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Health Care 2009

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#1 Omega

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Posted 09 September 2009 - 10:47 AM

Let's talk about health care around the world.  Every country has its own system, and some US states do different and interesting things as well.  What kinds of systems are there?  Are there basic patterns that are typically followed?  Are there convenient metrics for quantifying the efficacy of those systems?

#2 Rhea

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Posted 09 September 2009 - 03:12 PM

I wanted to look at Demark, because they've had public health care for almost 200 years in some form or another and a single payer system since the early 70's.

The funds for medical care trickle down from the central government to the counties and municipal entities - where you live is where you're treated, although recent legislation has been passed that allow patients some flexibility in that area.

Interestingly, Danes consume far less drugs by a significant margin than the U.S. In fact, they were one of the two lowest cosumers of drugs according to WHO (World Health Organization data).

http://www.euro.who....ment/e72967.pdf

The structure of health care is as follows:

Quote

The counties own and run hospitals and prenatal care centres. Most county
councils have set up committees on health and social affairs and hospital
committees to oversee their health care responsibilities. In 1994 the Copenhagen
Hospital Corporation was set up to manage hospital services in Copenhagen
and Frederiksberg. The corporation is run by a board of directors whose
members are local politicians and central government appointees.
The counties also finance general practitioners, specialists, physiotherapists,
dentists and pharmaceuticals through the National Health Security System
(NHSS), which replaced traditional health insurance schemes in 1973 and is
now financed by taxes. Reimbursements for private practitioners and salaries
for employed health professionals are agreed through negotiations between
the NHSS Committee, run by the Association of County Councils, and the
different professional organizations. The Ministry of Health, the Ministry of
Finance and the National Association of Local Authorities participate in these
negotiations as observers. The Minister of Health must formally approve any
agreements before they enter into force.

Quote

The 275 municipalities are also run by councils elected every four years (at the
same time as county council elections). Their responsibilities include services
such as nursing homes, home nurses, health visitors, municipal dentists and
school health services.4 These activities are financed by taxes, with funds
distributed through global budgets, and carried out by salaried health
professionals. Salaries and working conditions are negotiated by the National
Association of Local Authorities and the different professional organizations.

How it's financed:

Quote

The main sources of finance in the Danish health care system are state,
county and municipal taxes. Other sources of finance include out-ofpocket
payments for some health goods and services and voluntary health
insurance taken out to cover part of these out-of-pocket payments.
State taxes are a combination of personal income tax, value added tax (a
single rate of 25%), energy and excise duties, a labour market contribution
(8% on all personal income) and corporate income tax. Personal income tax
accounts for almost half of the state’s total tax revenue and is payable on wages
and almost all other forms of income, including profits from personally owned
businesses. It is calculated according to a progressive scale, with a basic rate
of 7.5%. The medium and top rates (6% and 15% respectively) are levied on
earned and capital income. A tax ceiling ensures that taxes collected at state,
county and municipal level are only levied on 59% of income. Although there
are no hypothecated or earmarked taxes in Denmark, some taxes are partly
motivated by a concern for health, for example excise duty on motor vehicles,
energy, spirits and tobacco products. In the 1990s the central government introduced
a green excise duty that is levied on the consumption of polluting or
scarce goods such as water, oil, petrol and electricity.
County and municipal taxes are levied proportionately on income and real
estate (property). Every year the central government agrees maximum rates of
county and municipal taxation with the Association of County Councils and
the National Association of Local Authorities, and distributes additional
resources to the counties and municipalities through subsidies based on the
size of their tax revenue. Because county and municipal taxes vary from region
to region, a certain amount of redistribution or financial equalization is necessary
to compensate for discrepancies in the tax base of different regions. In 1999
the county and municipal tax rate varied from 28.6% to 33.5%. Personal income
tax in 1999 was highest in Funen and Viborg counties (12%) and lowest in
Vejle county (10.9%); the average level of county personal income tax was
11.5%. Redistribution between counties and municipalities is devised according
to a formula that takes into account the following factors: age distribution, the
number of children in single parent families, the number of rented flats, the
rate of unemployment, the number of uneducated people, the number of
immigrants from non-EU countries, the number of people living in socially
deprived areas and the proportion of single elderly people. Personal income
tax covers approximately 81% of county expenses, general grants from the
state cover 13% and real estate tax covers 6%. Health care accounts for
approximately 70% of county councils’ expenditure.


