- Publicly-funded health care
Publicly funded health care, or publicly funded healthcare, is
health carethat is financed entirely or in majority part by citizens' tax payments instead of through private payments made to insurance companies or directly to health care providers ( health insurance premiums, copayments or deductibles).
Financing of health care in public systems
Publicly funded health care systems are usually financed in one of two ways: through
taxationor via compulsory social health insurance.Claude Blanchette, Erin Tolley. [http://dsp-psd.pwgsc.gc.ca/Collection-R/LoPBdP/BP/bp438-e.htm "PUBLIC- AND PRIVATE-SECTOR INVOLVEMENT IN HEALTH-CARE SYSTEMS: A COMPARISON OF OECD COUNTRIES."] May 1997. Retrieved September 12, 2006.]
In compulsory insurance models, healthcare is financed through a "sickness fund", which can receive income from a number of places such as employees' salary deductions, employers' contributions, or top-ups from the state.
Varieties of public systems
developed countriescurrently have partially or fully publicly funded health systems. For some examples, see the United Kingdom's National Health Service(NHS), or the Medicare systems in Canada and in Australia. In the United States, the role of the government in healthcare provision is a source of continued and sharp debate. According to the Institute of Medicineat the National Academy of Sciences, the United Statesis the only wealthy, industrialized nation that does not provide universal health care. [http://www.iom.edu/?id=17848 Insuring America's Health: Principles and Recommendations] , Institute of Medicine at the National Academies of Science, 2004-01-14, accessed 2007-10-22] [ [http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm The Case For Single Payer, Universal Health Care For The United States] ]
Even among these countries, different approaches exist to the funding and provision of medical services. Systems may be funded from general government revenues (as in the
United Kingdomand Canada), or through a government social security system (as in France, Belgium, Japan, and Germany) with a separate budget and hypothecatedtaxes. The proportion of the cost of care covered also differs: in Canada, all hospital care is paid for by the government, while in Japan patients must pay 10 to 30% of the cost of a hospital stay. Services provided by public systems vary. For example, the Belgiangovernment pays the bulk of the fees for dental and eye care, while the Australian government covers only eye care.
Publicly funded medicine may be administered and provided by the government, as in the United Kingdom; in some systems, though, medicine is publicly funded but most health providers are private entities, as in Canada. The organization providing public health insurance is not necessarily a public administration, and its budget may be isolated from the main state budget. Some systems do not provide universal healthcare, or restrict coverage to public health facilities. Some countries, such as Germany, have multiple public insurance organizations linked by a common legal framework.
Innovations in health care can be very expensive.
Population aginggenerally implies more health care, at a time when the taxed working population decreases.
Two-tier health care
Almost every country that has a publicly funded health care system also has a parallel private system, generally catering to private insurance holders. While one goal of public systems is to provide equal service to all, this
egalitarianismis often partial. Every nation either has parallel private providers or its citizens are free to travel to a nation that does, so there is effectively a two-tier healthcaresystem that reduces the equality of service.
From the inception of the NHS model (
1948), public hospitals in the United Kingdom have included "amenity beds" which would typically be siderooms fitted more comfortably, and private wards in some hospitals where for a fee more amenities are provided. These are predominantly used for surgical treatment, and operations are generally carried out in the same operating theatres as NHS work and by the same personnel. These amenity beds do not exist in other publicly funded systems, such as in Spain. From time to time, the NHS pays for private hospitals ("arranged hospitals") to take on surgical cases for which NHS facilities do not have sufficient capacity. This work is usually, but not always, done by the same doctors in private hospitals.
