British Columbia Medical Journal, September 2010 issue Please download or visit this entire issue online at http://bcmj.org/september-2010-0

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Private health care with public delivery?
A. Daniel Malebranche, MSc same country with unequal access to family physician. Nevertheless, there
health care resources. How could a first- is still merit in the question of whether
had the privilege of spending the world country have disparity of this private funding with public delivery,
I last winter holiday season with
family in the United States. I en-
joyed a good part of the time watching
magnitude for something so vital as the
health and well-being of its citizens?
I cannot help but be reminded of
or at least a modification of such a sys-
tem, could work elsewhere.
There are at least two conceivable
endless hours of satellite television. Switzerland’s health care model—not advantages of this approach. First,
Dominating the news was the Ameri- for its similarity but precisely the opening health insurance to the pri-
can president’s health care reform—a opposite. Although there are only 7 vate sector cultivates competition,
seminal piece of legislation that is million inhabitants, a tiny fraction of which not infrequently acts to lower
intended to help some 47 million US the United States, the Swiss govern- premiums. For example, a user is like-
citizens who have no medical insur- ment has made it against the law for ly to choose the insurer that is able to
ance. As a Canadian, I was well aware anyone to reside within the country’s provide reasonable coverage for the
of the health situation south of the bor- borders without having basic health lowest cost. In turn, a competing in-
surer may reduce rates further to
attract another customer, and so forth.
The second benefit is heightened user
awareness, which is crucial when
How could a first-world country have disparity health care systems are placed under
of this magnitude for something so vital as the unprecedented constraints. It was not
until living in a different system that I
health and well-being of its citizens?
considered what type of consumer of
health care resources I was and how
this impacted the type of coverage I
would be required to purchase. As an
infrequent user, for instance, it was
der. However, it never quite impacted insurance coverage. If one is unable to reasonable to minimize monthly pay-
me until I polled friends and family at afford the premiums, government ments by maximizing the “franchise,”
the dinner table and asked how many assistance is provided. This is the sit- or deductible. This type of custom-
were insured. I was shocked to hear uation that I found myself in while ization cuts user expenses, at least for
that less than half of the nine had no studying abroad on limited income. In the younger and healthier subpopula-
hospital insurance. Some of the unin- many cases, subsidies cover more than tion. But the situation is actually more
sured even had multiple comorbidities. half of the monthly premium, and to complicated because this discussion
The reasons for not being covered my knowledge a reasonable number primarily considers medical coverage
included lack of job or insufficient of students and unemployed citizens alone, not accident coverage. Never-
financial resources. It is unfortunate effectively live this way. Consequent- theless this basic understanding of
yet ironic. The unemployed and poor ly, this small European country does health care economics bolstered my
seem to be the least able to pay for not have the proportion of uninsured respect for how I use and access health
their own hospital costs. As I drove that the United States has. Indeed, the care resources.
through suburban southern Atlanta, confederation is small and wealthy, A much frequently discussed draw-
where many of the city’s marginalized thus making such laws much more back of private health care with public
communities are, I saw citizens of the practicable. Switzerland, however, is delivery is the creation of a two-tiered
not immune to the rising cost of health system. I observed this directly in
Mr Malebranche is in the University of care delivery, and recently there have Switzerland, not as a patient but as a
British Columbia Faculty of Medicine’s been discussions regarding increased clinical clerk. I found myself approach-
class of 2011. user fees for outpatient visits to the ing those who were privately insured
358 BC MEDICAL JOURNAL VOL. 52 NO. 7, SEPTEMBER 2010 www.bcmj.org

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differently than other patients, know- entire population—do not have sup- tization is not part of the reform, but
ing that they paid extra for their cov- ported access to health care services, I some socialist ideologies are never-
erage. Similarly, when patients were think of the people with whom I theless incorporated from European
under local anesthesia, the health care enjoyed that holiday dinner. Had they models. At this juncture, it will be
team’s level of engagement was often lived just a few hours north, every one most interesting to see the influence
increased. It almost seemed like oper-
ating rooms of privately insured
patients were happier places! Biased
opinions aside, the quality of care for I found myself approaching those who were
both types of patients was indistin-
guishable, and this is arguably what
privately insured differently than other patients,
most sick patients are interested in. It knowing that they paid extra for their coverage.
might be comparable to traveling first
class versus coach. The service might
be more extensive in one, but all con-
sumers arrive at the same destination of them would have been insured— that our neighbors east of the Atlantic
(assuming that both groups of patients regardless of their financial situation. have in the redefinition of both Cana-
seek services from the same hospital). The new American legislation, how- dian and American health care, partic-
Crossing the Atlantic back to the ever, has sparked excitement in the ularly with respect to private funding
United States, where more than 40 national community and indeed there with public delivery.
million people—more than Canada’s is much to be optimistic about. Priva-
Medical writing prize:
$1000
for best student article
The J.H. MacDermot Prize for Excellence in
Medical Journalism comes with a cash award
of $1000 for the best article on any medicine-
related topic submitted to the BC Medical
Journal by a medical student in British
Columbia.
The British Columbia Medical Association
awards the annual prize to the finest medical
student manuscript received by the BC Medical
Journal that year. The prize honors Dr John
Henry MacDermot (1883–1969), who became
the editor of the Vancouver Medical Bulletin at
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www.bcmj.org VOL. 52 NO. 7, SEPTEMBER 2010 BC MEDICAL JOURNAL 359