5% of Canada’s budget instead of 22% in U.S. Preserved D/P relationship, emphasis on primary

care Small population

Will it work here?

Entitlement mentality Cost, technology focus Powerful professions Government and insurance industries would

suffer in the bargain—balance of power would have to shift

Downsides to our System

Red tape—actually less administrative red tape and paper work

D/P relationship—we have managed care and too much non-patient contact compared to freeing the doctor to see patients and interact

External control to care

Downsides to their System

Long lines for elective procedures—reason we have no lines is because people know not to get in lines here—financial penalties too onerous

Must admit our addiction to technology and make social changes to our own behavior

Lower quality a myth—outcomes and health measures as well as satisfaction BETTER in Canada

Downsides

Rationing versus allocation Communal responsibility for allocation of

care NOT individual right ONLY prisoners in the US have a RIGHT to

care, no one else does—has this changed? In Canada everyone has a right to care that

is limited—is this more fair? Equitable?

Downsides

Presumed exodus of physicians—actually doctors happier in Canada because the paperwork is less, more patient contact and less direct oversight, negotiation

If money really matters then they move

REAL downsides

The availability of technology Portability Esoteric care Social control issues

Other issues

Universal access Financial control Do we trust and respect the state? Industrial invasion of medicine—who can

stop it?

German system

Insurance cost based not care based Subsidy of the old by the young Subsidy rich for poor Office/hospital dichotomy Drugs expensive L.E. dropped 9 years in last 15 years

British systems

Differentiate the financial control (Canadian system) and financial and organizational control (UK)

1948—took control of finances and organization– made doctors employees and eliminated private medicine

NHS as state model

Strengths

Universal access Cost control – 6-10% of GNP Better public health and prevention Better control of research and outcomes Less drugs, more health, more education and

self-reliance

Weaknesses

Regional inequalities Less technology Class variations in use Waits for invasive care

Restructuring NHS

Began in the 1980’s Managerial and regional control Performance indicators, quality control Localization of internal markets Empowering the consumer—the return of

private medicine and open markets Detailed lists of wait times and outcomes

Restructuring

Welfare pluralism Public and private funding returns Flexible firms with more local control and less

reliance on government funding A result of social action groups Result of flat technology advances,

sameness of care

Italian system

Public Universal coverage Regional differences in quality based on cost Unrealistic expectations Can retire at age 50—no contribution while

using resources

Concepts of prevention

Less harm, less disease with better health Prevention is better than cure and easier And less costly Public health and its separation in US

medicine—unlike the rest of the world

Refocusing the Debate over Health

Health comes from prevention in a world where chronic illness predominates

Health is preferable to disease Disease treatment is short term and

temporizing Health promotion is long term and lasting There is futility in both approaches

Refocus

NOT battle between makers of disease and health workers

Political economy of health—we make an industry of illness and the viability of that industry is dependent on lack of health

So get healthy, prevent harm Concept of PERSONAL moral health

entrepreneurship Need hierarchies—survival and beyond

Issues

Social Justice Universal coverage Who pays How much Access to careHave we solved these issues with

reform?