Brad Sallows said:
I already wrote that exceptions should be made for those on low income. I don't recall anyone here has proposed that people on low incomes be squeezed for the same amount of money - or, really, any significant amount of money - as the majority of Canadians whose incomes are just fine. I especially find it amusing to see the "very young" raised as an objection, unless adults under 30 are "very young" and uniformly underpaid. I have never, anywhere, heard or read a suggestion that the truly "very young" (ie. children) be presented with bills. Can we move past the straw-clutching now?
Before I continue, may we clarify the subject that this “sub-argument“ deals with. My post (what is routine care?), which seemed to initiate this current discussion, was an attempt to show some on this means that user fees would not realize the savings that they seem to think it could, when used either as a negative incentive or an income generator.
My impression as this discussion continued was that you count yourself among those who feel that market forces should be a (or the) primary factor in the evolution of a Canadian health care system; those that can afford to pay directly for their health care should do so either through personal spending or private health insurance. But those few (those
rare unhappy few) who cannot fend for themselves may be supported by a public system. However, I could be mistaken in my impression.
Brad Sallows said:
… I fully expect that with a single public insurer - one point of contact for most billing - we should have lower administrative costs. However, that tells us nothing about the desirability of public vs private delivery.
Or am I?
Brad Sallows said:
… If health care is a right, then I'm just about ready to quit my job and enjoy my leisure. Welfare is a right, too. That looks after pretty much everything I need. Now, where do I collect my rights?
Well, maybe not.
Brad Sallows said:
... But, while we may surely dispute the number of programs we need which provide benefits, the key should always be that the benefits are at least in principle universal - for example, education and health insurance.
So we may see eye to eye on some things, but maybe not on others.
Brad Sallows said:
… no, I'm not proposing "survival of the fittest" or that no government be involved in any of those areas.
What I would do, for example, is to have _everything_ associated with health care delivery turned over to the province, with a consequent strong pressure to further devolve spending responsibilities to whatever constitutes regional health authorities. This would probably result in different approaches to providing health care, and different standards of care. Some see this as a bad thing. What I see is that different provinces and regions need different types of care - …
However, maybe instead of asking “what is routine”, I should have asked “what is catastrophic” or “what is in between”. Is this the point at which you think that health insurance benefits should begin?
Brad Sallows said:
The reason for public catastrophic insurance is simple, and
Fred Reed makes it. Pay particular attention to his admonition in the last paragraph.
I did like the blog piece by Fred Reed so I’ll post the last paragraph here.
http://www.fredoneverything.net/SocializedMedicine.shtml
But let’s at least have the dignity to say what we mean. The truth is that large numbers of people cannot take care of themselves beyond showing up at work every day and spinning lug nuts on the assembly line. They aren’t going to invest wisely from youth because they aren’t smart enough. Employers aren’t going to provide retirements unless forced to. Hospitals won’t take them if they can avoid it. Do we say, “Screw’em, let’em croak”? Apparently. Then let’s say so plainly.
You appear to suggest that my view is flawed and I assume that you believe that I have reached such a conclusion solely on an ideological basis. Most discussions on this subject (both here and in the USA) are hampered by ideological bias on both sides of the debate. Do I have some biases? Sure, otherwise I would be the only person in the world without them. But, have I developed my opinion solely on altruistic, touchy-feely motives? No, I’m like most other people in this country; I don’t want to pay taxes that go for services others use and for which I (currently) have limited need. I could ***** about public education the same. Why should I (without children) be paying local school (property) taxes when I have no need of the services. Damn the rest of them who decided to procreate. What is the benefit that accrues directly to
me. And what about fire protection, public transportation, roads, etc? We long ago realized that there was a common social and economic benefit to these services being funded in common by all (through taxation). The same should hold for health care.