How it works:

Quote

Access to hospital care and general practitioners is free at the point of utilization
for all Danish residents. General practitioners act as gatekeepers to hospitals,
specialists and physiotherapists (although no referral is necessary for visits to
ear, nose and throat specialists and ophthalmologists). However, individuals in
Group 2 (see the section on Health care delivery system) are free to visit any
general practitioner and any specialist, without referral, for the price of a small
co-payment (paid to the general practitioner or specialist).
Some services, such as health examinations and dental treatment, are free
for children and young people up to the age of 18. Pregnant women also have
access to free health examinations. Hearing aids (both analogue and digital)
are free of charge, but the waiting time for hearing aids is up to one year in
some counties, so patients also purchase them privately.
Patients are required to pay for part of the cost of physiotherapists and
dental care. Care in nursing homes is paid for by patients on a means-tested
basis. Patients have to pay the full cost of spectacles, unless they have very
poor sight. Pharmaceuticals are provided free of charge in hospital, but pharmaceutical
expenditure in the primary health care sector is subject to different
levels of patient co-payment.
To be free of charge, some treatments must be considered useful or necessary
by a doctor, on a case-by-case basis. For example, cosmetic surgery may be
performed free of charge if a doctor finds it to be necessary on psychological
or social grounds. Reproductive treatment is an unusually carefully regulated
aspect of curative Danish health care, with different fixed limitations on some
procedures. Assisted fertilization (that is, any measure to help a woman become
pregnant) is limited to heterosexual couples where the woman is less than
45 years old. In vitro fertilization is only offered to childless couples where the
woman is less than 40 years old and is limited to three trials. Because waiting
times for assisted fertilization are often over 12 months, several private clinics
also offer this treatment.
Treatment that is considered to be ‘alternative’ is excluded from publicly
financed health care in Denmark; examples of alternative treatment include
zone therapy, kinesiology, homeopathy and spa treatment. Alternative
practitioners without a medical education are permitted to practise, but they
are not allowed to perform invasive treatments or prescribe drugs and they do
not receive any public funding.
The central government finances public health measures such as
vaccinations, health campaigns and public health officers.

Quote

Patients have to pay for part of the costs of dental care and physiotherapy. For
dental care the reimbursable amount depends on the procedure performed, but
is usually only a small part of the total cost. High co-payments for dental care
have caused some controversy, as it is claimed that they are inequitable.
Expenditure on pharmaceuticals in hospital is reimbursed in full, whereas
pharmaceutical expenditure in the primary health care sector is subject to
different levels of patient co-payment. Under the new reimbursement system
individual annual pharmaceutical expenditure is reimbursed at the following
levels: below 500 DKr – no reimbursement; 501–1200 DKr – 50%;
DKr 1200–2800 – 75%; above 2800 DKr – 85%. Chronically ill patients with
a permanent and high utilization of drugs can apply for full reimbursement of
any expenditure above an annual ceiling of 3600 DKr. Special rules for
pensioners have been abolished, although pensioners who find it difficult to
pay for pharmaceuticals can apply to their municipality for financial assistance.
Patients with very low incomes can receive partial reimbursement, on a case
by case basis, under the Social Security Pensions Act and the Social Assistance
Act. In addition, many individuals purchase voluntary health insurance to cover
the cost of paying for pharmaceuticals.

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#3 Themis

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Posted 15 September 2009 - 07:41 AM

Where's the input from the UK and Canada here?  Maybe people haven't discovered this section of the board?
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#4 Hawkeye

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Posted 15 September 2009 - 03:11 PM

I dont have enough knowledge on the subject to give an indepth explanation of health care in the UK, but here it is in a nutshell:

We have socialised health care. We pay our taxes and live safe in the knowledge that if we're hurt or fall ill, we'll be able to roll up to a hospital and get treated and not get landed with a massive bill at the end of it. It's not perfect, obviously. There are horror stories about people being left to die on beds in corridors, the staff are over worked and under appreciated, but on the whole they do a damn good job. I'm a big fan of the NHS, as they took care of me when i was a baby with bad Asthma, Eczema and allergies to just about everything.

