Ronald F. White, Ph.D. Professor of Philosophy College of Mount St. Joseph

National Health Care Systems What is the “Ideal National Health Care System?” –UNIVERSAL ACCESS A formal principle or abstraction –Access to what? »Wants v. Needs –QUALITY OF HEALTH CARE What is “Good Health Care?” –Individual v. Collective Measures Quality of what? –Health care professionals, hospitals, drugs, biomedical technologies, laboratories, research institutions, medical schools, health insurance Quality Sensitivity –Availability of qualitative information –Ability to act on qualitative information Quality as Comprehensiveness –Number of products and services available –Health Care Needs v. Wants Scientific Medicine –Regulation of Research –AFFORDABLE COST What is “Affordable Health Care” –How much does it cost? –How much is too much? Who Benefits and Who Pays the Cost?

The U.S. Health Care System ACCESS In 2005, the Census Bureau reported that at least 44.8 million Americans were without health insurance coverage. –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 and older adults (Census Bureau, 21) –The uninsured rate among young adults, signals a corresponding rise in the number of uninsured young children. QUALITY –Global Measurement of Quality 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) –Hamilton County, Ohio 13.9 (More than twice the National Average) Medical Mistakes Comprehensiveness –Number and Quality of Products and Services –Heroic Medicine and Enhancement –Quality of Insurance Products COST –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 Imperfect Information- ”learned intermediaries” Imperfect Freedom- Imperfect Competition- Free 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 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 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 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: 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 –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?”