Issues regarding publicly funded health care are frequently the subject of political debate. [ [http://www.democracynow.org/article.pl?sid=04/09/16/147244 Democracy Now! | Election Issue 2004: A Debate on Healthcare ] ] [http://www.cfpc.ca/local/files/Communications/Health%20Policy/Private_public_debate19Aug05.pdf] In the United States, whether or not a publicly funded universal health care system should be implemented is one such example. [ [http://www.upenn.edu/pnc/ptbok.html "The Great Health Care Debate of 1993-94" ] ]
The case for publicly funded health care
Supporters of publicly funded health care claim that publicly funded health care has several advantages over
Some studies have found that private for-profit hospitals are more expensive and have higher death rates than private not-for-profit hospitals. The researchers attribute these patterns to the for-profit nature of the hospitals. [http://www.pnhp.org/single_payer_resources/forprofit_hospitals_cost_more_and_have_higher_death_rates.php For-Profit Hospitals Cost More and Have Higher Death Rates] , "Physicians for a National Health Program"] The quality of
health maintenance organizationsand managed carehas also been criticized by proponents of publicly funded health care. [ [http://www.pnhp.org/single_payer_resources/forprofit_hmos_provide_worse_quality_care.php For-Profit HMOs Provide Worse Quality Care] , "Physicians for a National Health Program"]
According to a 2000 study of the
World Health Organization, publicly funded systems of industrial nations spend less on health care, both as a percentage of their GDPand per capita, and enjoy superior population-based health care outcomes. [ [http://www.who.int/whr/2000/en/whr00_en.pdf Prelims i-ixx/E ] ] However, conservative commentators have criticized the WHO's comparison method for being biased; the WHO study marked down countries for having private or fee-paying health treatment and rated countries by comparison to their expected health care performance, rather than objectively comparing quality of care.
Cost and efficiency
Proponents of publicly funded health care point out that the United States, which has a partly free market health care system, spends a higher proportion of its GDP on health care (15%) than most other countries. [ [http://www.who.int/whr/2006/whr06_en.pdf The World Health Report 2006] ] They have claimed that the need to provide
profits to investors in a predominantly free market health system, and the additional administrative spending, tends to drive up costs, leading to more expensive health care provision. Some studies have found that private for-profit hospitals are more expensive and have higher death rates than private not-for-profit hospitals. The researchers have attributed this to the for-profit nature of these hospitals.
Some commentators on the political left argue that a publicly funded health care system is inherently superior because they regard health care as a
human right,United Nations, [http://www.un.org/Overview/rights.html Universal Declaration of Human Rights] , Adopted and proclaimed by General Assembly resolution 217 A (III) of 10 December 1948. Article 25 states: "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control."] and argue that access to health treatment should not be based on ability to pay. [ [http://cesr.org/ushealthright?PHPSESSID=91...a78f9969da61bd9 The Right to Health in the United States of America: What Does it Mean?] , Center for Economic and Social Rights, October 2004] [ [http://www.nhchc.org/humanright.html Human Rights, Homelessness and Health Care] , National Health Care for the Homeless Council] Proponents of publicly funded health care also criticize the profit motive in medicine as valuing money above public benefit.cite journal |author=Woolhandler S, Himmelstein DU, Angell M, Young QD |title=Proposal of the Physicians' Working Group for Single-Payer National Health Insurance |journal=JAMA |volume=290 |issue=6 |pages=798–805 |year=2003 |pmid=12915433 |doi=10.1001/jama.290.6.798 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=12915433 |accessdate=2008-01-20] For example, pharmaceutical companies have reduced or dropped their research into developing new antibiotics, even as antibiotic-resistant strains of bacteria are increasing, because there's less profit to be gained there than in other drug research. [cite news |first=Sabin |last=Russell |title=Bacteria race ahead of drugs
url=http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/01/20/MN1234A1.DTL |work= |publisher=San Francisco Chronicle |date=2008-01-20 |accessdate=2008-01-20 ]
The case against publicly funded health care
Those who oppose publicly funded health care, predominantly on the political right, have pointed out a number of flaws in publicly funded health care systems, such as those which operate in Canada, the United Kingdom and Germany. Public health care systems have been criticized for poor quality of care, long waiting lists, and slow access to new
drugs. [http://www.freemarketcure.com/whynotgovhc.php Why Isn't Government Health Care The Answer?] , "Free Market Cure", 16 July 2007] [http://www.freemarketcure.com/singlepayermyths.php The Myths of Single-Payer Health Care] , "Free Market Cure", 16 July 2007] [http://www.washingtonpost.com/wp-dyn/content/article/2007/07/16/AR2007071601391.html A Story Michael Moore Didn't Tell] , "Washington Post", 18 July 2007]
Quality of care
International comparisons of health care quality are difficult and have yielded mixed results. For example, an international comparison of health systems in six countries by the
Commonwealth Fundranked the UK's publicly funded system first overall and first in quality of care. Systems in the United States and Canada tied for the lowest overall ranking and toward the bottom for quality of care. [ [http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678 "Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care"] by Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea Commonwealth Fund, May 15, 2007.]
