Market advocates claim that patients, now
called consumers are dissatisfied with the health system and that the
market solves this problem. The former is partly correct. The latter
is not supported by the evidence.
Dissatisfaction:- The system which has caused more dissatisfaction than any other is the market system in the USA. Nowhere else has it ever been necessary to introduce legislation to protect citizens from deliberate exploitation by those who are there to help them - a frightening indictment of the market system in that country. Any proposals for a health care marketplace has to confront this. There is now a growing professional and public movement in the USA towards the Canadian system - a move away from market based systems.
Managed care:- During the last year there has been a strong community move away from managed care, a system based on contracts. There has been a revival of the older fee for service system. Doctors whose principles refused to allow them to enter into contracts with HMO's initially struggled. One doctor writing to me a few years ago explained that he had downgraded his lifestyle but was satisfied that his integrity was intact. Those able to afford it are now supporting these doctors strongly and thousands of colleagues are joining them. They are doing well.
Equity and the Samaritan tradition:- The US health system has claimed to be both Samaritan and also free enterprise for at least 40-50 years. The combination made it both the most technologically advanced and the most expensive system in the world. In practice its Samaritan traditions and professional underpinning preserved its humanitarian commitment to the less fortunate and so a measure of equity was maintained. Its Samaritan traditions and its humanity have taken a severe beating with the introduction of health systems which have used market pressures to control costs. Strong competition has destroyed the ethics of the hospitals' Samaritan culture and the professionalism of the health care providers on which it depended.
Equity has become an acute problem. Even 40 years ago the excesses of the free enterprise activities in the USA were quietly criticised by the profession internationally. Many practices were held up as examples of practices which were not acceptable elsewhere.
US doctors who support market principles
believe that what they had before corporate intrusion was the way the
market should operate. They argue that the move away from managed
care is an example of the market responding and correcting itself. As
the New York Times points out this creates a two tired system and
inequity. My own view is that it is a way back and not a way forward.
It does not solve the problems.
In other countries a more socialised system of medicine has resulted from a post war grass roots movement away from market based health care. It was and is still accepted by most citizens that society should recognise an obligation to attend to the health needs of citizens and that others should not exploit their vulnerability for profit. These systems have not denied citizens the right to go outside the system provided and to pay for more. Some like the National Health System in the UK were until a number of years ago entirely state funded and run. Other countries including Canada and Australia have developed intermediate systems of different sorts.
The public clearly would like more than they get and the major complaint in all of these countries has been a failure to fund their public systems properly. There has not been a marked population move towards private medicine. In most including Australia the move has been away. In Australia a massive bribe was needed to arrest this drift.
In these countries there has been a backlash and intense criticism of attempts to privatise the system. There is a strong perception in both Australia and Canada that government is deliberately underfunding and running down the public system for ideological reasons. The figures they produce are persuasive. Citizens have not been given full information and the choice of allocating more funds to this more economical way of providing health care. Instead they are being asked to prop up an ever more costly private system.
Canada:- In Canada the medicare system was introduced in large part because of the failure of private systems. A very bitter battle was fought against private commercial interests. The system is strongly supported by the community and there is a strong grassroots movement to resist any attempt to move back to a market. The American system is just south of the border and they don't want it. There has been a very strong backlash in Alberta where the government ran down the public system and embarked on a program of privatisation. Many thousands have marched and protested against government's plan to privatise.
New Zealand:- New Zealand has been at the forefront in attempting to use market principles to reform its health system. There has been a hidden ideological agenda. There was widespread discontent. A survey found that New Zealanders were more worried about the care they received than the four other large English language speaking countries including the USA. Health became a major political issue leading to the election of a labour government. The new government has promised that "profit should not be the motive driving public health services" and to run the system "on cooperation rather than competition".
Australia:- Australians too strongly resist any changes to medicare and are satisfied with its performance. They have left the private system in droves. Dissatisfaction with the public system is primarily with waiting lists and much of the dissatisfaction and anger is at the failure to fund the system properly. The public has not been given the facts or the opportunity to allocate more money.
Accusations about the failures of the public system:- Many in Canada and Australia argue that government funded systems are being deliberately underfunded for ideological reasons. The figures they produce are persuasive. Citizens have not been given full information and the choice of allocating more funds to this more economical way of providing health care. Instead they are being asked to prop up an ever more costly private system. The government has used tax payers money to bribe citizens to stay in the private system, on the pretext that this protected the overloaded public system. The same money would have provided more care to more citizens if spent on the public system.
The move away from conventional medicine:- The move away from conventional medicine towards alternate systems of medicine is an interesting phenomenon but hardly one to support a marketplace solution. It is clear that conventional medicine is not meeting the expectations of those with less serious disorders, and a number of explanations have been suggested. That medicine is dominated by modern thinking whereas the population is increasingly post modern is an interesting explanation. (see Chan & Chan MJA 3/4/2000 p332)