As for things we do have to pay for: There are set prices for dentist checkups and any work that gets done. You have to pay for prescriptions too, unless you're a kid or a student.

And if you don't like this option, you can sign up to BUPA or something and go private.
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#5 Annibal

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Posted 15 September 2009 - 03:42 PM

^You can option out of socialized care? See, I think that balance would be key, for me to accept socialized health care. I think that while every person deserves and should get the health care they need, no matter what, I think that people should have a choice to take care of that privately--in which case I also think they should pay taxes for everyone else. Maybe idealized, but I don't really know more about it to form a more detailed one.

I've also thought there should be "teaching hospitals" that are gov't funded, or something along those lines, where newer doctors can work for a certain amount of time, get at least some of their loans paid off by the hospital, and where they can treat patients who wouldn't get cheap/free care anywhere else. Not a perfected idea, by any means.

I like having privatized health care right now, while my dad pays for it, but my opinion might change once I'm 24 and have to get my own insurance....^_^;;;
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#6 Nonny

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Posted 15 September 2009 - 04:29 PM

VA hospitals are teaching hospitals, which is why I have a Do Not Resuscitate order on file.  Nothing like getting forced back to life so residents can practice.
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#7 Cardie

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Posted 15 September 2009 - 06:57 PM

I only discovered by all the stuff being discussed with the healthcare debate that the NHS in the UK runs its own hospitals and hires its own doctors.  I thought it worked like Medicare, where doctors choose or don't choose to accept Medicare patients and are reimbursed if they do, but it is much more like the VA, where doctors work for them and are on salary (right, Nonny?)

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#8 Nonny

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Posted 15 September 2009 - 07:50 PM

View PostCardie, on Sep 15 2009, 04:57 PM, said:

I only discovered by all the stuff being discussed with the healthcare debate that the NHS in the UK runs its own hospitals and hires its own doctors.  I thought it worked like Medicare, where doctors choose or don't choose to accept Medicare patients and are reimbursed if they do, but it is much more like the VA, where doctors work for them and are on salary (right, Nonny?)
Basically, yes, but as I understand it, some doctors are salaried VAMC staff and others are from the associated medical school and have residents in their charge and teaching duties.  Every July we get a new bunch of residents, who think nothing of rushing through the halls in large, happy groups, forcing disabled veterans to the walls to keep from getting trampled, but I digress.  Where was I?  Oh yeah, my VAMC is associated with a medical school from a private religious university, unfortunately, and I get a little tired of the unsubtle fishing expeditions for patients with like views.  

Anyway, we don't have, as far as I know, doctors who just have hospital privileges.  Even the ones also in private practice are part time staff on salary.  I don't know the jargon well enough to explain this better.   :(
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"Give a man a gun and he can rob a bank, give a man a bank and he can rob the world." Can anyone tell me who I am quoting?  I found this with no attribution.

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Stupid is stupid, this I believe. And ignorance is the worst kind of stupid, since ignorance is a choice.  Suzanne Brockmann

All things must be examined, debated, investigated without exception and without regard for anyone's feelings. Diderot

#9 SparkyCola

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Posted 16 September 2009 - 09:11 AM

What Hawkeye Said- the NHS is hugely popular in the UK. I'm a huge fan too. And yes, though you pay for NHS on taxes either way, you can go private if you prefer.

Cardie - that's right; our doctors, nurses and paramedics are on a salary and accept every patient that comes in. By law, they cannot turn anyone away.

The UK spends much less on healthcare than the US, but it provides universal coverage. [the UK spends 7.7% of the GDP, the US spends 16%. Canada spends 10.7%.].

Does anyone know about New Zealand's healthcare system? As far as I can gather they are private but subsidised. It seems a strange system.


Sources/ Further reading:

Health data per country from OECD, including US, UK and Canada.
Expenditure on Healthcare in the UK 2008
Access to Healthcare services in Canada
CIA Factbook: Contains info on life expectancy, birth rate, death rate etc.
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#10 Themis

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Posted 16 September 2009 - 09:42 AM

Nashville's VA hospital is practically across the street from Vanderbilt and Vandy's doctors and residents put in time there.

