Here is a recent, short paper I wrote for my initial class at Creighton University for the master’s in health care ethics program:
Robert C. Baker
MH 601
September 11, 2009“Is there anything else I can get you, Herr Baker?”
“Nein; vielen Dank. Auf Wiedersehen.”
And so ended my first exposure to German emergency medical care, necessitated by a cheap can of bad tuna. The slender, intelligent, spectacled Notarzt on call that evening probably saved my life.
While many Americans can tell the tale of surviving food poisoning (or at least “Montezuma’s revenge”) while living or traveling overseas, the truth is that due to disparities in health care many “locals” cannot. That includes those who live within our own borders. Inequities in healthcare access, delivery, and affordability plague not only developing countries, but also “first-world” countries such the United States. Unfortunately, these inequalities are not easily remedied by two quick injections in the backside meant to cure issues at both ends of the alimentary canal. Rather, their their causes and contexts are complicated, and require more than short-term evaluations. . . or solutions.
Commonwealth Health Fund and OECD data provide a helpful and needed starting point for examining health-care inequalities experienced by those living within the United States, especially vulnerable populations. A cursory examination of figures comparing coverage, delivery of care, and performance of the American system, when compared to Canada and most Western European nations, leaves one appalled. Nevertheless, while I utilize external resources to compare and contrast various health systems, noting the strengths and weaknesses of each, I will also suggest that a more thorough analysis of these systems, vis-a-vis their application to the the American context, is needed. The infirmity in America is clear. What is not so clear is the treatment.
In Special Issues with Single-Payer Health Insurance Systems, Gerard F. Anderson and Peter Hussey break single-payer systems down into four categories: regional/private (example: Canada), regional/public (Sweden), central/private (Taiwan), and central/public (the United Kingdom), and multiple-payer systems.(1) Working from a social solidarity framework, Anderson and Hussey find for Canada progressive general taxation, lack of private/public insurance overlap, and capital allocation decisions based on need as strengths. I would add that Canada’s regionally-based system as an additional strength. As weaknesses, Anderson and Hussey note that Canadian provinces may opt out of providing certain drugs or special services. However, Canada’s most serious weakness, in my opinion, is that health care practitioners are relocating to areas where they can make a living, which has resulted in some smaller Canadian locales creating informal “lotteries” for primary care. Canada could be classified as a “Type II” system.
The United Kingdom has a more central/public system that could rightly be called “socialized medicine,” since most hospitals are publicly owned and most physicians are on the government payroll. Health care functions are operated by the National Health Service. Anderson and Hussey note a uniform benefit package, lack of user charges (“co-pays”), and progressive nature of the finance system as strengths. Weaknesses cited include vast disparities in service that can occur between patients who are able to afford private insurance and and those who are unable to afford it. I would add that an additional and unbearable weakness of the UK system is its method of draconian rationing, including the area of much-needed palliative care. The UK can be considered as a “Type 1” system.
Which brings us back to Germany. Although not treated by Anderson and Hussey, like the Netherlands, Germany can be classified as a “Type 3” system. Insurance is mandatory, with the majority of residents (including “temporary” workers) participating in a federal insurance scheme. Workers making above a certain level of income, or the self-employed, may opt out of the federal insurance program so long as they contribute to a private insurance fund. The strengths of Germany’s system are that it enforces health-care enterprises, including insurances companies, to operate on a non-profit basis, that it allows hospitals and health care workers to work in the public sector, and that premiums are based on income. While the federal government operates as a centralized collection agency for health care revenues, it distributes financial resources to privately-run, independent “sickness funds” among which Germans can choose. (2)
Anderson and Hussey make an additional observation worth our consideration. They demonstrate a lack of confidence in “templating”(3) a European health insurance model on America by stating that “there is no universal paradigm for the design of health insurance systems.” (4) This, along with a recognition that a cursory comparison of European vs. American health delivery and outcome statistics may result in a skewed analysis, (5) should give us some pause before suggesting that one system be adopted over another.
Clearly, something needs to be done. But what should be done remains the question. The mixed (types I, II, and III) system we have inherited in the United States works for some, but not for others. But I would argue that a cursory comparison of these figures, that is, a level one comparison, is insufficient for providing us a workable plan for providing better coverage, delivery, and performance.
Because, in the end, a can of bad tuna is a can of bad tuna. But how well you are treated depends on where you eat it.
(1) Anderson, Gerard F. and Hussey, Peter. September, 2004. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/AndersonSpecialIssuesFinal.pdf/. (Accessed September 10, 2009.)
(2) Reinhardt, Uwe E. Reinhardt. “Health Reform Without a Public Plan: The German Model.” April 17, 2009. http://economix.blogs.nytimes.com/2009/04/17/health-reform-without-a-public-plan-the-german-model/. (Accessed September 11, 2009.)
(3) See “Templating.” http://bioethike.com/bakernitions/. (Accessed September 11, 2009.)
(4) Anderson and Hussey, 31.
(5) For example, see Carey, David, Herring, Bradley, and Lenain, Bradley. “Health Care Reform in the United States, Economics Department Working Paper No. 665,” p. 11. http://www.olis.oecd.org/olis/2009doc.nsf/linkto/eco-wkp%282009%296. (Accessed September 11, 2009). In this OECD document, Carey, et. al., note that higher levels of infant mortality in countries such as the United States may be attributable to better pre-and post-natal care that nevertheless ends in infant death.