Overall, Canadians are quite satisfied with the quality of health care they receive. In a regularly conducted opinion poll, 70% of Canadians reported that they were either very satisfied or somewhat satisfied with the quality of care they receive compared to 30% being somewhat dissatisfied or very dissatisfied. The main factor of dissatisfaction is waiting times. [http://www.mediresource.com/e/pages/hcc_survey/pdf/HCiC_1998-2003_retro.pdf A POLLARA Report: Health Care in Canada Survey: Retrospective 1998-2003] A
2006study by Nadeen Esmail and Michael Walker of the Fraser Institutefound that Canadians are more likely than citizens of most other developed countries to experience long waiting lists for medical care, and that access to doctors is comparatively difficult; the study criticized the Canadian model of universal health care. [ [http://www.fraserinstitute.ca/admin/books/files/HowGoodHealthCare2006.pdf How Good is Canadian Health Care] , Fraser Institute, 24 July 2007]
Public health care varies significantly from country to country. Many countries allow for private medicine in addition to the public health care system. Some countries, e.g. Norway, have more doctors per capita than the United States. [ [http://www.who.int/whosis/database/core/core_select.cfm Core Health Indicators ] ] Also, the US does not have any official record for waiting lists, but a 2005 survey by the Commonwealth Fund of sick adults in six nations found that only 47% of US patients could get a same- or next-day appointment for a medical problem, worse than every other country except Canada. [ [http://www.businessweek.com/magazine/content/07_28/b4042072.htm The Doctor Will See You—In Three Months ] ]
Innovation and development of new treatments
It has also been noted that the largely free market system of health care in the United States has led to the faster development of more advanced medical treatment and new
drugs, and that cancer patients in the United States for many forms of cancer, including those of the breast, thyroid and lung, have higher survival rates than their counterparts in publicly-funded health systems in Europe. Some analysts have pointed out the difficulty of comparing international health statistics. In particular, the mortality rates for cancer in the United States is at about the same level as many other countries, suggesting that the higher survival rates are a function of the way cancer is diagnosed. [ [http://ezraklein.typepad.com/blog/2007/10/rudy-and-social.html Ezra Klein: Rudy and "Socialized Medicine" ] ] Many have theorized that public care systems, in which there is more bureaucratic government involvement and less financial incentive in the health care industry, lead to less motivation for medical innovation and invention. [Pipes, S. [http://www.pacificresearch.org/press/opd/2003/opd_03-10-17sp.html Border Crossings] , Pacific Research Institute, October 17, 2003. Retrieved September 18, 2006.]
Impact on physicians
Some commentators have pointed out that in publicly funded systems, health care workers' pay is often unrelated to quality or speed of care. Thus very long waits can occur before care is received. There is also less financial motivation for the most able people to enter health care professions. For example, in Canada, which has a broad publicly-funded health system, the average physician earns only 42 percent of the annual salary earned by their counterparts in the United States,Fact|date=January 2008 this has led to long waiting lists for care (17.8 weeks in 2006).Fact|date=January 2008 This difference in physician income reflects Canada's more limited spending on health care overall; in 2004, combined public and private spending on health care consumed 15.4% of U.S. annual GDP; in Canada, 9.8% of GDP.cite web |url=http://www.who.int/whosis/database/core/core_select_process.cfm?countries=all&indicators=nha |title=World Health Organization: Core Health Indicators |accessdate=2007-06-20 |format= |work= ] By limiting the amount of money in the health care system through political mechanisms, shortages of health care resources (such as physicians, nurses, medical equipment, medical devices, pharmaceuticals, and hospitals) are more likely to occur. Opponents claim that higher salaries constitute an incentive to enter the profession and attract more qualified individuals who would otherwise choose a different profession.Fact|date=January 2008
Another possible criticism of publicly-funded systems cites the fairness of paying for people's poor individual decisions (smoking, drinking, taking drugs, etc.) as they relate to health care costs. It is argued that these costs should be incurred solely by those making those poor decisions. Some American commentators have opposed publicly-funded health systems on ideological grounds, as they argue that public health care is a step towards
socialismand involves extension of state power and reduction of individual freedom. [ [http://article.nationalreview.com/?q=ZmY0ZGVjYjIyZjZmMDExZTJlYmY4MGFiZGQ4NjgwOGE Moore "World of We"] , "National Review", 13 July 2007]
Aspects of the United States health system
Whether publicly funded health care can adequately deliver health care more cost effectively than the free market is a matter of much debate. Of all developed nations, the healthcare system of the United States has the highest degree of privatization. Consequently, it is frequently cited by those favoring or opposing universal health care.