I was going to say almost everybody in Nashville is fishing for religious converts but then I remembered a lot of the doctors-in-training are from out of state or out of country.

OK, the UK and Canada have checked in and Rhea gave us lots of info on Denmark.

There's a good article in this week's Newseek that talks about healthcare in other countries - I'll see if it's on line after I do some actual work at the office!
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#11 Nonny

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Posted 16 September 2009 - 09:56 AM

View PostThemis, on Sep 16 2009, 07:42 AM, said:

Nashville's VA hospital is practically across the street from Vanderbilt and Vandy's doctors and residents put in time there.
Vanderbilt is private and not religious, right?  

Quote

I was going to say almost everybody in Nashville is fishing for religious converts but then I remembered a lot of the doctors-in-training are from out of state or out of country.
Loma Linda University is Seventh Day Adventist, and recruits converts from all over the world for their university and medical school.  I don't know if this is still the case, but as recently as twenty years ago, if you attended their medical school and were not SDA, you were still required to attend religious services and contribute financially to the church.  

And since the SDA is vegetarian, doctors have been known to lie about nutritional information to persuade patients to make food choices.  It happened to me.  Heh, the first SDAer who tried to proselytize me assured me I wouldn't really have to be a vegetarian, as if that was my objection to joining her weird cult.    :headshake:
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"Give a man a gun and he can rob a bank, give a man a bank and he can rob the world." Can anyone tell me who I am quoting?  I found this with no attribution.

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All things must be examined, debated, investigated without exception and without regard for anyone's feelings. Diderot

#12 Cardie

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Posted 16 September 2009 - 10:29 AM

View PostSparkyCola, on Sep 16 2009, 10:11 AM, said:

What Hawkeye Said- the NHS is hugely popular in the UK. I'm a huge fan too. And yes, though you pay for NHS on taxes either way, you can go private if you prefer.

That's probably the biggest stumbling block to getting any single-payer system here: taxes.  Significant segments of the US electorate hate supporting the government with their money, and free-for-all capitalism owns the legislatures.  I think that you could demonstrate that a national healthcare tax would be only half what a person's annual private premiums are now and plenty would still reject it because it goes to the government and might therefore pay for someone else's care rather than their own.  "Socialism" is, after all, about the welfare of all being the highest priority: it is social and not individualistic.

It is a miracle we ever got Social Security and Medicare.

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#13 Themis

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Posted 16 September 2009 - 12:53 PM

View PostCardie, on Sep 16 2009, 03:29 PM, said:

View PostSparkyCola, on Sep 16 2009, 10:11 AM, said:

What Hawkeye Said- the NHS is hugely popular in the UK. I'm a huge fan too. And yes, though you pay for NHS on taxes either way, you can go private if you prefer.

That's probably the biggest stumbling block to getting any single-payer system here: taxes.  Significant segments of the US electorate hate supporting the government with their money, and free-for-all capitalism owns the legislatures.  I think that you could demonstrate that a national healthcare tax would be only half what a person's annual private premiums are now and plenty would still reject it because it goes to the government and might therefore pay for someone else's care rather than their own.  "Socialism" is, after all, about the welfare of all being the highest priority: it is social and not individualistic.

It is a miracle we ever got Social Security and Medicare.

Cardie

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Here's that Newsweek article, which speaks to the different social and moral aspects of a country's approach to health care:  http://www.newsweek.com/id/215290

I'd be interested in more information on Sweden - I think they have the reputation of being taxed very heavily; on the other hand, they are secure knowing their disposable income is actually disposable, i.e., available for wants and not needs because a medical crisis won't throw them into debt, an advantage in all countries with some kind of universal health care plan.  

Another story in today's Nashville paper about somebody who obviously works close to home and doesn't have medical insurance.  She commutes by bicycle and was attacked by a pack of dogs roaming her area; the bites have cost her thousands for treatment.  

Yes, Nonny, Vanderbilt is private and officially non-religious.  But it is in Nashville.  There was a casual conversation in some doctor's office I was in - a nurse was asked her favorite kind of music and the answer was "praise and worship."  Which, of course, means Christian praise and worship; the nurse didn't think there was any need to elaborate on praise and worship of what... That was an answer to that question I'd never heard before!

