Health Care: A Right or a Privilege?

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Health Care A Right or a Privilege?

• S. Theodoulou

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Health Policy

• Goal to promote and attain the populations good
  health
• Involvement of the State in the provision of
  health is a modern phenomenon
• Link between welfare provision and good health
• Clear link between labor productivity, economic
  growth, and the populations good health
• 1 more year of male life expectancy1 GDP growth
  after 15 years
• 2000- World Health Organization (WHO) published
  the first ever analysis of health systems (192
  countries)

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WHO

• Health insurance sould be extended to as many
  individuals as possible (especially the poor)

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State Roles in the Provision of Health

• Regulator
• Funder/Purchaser
• Provider/Planner

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Brazil

• 1940 Special Services for Public Health (SESP)
• 1960s-80s The military centralized the
  system Privatization
• 1967 National Institute of Social Wellness (INPS)
  optional care to the (urban) employed
• Early 1970s Movement supporting public health
  reformObstacles (lack of resources, opposition
  of the private sector, the bureaucracy,
  corruption) The same obstacles exist today)
• 1975 Plan for Immediate Care (PPA) First real
  step towards universalization- the INPS becomes
  more ambitious in scope, with the creation of the
  National Institute of Medical Assistance and
  Social Security.
• Early 1980s Centralization (Integrated Health
  Act Program)

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• Reforma Sanitaria decentralization inthe
  provision of health services.
• Goal to create a network of health services that
  cover the entire populationalso the rural part
  of the population.
• 1988 Constitution Sistema Único de Saúde (SUS)
  Single and ambitious health system, in principle
  covering the whole nation. Foundation of the
  present system
• 1990 Organic Health Law Universal State health
  care
• Hindered by successive financial (and debt)
  crises
• Gvt. Stronger commitment from 1985-92, then
  diminished for financial problems (IMF, World
  Bank loans, etc)

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Organization

• Two health care systems in Brazil
• Public federal (basic services), state (endemic
  diseases, parental and infant care), municipal
  (emergency)
• Private for profit institutions, philantropic
  institutions (Catholic Church), prepaid systems,
  cooperativesManaged care (corporations) since
  the mid 1990s
• Imbalanced system, both geographically and in
  terms of class

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Germany

• Corporatist-Governmed system established by
  Bismark in the 1880s
• Autonomous from the State
• 90 Germans are covered
• Principles
• Solidarity commitment to take care of each other
• Subsidiarity belief in shared power, mutual
  respect, and incorporating as many people as
  possible into the system. Self-help, family,
  voluntary associations
• Corporatism party and labor forms of
  representation

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History

• 1864 Mutual Aid Societies
• 1883 Health Insurance Act (sickness funds)
• After WWII, 2 systems
• East nationalized health care (erosion of the
  private sector)
• West renewed commitment to the pre-War
  principles. Extension of coverage in the 1960s
• 1970s Cost crisis (1975-1992, 13 laws addressed
  the problem)
• 1992 Health Care Structural Reform Law (limits
  budgets to contributions, increases consumer
  choice, stricter controls, opens sickness funds
  to competition for clients)

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Organization

• Productive Efficient system
• Corporatist, decentralized, multi-payer system
  based upon the same principles
• The Federal gvt. Has no power of implementation
• System centered on sickness funds, which have the
  status of public-law bodies and make health care
  decisions
• Sickness funds are intermediaries between the
  Gvt. And the people
• Comprehensive benefits
• 9/10 Germans are enrolled in sickness funds
• Disincentives to profit
• Funded by taxes, gvt. Subsidies, and individual
  contributions. Also, private insurance

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Great BritainHistory

• The Poor Laws (workhouses/poorhouses)
• 1911 National Health Insurance (all manual
  workers over 16 earning small salaries). Weekly
  payment
• Until 1948, administered through voluntary
  associations and a few public facilities (most
  medicine was paid)
• WWII and post-War led to the expansion of the
  system
• 1942 Beveridge Report recommended the creation
  of a comprehensive national health system
• 1946 National Health Service Act (NHS)
  nationalization of all hospitals, creation of
  health centers, redistribution of physicians
  across the country, teaching facilities,
  physicians could have private practice. Funded
  through taxes.

