Ronald F. White, Ph.D.
Professor of Philosophy
College of Mount St. Joseph
National Health Care Systems
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What is the “Ideal National Health Care System?”
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UNIVERSAL ACCESS
• A formal principle or abstraction
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Access to what?
» Wants v. Needs
QUALITY OF HEALTH CARE
• What is “Good Health Care?”
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Individual v. Collective Measures
• Quality of what?
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Health care professionals, hospitals, drugs, biomedical technologies, laboratories, research institutions, medical schools, health
insurance
• Quality Sensitivity
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Availability of qualitative information
Ability to act on qualitative information
• Quality as Comprehensiveness
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Number of products and services available
Health Care Needs v. Wants
• Scientific Medicine
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Regulation of Research
AFFORDABLE COST
• What is “Affordable Health Care”
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How much does it cost?
How much is too much?
• Who Benefits and Who Pays the Cost?
The U.S. Health Care System
• ACCESS
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In 2005, the Census Bureau reported that at least 44.8 million Americans were without health
insurance coverage.
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By 2006, that number rose to 47 million: a 15% increase in the number of uninsured.
Since, 2000 the number of uninsured Americans has grown by 8.6 million: an increase of about 22 percent.
(Census Bureau 18).
The largest segments of uninsured are employed, young adults 19-29 and older adults 45-64. (Census Bureau,
21)
The uninsured rate among young adults, signals a corresponding rise in the number of uninsured young
children.
• QUALITY
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Global Measurement of Quality
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Life Expectancy : As of 2006 U.S. Ranks 38 th COMPARED TO: 1. Japan (82.6), 2. Hong Kong (82.6), 3. Iceland (81.8)
Infant Mortality: As of 2006 U.S. ranks 32 nd (6.3) COMPARED TO: 1. Iceland (2.9), 2. Singapore (2.9) , Japan (3.2)
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Medical Mistakes
Comprehensiveness
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Hamilton County, Ohio 13.9 (More than twice the National Average)
Number and Quality of Products and Services
Heroic Medicine and Enhancement
Quality of Insurance Products
• COST
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In 2007, the Kaiser Family Foundation reported that the cost of providing health care in the United States has
grown from 7.2% of the nation’s economy in 1970 (or $356 per person per year), to about 16% in 2005 (or
$6,500 per person).
This is nearly twice the cost of providing care in Canada ($3,161), France ($3,191.) and Australia ($3,128.); and
more twice as much as Japan ($2,358) and the United Kingdom ($2,560.).
• Economic Reality
– Cost of Healthcare– Healthcare as Social Construction
• What is disease?
– Socialized Medicine Inefficiencies
• Reliance on experts
• Determination of a social minimum: what is basic healthcare?
– Wants become needs
• Moral Hazard-Overuse of the System
• Weak on Research– Free Riders on U.S. Research
– Market-Based Inefficiencies
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Imperfect Information- ”learned intermediaries”
Imperfect FreedomImperfect CompetitionFree Riders- no health insurance
Emphasis on Disease rather than health
– Weak on preventative medicine
• Real World Systems: Mixed Systems
• Emphasize Comprehensiveness (Free Market)
– Healthcare is a Business: Free Market
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Maximize Private Enterprise
Minimize Public Enterprise
Maximize Private Charity
Maximize Innovation
• Maximize Competition– Regulate Monopolies:
» Natural Monopolies
» Artificial Monopolies
– Licensure, Patents, etc
• Emphasize Universality (Socialized Medicine)
– Healthcare is a Public Good
• Marxism
• Welfare Liberalism
– Social Minimum
» Safety Net (needs v. wants)
Beveridge Model
• William Beveridge (England)
• Great Britain, Italy, Spain, Scandinavia, Cuba, and Hong
Kong
• Health Care financed and provided by government via
taxation
– No medical bills, public service
– Most doctors are government employees
– Most doctors are private doctors collect fees from govt.
• U.S. Correlate:
• Military and Veterans, Indian Health Service
• Problems: High Taxation, Shortage of Specialists, Waiting
Lines, Patients may not be treated if the doctor deems
unimportant, Government (not price) rations health care
National Health Insurance Model
• Canadian System
– Canada, Taiwan, South Korea
– Single-Payer System
– Principles Governing Canadian System
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Public Administration
Comprehensiveness
Universality
Portability
Accessibility
– U.S. Correlate: (Medicare)
• Individuals over 65
– Basic Problems: Waiting Lines, High Taxes
Bismarck Model
– Germany, Japan, France, Belgium, Switzerland, Japan
• Otto Von Bismarck (Germany)
– Universal Coverage
– Providers and Payers are Private
– Insurance Financed by Employers and Employees
• Non-Profit Sickness Insurance Funds
• Individual and Employer Mandates
• Price controls on medical services
– U.S. Correlate: Four-Party System
• Most working individuals under 65
– Basic Problems:
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Sickness Funds run out of money
Doctors not highly compensated
Unemployment
Perverse Incentives: Job-Lock, Job-Flight
Out-of-Pocket System
• Countries without any Organized Health Care System
– Somalia, Afghanistan etc.
• Products and Services not covered by Countries with Health Care
Systems.
– Treatments that address wants (elective v. necessary treatments)
• Cosmetic surgery, Sex change, weight reduction surgery etc.
– Treatments with marginal cost-benefit ratios
• Joint replacement surgery
– Dental care, psychiatric care, pharmaceuticals
– Illegal Treatments on the black market (Rhino Horn etc.)
• The United States
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Unemployed or Underemployed
Uninsured with pre-existing conditions
Exceed Lifetime Insurance Limits
Under-Insured
• Contractual Exclusions
• Problems: Access to health care by the poor, inequality of quality
(the rich get better care).
Health Care
Systems in the United
States
• Decentralized Mixed System Based on Groups
• Four-Party System (workers)
– Bismarck Model
• Multiple Systems
– Federal Employees Health Benefit Program (employees of
government)
– Medicare (elderly)
– Beveridge Model
– Medicaid (poor)
– National Health Insurance Model
– Veteran’s Medicine (veterans)
– Beveridge Model
– State Children’s Health Insurance Program (SCHIP)
– National Health Insurance Model
– Reauthorized in 2009
– Cobra Consolidated Budget Reconciliation Act COBRA (unemployed)
Questions for Discussion
• Why are all national health care systems
always subject to “reform?”
• Are comparisons between the U.S. health
care systems and European systems fair?
• Why do all health care systems struggle
with the conflict between “market justice”
and “social justice?”