Back on topic, as we've seen from many of the discussions in OT, a lot of people in this country, as Cardie noted, have a great reluctanceto the idea of paying for someone else's care, despite the fact that we're doing it now in higher fees and higher insurance premiums to attempt to make up for emergency room care given to the uninsured...  I attribute the attitude to the country's pioneer origins and rebellion against the UK.  Canada had the same origins but kept its affiliation.  Wonder if that has something to do with the different attitudes?
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#14 ilexx

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Posted 16 September 2009 - 01:37 PM

Okay, some info on healthcare German style:

We have 3 mandatory health benefits: accident insurance - covered by the employer, long term care and health insurance - covered 50%-50% by both the employer and the employee and represents about 10-15% of the monthly income. There are basically 2 types of health insurance: public and private, with more than 80% of the population paying into the first.

All salaried employees with a salary below 4200,- €/month must have a public health insurance, that will also cover unemployed spouses and children up to the age of 27. When the salary exceeds this mark, when you are self-employed or a public servant etc. you may opt for a full private insurance, that most people have anyway for additional/optional treatment with specialists - especially dentists, ophtalmologists etc. - and for special treatment when hospitalised (single room, free choice of doctors etc.). The fees for this type of additional insurances can vary, but they very seldom surpass 100,- €/month.

In addition to that, every patient (children to the age of 18 are exempted from this) in need of medical services has to pay a so-called "practice-fee" - that can't surpass 10,- €/quarter year (40,- € max. per year, thus, if you go to the doctor's every three months). Incidentally, the fee has nothing to do with the doctor's practice, but is paid directly to the public insurance company covering for you.

#15 Pixiedust

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Posted 16 September 2009 - 02:18 PM

View PostThemis, on Sep 16 2009, 06:53 PM, said:

I'd be interested in more information on Sweden - I think they have the reputation of being taxed very heavily; on the other hand, they are secure knowing their disposable income is actually disposable, i.e., available for wants and not needs because a medical crisis won't throw them into debt, an advantage in all countries with some kind of universal health care plan.

Oddly, I always thought Sweden's taxes were much higher than the UK's, until I moved to the latter and realised that it's probably actually the same or even higher, just divided up into income tax and council tax so you pay twice...

But Sweden's health care system is quite good, the one time I went to hospital I got my own room with a TV and en suite bathroom. :D I don't know if that was just the kid's department though...
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#16 SparkyCola

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Posted 17 September 2009 - 11:45 AM

Cardie- isn't it similar, in principle though, to firefighters and police? The only difference is that you're actually MUCH more likely to require the health service than you are a firefighter or police officer.

In Sweden they used to have a privatised fire department - you put a shield on the house if you'd paid them, and they only tried to put the fire out if you had the shield- otherwise they'd just let your house burn!

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#17 Pixiedust

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Posted 17 September 2009 - 03:14 PM

^ That would be hilarious if it wasn't so disturbing. :p
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#18 Cardie

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Posted 17 September 2009 - 03:40 PM

Firefighters and police are hired locally.  A lot of "big government" foes are particularly against the Federal government.  Also there seems to be less animus about money going to people for a specific public job and it going to everybody to pay for some item or service they personally need.  I don't feel this way and am not in these people's heads, so I can't quite explain why.

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#19 maryavatar

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Posted 20 September 2009 - 04:03 PM

I live in the UK, and until I was in my mid twenties I lived below the poverty line.  I'd be dead without the NHS, simple as that.  Now that my husband and I both have well paying jobs, I have health insurance - this is for my glasses and my dental, and any 'alternative' treatments I might want/need.  If I had a serious medical condition, I'd go to the NHS - they have the best doctors and the most up-to-date facilities.
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#20 Chakoteya

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Posted 21 September 2009 - 06:16 AM

View PostAnnibal, on Sep 15 2009, 09:42 PM, said:

^You can option out of socialized care?

You can choose to be treated privately if you fall ill, and pay for it through separate insurance cover or whatever, but you can't opt out of paying the taxes that go towards maintaining the NHS. That's because it all comes out of general taxation and 'National Insurance payments' - which is the extra tax that employees and employers have to pay for the privilege of having a job or running a company.
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