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• 1974 Attempt to integrate the national with the
  regional with the local levels. Creation of
  Regional Health Authorities (RHA) and District
  Health Authorities (DHA)
• 1980 NHS becomes more autonomous and specialized.
  More power ffor RHAs
• 1982 Elimination of RHAs. DHAs become fully
  responsible for the administration of health
• 1979 Margareth Thatcher (backed by Milton
  Friedman and von Hayek) believed that
  privatization would improve the performance of
  the system
• 1983 Griffith Report, recommended to move to an
  insurance-based health system. Did not work

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The 1990s and New Labour

• 1989 the NHS in crisis
• 1990 National Health Service and Community Act
  (encourages competition within the health
  industry)
• Since 1997 New Labour has maintained the system
• 1990sthe State imposed a Market into the
  state-administered system

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Organization

• Universal Access to Health Care for all citizens
• 80 paid through general taxation (plus
  individuals regular contributions plus
  co-payments)
• NHS, internal market made up of purchasers and
  providers. State central control
• DHAs buy services from public, private, or
  semi-private providers
• 2002 Integrated care, groups practitioners in
  local community groups
• Health gap (mostly geographical)

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Japan

• WHO 2000 Report ranks the Japanese as the 1
• Japanese culture introduces healthy habits
• Comprehensive national health care program

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History

• Before WWII, German influence
• 1922 Health Insurance Law offered coverage to
  certain workers (2,000,000)
• 1938 Ministry of Health and Welfare
• War led to extend coverage to many more Japanese
• After WWII and the American occupation
• 1948 Medical Service Law/Social Medical Fee
  Payment Fund
• 1961 Every Japanese had coverage (Universal
  System). Golden Era

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Problems

• 1970s Rising Costs (1972 Free Health for 72)
• 1970s/80s Gaps and inequities
• New Health Problems drugs, suicide, pollution,
  inadequate housing, cancer
• Japan has the fastest-aging population in the
  world

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Organization

• Universal Coverage
• More beds than any other nation
• Sophisticated technology
• Insurance funded by both employers and employees
• Physicians are revered (and make a lot of )
• Complex and fragmented system
• Public health centers (prevention), physicians
  offices (diagnoses), clinics (treatment), and
  hospitals (intensive care)
• Public/private (20 co-payments)
• 2000 National Long Term Care Insurance Program
  (foreign corporations)

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Sweden

• 1660 Collegium Medicum
• 1752 First General Hospital in Stockholm
• 1800 King Gustavus Adolphus created crown
  hospitals (for soldiers with syphilis)
• 119th century- Expansion of crown hospitals in
  scope and territoryDecentralization of health
  care at the county level
• 1874 Public Health Act (expanded coverage)
• From the late 1930s, the Social Democrats
  organized a universal health care system
• 1955 the National Insurance Law covered the
  entire population
• 1959 Elimination of private beds
• 1969 Elimination of private practice for
  physicians
• 1976 Reversal (allows private health services)
• 1982 Health and Medical Services Act
• 1990s Objective decentralization

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Organization

• Health Care is seen as public responsibility and
  supported by the national insurance system
• Health care is seen as a basic human right
• All residents are covered
• Physicians perceive salaries
• National Ministry, National Board of Health and
  Welfare, County councils (provide health, run
  hospitals). Some competition with private
  providers
• System funded by personal income taxes, the
  National Health Insurance System, National
  Grants, and user fees

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Problems

• Lack of physicians
• Uneven geographical distribution of resources

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United States

• 1 in per capita expenditure in health
• 37 in performance (in our sample, only better
  than Brazil)
• The best technology and research, but...
• 18 population uninsured, and 50 underinsured
• Why?

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History

• Entrepreneurial tradition
• Since the 1798 Public Health Service, Gvt. Seen
  as only a safety net for the poorest
• Prior to WWI, 4,000 hospitals run by religious or
  civil associations were established (charged
  fees)/ workshops for training physicians
• 1933 Blue Cross (1st pre-payment system)
• 1940s Private Insurance growth
• 1946 Hill-Burton hospital and Survey and
  Construction ActFederal contribution to build
  hospitals
• President Trumans attempt to develop national
  insurance defeated by lobbysts from the American
  Medical Association

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• 1960s, Johnsons extension of health insurance to
  those who qualified for social security
• 1963 Community Mental Centers
• 1966 Comprehensive Health Planning Act
• Medicare/Medicaid (intended to work as private
  insurance)
• 1973 Health Maintenance Organization Act (HMO)
  subsidized the formation of prepaid insurance
  groups (offering good services)
• Managed Care System (PPOs IPAs)
• 1974 National Health Planning and Resource
  Development Act (NHPRD)200 health planning areas
  to guide the provision of health services
• 1980s Reagans further privatization
• Escalating health costs

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The 1990s

• Acknowledgment of crisis of the system
  (emergency)
• Congress examined different plans to reorganize
  the system
• 1992 Clintons goals to extend health insurance
  to all Americans, to reduce costs
• October 1993 Clintons project begun to be
  discussed. Proposal to pass a Health Security
  Act. Republicans had their own plans. All plans
  reached a dead end.
• Why? Lobbying by the Medical Associations and
  drug corporations

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Problems

• Business lobbying
• American political culture that sees national
  health care as socialism and fears big gvt.
• The American system of checks and balances does
  not work well in the area of health
• The U.S., a paradox of excess and deprivation
• 3 tiers people with private insurance coverage,
  people in the HMOs, and the uninsured
• System financed with federal funds (56), and
  resources provided by the state and local levels