In the world of public health care

Not long ago, well, actually it is still happening now, some people in Canada proposed going to a two-tier private/public healthcare system. Not many people were down with that but here's a good little blurb on some of the issues surrounding public health care in countries where it exists.

"The two tier debate continues here, and in fact we have a 'second tier' if you will. The biggest thing from a Canadian perspective is that we as a country totally endorse the concept of universal healthcare -- that is to say it is considered an absolute that everyone has a right to access the full range of healthcare services indicated by their medical condition. That’s the fundamental principle behind the Canada Health Act. The federal government enforces it fairly fiercely – and that’s the challenge for two tier here. Given the provisions of the Canada Health Act, private clinics are left to ‘augment’ the system – so you see it coming up mostly in private diagnostics and cosmetics kinds of medicine. The other big issue here though is that we have an odd sort of combination. While we all tend to think we have a universal, or publicly operated health system….there is one area that is out. Physicians remain private businessmen, operating their own practices and billing on a piece rate sort of basis. So though it is the government purse for all parties, docs can dictate their own level of work and patient flow, and make as much as they can organize making through office and procedures fees, on call billings and so forth. The rest of the system is given global budgets to operate within, which naturally rations the level of services we can provide. Case in point – Kelowna General Hospital is in desperate need of expansion, due to suddenly becoming the tertiary facility for the whole Interior region overnight, with no accompanying increase in beds or budget. Something that a private operation would not need to deal with. So, now suddenly instead of serving a population of 150,000, they serve the same 150,000 as the community hospital, but now must also provide specialty medicine for 750,000. To get the funds they need to expand, they have to compete for capital funding with all the other projects, bridges, Olympics etc for some dough – which has taken 5 years just to get approval, and will take another 3 or 4 to build. Meanwhile, they must still provide the services, and are require to operate with a ‘no refusal’ policy. Hence stretchers in the hallways and nasty headlines. A physician working out of Kelowna General is a private businessman. Can take as many, or as few patients as he or she chooses. And gets paid more for moving folks through quickly than for taking time to listen and do a thorough assessment. If a surgeon and keen to make lotsa money (or if one is more Pollyanna….to provide better service to larger numbers of needy patients J)his or her ability to do so is contingent upon getting all the OR time they are able to book. So lots of different docs all competing for OR time, in a hospital that is tight on resources and trying desperately to prioritize while they wait for government funding to expand. Which creates political pressure to keep giving the specialists what they want. Just try asking for more money for home care or preventative care in the middle of that melee. The US HMO’s were/are an attempt to meet in the middle…….create a managed ‘system’ which provides access in a sustainable way to all members of the group. Problem is in who gets to say what the client gets or who provides their care. The docs are on salary though, which is probably a good thing. It’s a sticky issue – the British NHS has some interesting lessons to look at in all this as well. Also Germany and Sweden. And no one has figured out how to create an accessible, high quality system that is economically sustainable. At present 45 cents out of every tax dollar goes to health care in Canada. There are those who argue that with the trajectory it is on (costs rising at 8%, GDP rising at 2%) in another 10 years we’ll be chewing up 70%, with education taking another 20%....leaving not much for everything else. I’m not sure I buy that argument myself….but its certainly out there. Most consider our system one of the best in the world. Along with a few countries in Europe, the fact that access to the care you need is not dependent on income is, I believe fundamental to a civilized society." -Katie Hill, Leader, Home and Community Care, Interior Health Authority