On what do I base my viewpoint. Some of the sources I used were found in reports or studies from the following organizations: (I recommended both for relatively un-biased information)
The Canadian Institute for Health Information http://www.cihi.ca/cihiweb/dispPage.jsp?cw_page=home_e
The Canadian Institute for Health Information (CIHI) is an independent, not-for-profit organization that provides essential data and analysis on Canada’s health system and the health of Canadians.
CIHI tracks data in many areas, thanks to information supplied by hospitals, regional health authorities, medical practitioners and governments. Other sources provide further data to help inform CIHI’s in-depth analytic reports.
The Henry J. Kaiser Family Foundation http://www.kff.org/
A leader in health policy and communications, the Kaiser Family Foundation is a non-profit, private operating foundation focusing on the major health care issues facing the U.S., with a growing role in global health. Unlike grant-making foundations, Kaiser develops and runs its own research and communications programs, sometimes in partnership with other non-profit research organizations or major media companies.
We serve as a non-partisan source of facts, information, and analysis for policymakers, the media, the health care community, and the public. Our product is information, always provided free of charge – from the most sophisticated policy research, to basic facts and numbers, to information young people can use to improve their health or elderly people can use to understand their Medicare benefits.
In reaching my conclusion I asked myself some of the following questions.
How much of Canada’s health care spending is from public funding?
Total Health Expenditure by Source of Finance 2005 and Outlook for 2006 and 2007
In 2005, governments and government agencies in Canada (the public sector) spent $99.1 billion. Public sector expenditure is forecast to be $105.7 billion in 2006 and $113.0 billion in 2007. The growth rates associated with these increases are 6.7% and 6.9%, respectively. In 2005, private health insurers and households (the private sector) spent $42.2 billion. Private sector expenditure is forecast to reach $44.6 billion in 2006 and $47.1 billion in 2007, assuming growth rates of 5.7% in 2006 and 2007.
Since 1997, the public sector share of total health expenditure has remained relatively stable at around 70%. It accounted for 70.1% of total expenditure in 2005 and is forecast to account for 70.3% in 2006 and 70.6% in 2007.
What percentage of total (public and private) funding is used for what we characterize as providing sickness services. i.e. physician services, diagnostic services, hospitalization, drugs
Who uses these services the most?
One interesting comment regarding utilization from an American perspective. While it may not be the exact situation in Canada, there are similarities in utilization patterns between the two countries.
Concentration of Health Spending
While discussions about the costs of health care often focus on the average amount spent per person, spending on health services is actually quite skewed. About ten percent of people account for over 60% of spending on health services; over 20% of health spending is for only 1% of the population. At the other end of the spectrum, the one-half of the population with the lowest health spending accounts for just over 3% of spending .
Does socioeconomic factors (income and education) determine access and use?
Several studies that researched this question had results similiar to this study.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1829158
We found that lower income was associated with less contact with general practitioners, but among those who had contact, lower income and education were associated with greater intensity of use of general practitioners. Both lower income and education were associated with less contact with specialists, but there was no statistically significant relationship between these socioeconomic variables and intensity of specialist use among the users. Neither income nor education was statistically significantly associated with use or intensity of use of hospitals.
Do dual insurance systems improve access and increase the availability of services to augment the public funded system?
I’ll refer you to this paper. Some of its findings mirror other studies of the subject, but I haven't quoted the findings here due to space limitations.
http://www.parl.gc.ca/information/library/PRBpubs/prb0571-e.htm
This paper examines the experience of Australia, New Zealand and the United Kingdom – where duplicate private health care insurance is permitted – to assess the potential implications of duplicate private insurance for Quebec’s (and Canada’s) health care system.
But don’t user fees work well in other countries?