The cost and quality of care in the United States are frequently the two major issues of discussion. The United States performs worse than the average developed country in health measures such as
infant mortality[ [http://www.cdc.gov/omh/AMH/factsheets/infant.htm Infant Mortality Fact Sheet ] ] , maternal death[ [http://query.nytimes.com/gst/fullpage.html?sec=health&res=990CE3DF1338F935A15754C0A963958260 In a Ranking of Maternal Health, U.S. Trails Most Developed Nations - New York Times ] ] , and life expectancy[ [http://www.who.int/inf-pr-2000/en/pr2000-life.html PR-2000/ WHO Issues New Healthy Life Expectancy Rankings ] ] , although some studies claim the data collected regarding infant mortality and life expectancy do not lend themselves to fair comparison. [ [http://www.nationalcenter.org/NPA547ComparativeHealth.html Don't Fall Prey to Propaganda: Life Expectancy and Infant Mortality are Unreliable Measures for Comparing the U.S. Health Care System to Others ] ] Access to advanced medical treatments and technologies is greater than in most other developed nations and waiting times may be substantially shorter for treatment by specialists. [ [http://www.nytimes.com/2006/02/26/international/americas/26canada.html?ex=1142053200&en=06d7eacb3aa96155&ei=5070 As Canada's Slow-Motion Public Health System Falters, Private Medical Care Is Surging - New York Times ] ]
The United States does spend more on health care, as an absolute dollar amount and per capita, than any other nation. It also spends a greater fraction of its national budget on health care than Canada, Germany, France, or Japan. In 2004 the United States spent $6,102
USDper person on health care, 92.7% more than any other G7country, and 19.9% more than Luxembourg, which, after the US, had the highest spending in the OECD. [http://ocde.p4.siteinternet.com/publications/doifiles/012006061T02.xls] Risk factors specific to the US population, such as a relatively high prevalence of obesity, may partially explain increased health care spending; however, many other industrialized nations do share these problems to some extent.Fact|date=April 2007 Although the US Medicare coverage of prescription drugs began in 2006, most patented prescription drugs are significantly more costly in the US than in most other countries. Factors involved are the absence of U. S. government price controls, enforcement of intellectual property rightslimiting the availability of generic drugs until after patent expiration, and the monopoly purchasing power seen in national single-payer systems Fact|date=October 2007. Some US citizens obtain their medications, directly or indirectly, from foreign sources, to take advantage of lower prices.
The United States system already has substantial public components. Of every dollar spent on health care in the US, 45 cents comes from some level of government. [cite news |first=Julie |last=Appleby |title=Universal care appeals to USA |url=http://www.usatoday.com/money/industries/health/2006-10-15-universal-usat_x.htm |work= |publisher=USA Today |date=2006-10-16 |accessdate=2007-05-22 ] The federal Medicare program covers the elderly and people with disabilities, the federal-state
Medicaidprogram provides coverage to the poor, the State Children's Health Insurance Program ( SCHIP) extends coverage to low-income families with children, merchant seamen are covered by the Public Health System, and retired railway workers and military veterans are also covered by the government. [ [http://www.cms.hhs.gov/ U.S. Department of Health & Human Services, Centers for Medicare and Medicaid Services] ] Government also affects private sector medicine through licensing and regulatory barriers to entry into health professions.
