Comparative Health Systems Why compare? We have problems and others have different and perhaps better solutions What kind of comparison? Scientific enterprise Inefficiency, efficacy, inequity and cost Repair versus prevent

Criteria for comparison Legitimation and Regulation Services and benefits Finances Eligibility Organization and administration Liabilities and benefits of parties to the medical organization

Other modes of comparison Outcomes Equity Disease versus prevention and public health

Mutual aid model Communal risk and communal cure Minimize financial risk Emphasize prevention Power local and communal Team oriented care delivery Patient not educated except in prevention

State model Strengthen state control Minimize cost, and disease prevalence Universal access Centered on governance and control Not patient or physician centered Primary care, basic care Financed by state taxes

Professional model Professional core delegated the responsibility and the power to provide medical care, finance it and decide who gets it Best care, compassionate care Professional associations control Less primary care, more specialized care Private finance, risk pooling if able Expensive, secret and less equity

Corporatist model Medicine as industry, buyers and sellers Minimize conflict Cost versus provider interests at issue Institution is the corporate body of medicine Negotiated between unequal negotiators Finance depends on the intervention of the state Inequity and cost high

Canada National system with central finance and regional control of allocation Cost controls Indirect care availability controls 12.5% of GNP instead of 20.3% in U.S. 8.5% of Canada’s budget instead of 22% in U.S. Preserved D/P relationship, emphasis on primary care Small population

Will it work here? Entitlement mentality Cost, technology focus Powerful professions Government and insurance industries would suffer in the bargain—balance of power would have to shift

Downsides to our System Red tape—actually less administrative red tape and paper work D/P relationship—we have managed care and too much non-patient contact compared to freeing the doctor to see patients and interact External control to care

Downsides to their System Long lines for elective procedures—reason we have no lines is because people know not to get in lines here—financial penalties too onerous Must admit our addiction to technology and make social changes to our own behavior Lower quality a myth—outcomes and health measures as well as satisfaction BETTER in Canada

Downsides Rationing versus allocation Communal responsibility for allocation of care NOT individual right ONLY prisoners in the US have a RIGHT to care, no one else does—has this changed? In Canada everyone has a right to care that is limited—is this more fair? Equitable?

Downsides Presumed exodus of physicians—actually doctors happier in Canada because the paperwork is less, more patient contact and less direct oversight, negotiation If money really matters then they move

REAL downsides The availability of technology Portability Esoteric care Social control issues

Other issues Universal access Financial control Do we trust and respect the state? Industrial invasion of medicine—who can stop it?

German system Insurance cost based not care based Subsidy of the old by the young Subsidy rich for poor Office/hospital dichotomy Drugs expensive L.E. dropped 9 years in last 15 years

British systems Differentiate the financial control (Canadian system) and financial and organizational control (UK) 1948—took control of finances and organization– made doctors employees and eliminated private medicine NHS as state model

Strengths Universal access Cost control – 6-10% of GNP Better public health and prevention Better control of research and outcomes Less drugs, more health, more education and self-reliance

Weaknesses Regional inequalities Less technology Class variations in use Waits for invasive care

Restructuring NHS Began in the 1980’s Managerial and regional control Performance indicators, quality control Localization of internal markets Empowering the consumer—the return of private medicine and open markets Detailed lists of wait times and outcomes

Restructuring Welfare pluralism Public and private funding returns Flexible firms with more local control and less reliance on government funding A result of social action groups Result of flat technology advances, sameness of care

Italian system Public Universal coverage Regional differences in quality based on cost Unrealistic expectations Can retire at age 50—no contribution while using resources

Concepts of prevention Less harm, less disease with better health Prevention is better than cure and easier And less costly Public health and its separation in US medicine—unlike the rest of the world

Refocusing the Debate over Health Health comes from prevention in a world where chronic illness predominates Health is preferable to disease Disease treatment is short term and temporizing Health promotion is long term and lasting There is futility in both approaches

Refocus NOT battle between makers of disease and health workers Political economy of health—we make an industry of illness and the viability of that industry is dependent on lack of health So get healthy, prevent harm Concept of PERSONAL moral health entrepreneurship Need hierarchies—survival and beyond

Issues Social Justice Universal coverage Who pays How much Access to care Have we solved these issues with reform?