Some cite other countries as examples of publicly funded health systems that are more efficient than ours and have user fees. Sweden is one that is often so described. (Recently discussed in a Frasier Institute report)
http://www.sweden.se/templates/cs/FactSheet____15865.aspx
Financing
Costs for health and medical care amount to approximately 9 percent of Sweden’s gross domestic product (GDP), a figure that has remained fairly stable since the early 1980s. In 2005 care and services provided by the county councils, including the subsidization of pharmaceuticals, cost SEK 175 billion (USD 25.4 billion). Seventy-one percent of health care is funded through local taxation, and county councils have the right to collect income tax, the average level being 11 percent. Contributions from the state are another source of funding, representing 16 percent, while patient fees only account for 3 percent. The remaining 10 percent come from other contributions, sales and other sources.
Most county councils use some form of purchaser–provider system, in which a council negotiates compensation agreements with health care units – for example, performance-based compensation determined by diagnosis-related group (DRG), that is, a system to classify hospital cases into one of approximately 500 groups expected to have similar hospital resource use. This allows hospitals to become more independent of political bodies. In some cases hospitals have become corporations owned by the council. It is now more common for county councils to buy health care services – 10 percent of health care is financed by county councils but carried out by private health care providers.
Patient fees
The fee for staying in a hospital is SEK 80 per day. Fees for outpatient care are decided by each county council. Fees to consult a primary care physician range from SEK 100 to 150. An appointment with a specialist will cost more. To limit costs for the individual there is a high-cost ceiling, which means that after a patient has paid a total of SEK 900, medical consultations in the twelve months following the date of the first consultation are free of charge. A similar ceiling exists for prescribed medication, so no one pays more than SEK 1,800 per twelve-month period.
1.0 CAD = 6.25518 SEK
Organization
Primary care has traditionally played a less important role in Sweden than in many other European countries. However, the aim is now to make it the basis of the health and medical care system. Today most health care is provided in health centers where a variety of health professionals – doctors, nurses, midwives, physiotherapists and others – work. This should simplify things for patients and foster teamwork. Patients should be able to choose their own doctor. Around 25 percent of health centers are privately run by enterprises commissioned by county councils. There are special clinics for children and expectant mothers as well as family planning clinics for teenagers.
Sixty hospitals provide specialist care with emergency room services 24 hours a day. Eight are regional hospitals where highly specialized care is offered and where most teaching and research is located. Since many county councils have small service areas, six health care regions have been set up for more advanced care. Furthermore, as Sweden only has nine million inhabitants, the entire country must serve as one service area for the most advanced specialist care. This is coordinated by a newly formed committee, Rikssjukvårdsnämnden, within the National Board of Health and Welfare.
The county councils own all emergency hospitals, but health care services can be outsourced to contractors. For pre-planned care there are several private clinics from which county councils can purchase certain services to complement care offered within their own units. This is an important element of the effort to increase accessibility.
Yes, the Swedish model does offer some good points, but to make an example of their user fees in isolation as a panacea for what ails our system is disingenuous. The Swedish system works well for Sweden and there may be things we could adopt from them, but you also have to look at it in conjunction with the Swedish “welfare state’ (and high tax) mentality (though that is changing). Also they have complaints similar to ours with regards to “waiting times” and physician shortages especially in primary care. One of the factors that may be related to the last issue is that steps taken to control use (costs) included regulating the working volume and income levels of GP’s, forcing older doctors to retire to reduce “surplus output” and banning doctors from opening a new practice without a council agreement. Now that would be a major paradigm shift for Canadian doctors. Of course, if one of the benefits of a “Swedish” system were an increase in the availability of tall, slender, blonde women, I am all for it.
Clutching at straws, I think not. My review of the question led me to the conclusion that simply imposing user fees would not substantially reduce public health care spending and thus lowering my taxes without, at the same time, increasing my out of pocket health costs. So I’ll stick to my conclusion as you haven’t provided any evidence to the contrary, other than a mantra that everyone should pull themselves up by their bootstraps and take care of themselves. “Routine health care is something most people can and should pay out of their own pockets”. Actually they already do, it’s just that they feel that their share of the cost (their taxes) is inequitable.