Market failure issues
Various health care analysts have asserted that
market failureoccurs in health care markets, [ [http://www.oheschools.org/ohech3pg2.html Economics of health care. Market failure - an overview ] ] but some have suggested that it is a result of too much government involvement rather than too little. [http://www.massey.ac.nz/~kbirks/hecon/pha93.htm] [ [http://www.fff.org/freedom/fd0409g.asp America's Socialized Health Care ] ]
The consumers of health care often lack basic information compared to the medical professionals they buy it from, and fully informed choices (particularly in emergencies) are often not plausible. Meanwhile, health insurance companies and care providers also suffer from
information asymmetry, as patients are almost always more aware of their particular family histories and risky behaviors than the firms are. Price theory dictates that the risk cost associated with this lack of information gets passed on to consumers. Demand is likely to be inelastic. The medical profession potentially may set rates that are well above ideal market value, and they are controlled by licensing requirements, with some degree of monopolyor oligopolycontrol over prices. Monopolies are made more likely by the variety of specialists and the importance of geographic proximity. Private insurance has been perhaps the only stabilizing force as they pay a contractually fixed cost for a given procedure. With no more than one or two heart specialists or brain surgeons to choose from, competition for patients between such experts is limited so contractually pre-arranged pricing helps reduce supply-limited pricing.
Preventive medicine issues
There is much conflicting information about the role of preventive medicine in controlling medical costs and improving the health of citizens. Advocates of publicly funded medicine claim that preventive care saves money and prolongs life, [ [http://www.healthcareforall.org/basics.html Basic questions about universal health care insurance ] ] [ [http://newstandardnews.net/content/index.cfm/items/2759 Health Care Reformers Decry Bush?s ?Savings Accounts? - The NewStandard ] ] but opponents assert that it does neither. [ [http://www.ncpa.org/ba/ba188.html NCPA - BA #188 - Is Preventive Medical Care Cost-Effective? ] ] [ [http://www.debate-central.org/topics/2002/book2.pdf 20 Myths About Single-Payer Health Insurance ] ]
Difficulties of analysis
Cost-benefit analyses of various health care systems are frequently mentioned by advocates and opponents of publicly funded healthcare programs. Others caution that these analyses are difficult to do accurately due to the multifactoral nature of health, healthcare delivery, and healthcare financing, as well as the lack of consensus on what is "best" for a nation or its people.
Canadian and American health care systems compared
Kaiser Family Foundation
Massachusetts health care reform
National health insurance
National Physicians Alliance
Physicians for a National Health Program
Single-payer health care
United States National Health Insurance Act
Universal health care
*Devereaux PJ, Heels-Ansdell D, Lacchetti C, Haines T, Burns KEA, Cook DJ, et al. [http://www.cmaj.ca/cgi/content/full/170/12/1817 Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis] . CMAJ 2004;170(12):1817-24.
*Devereaux PJ, Choi PT, Lacchetti C, Weaver B, Schunemann HJ, Haines T, et al. [http://www.cmaj.ca/cgi/content/abstract/166/11/1399 A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals] . CMAJ 2002;166(11):1399-406.
*Woolhandler S, Himmelstein DU. [http://content.nejm.org/cgi/content/full/341/6/444 When Money is the Mission — The High Costs of Investor-Owned Care] . N Engl J Med 1999;341:444-6.
*Krauss, C. [http://www.nytimes.com/2006/02/26/international/americas/26canada.html?ex=1142053200&en=06d7eacb3aa96155&ei=5070 As Canada's Slow-Motion Public Health System Falters, Private Medical Care is Surging] , New York Times, February 26, 2006.
* [http://npalliance.org/content/pages/2008_presidential_candidate_health_plan_report_card 2008 Presidential Candidate Health Plan Report Card] issued by the
National Physicians Alliance
* [http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=647708 Envisioning the Future: The 2008 Presidential Candidates' Health Reform Proposals] from The Commonwealth Fund
* [http://www.reuters.com/article/healthNews/idUSN3143203520080331?feedType=RSS&feedName=healthNews&rpc=22&sp=true Doctors support universal health care: survey] , Reuters, March 31, 2008 (first reported in Annals of Internal Medicine).
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