Key problem of public health care systems – what’s enough?

All over the world countries with public health care systems are fighting the ever increasing cost of their systems. Whereas people have natural limitations for the number of free Coke they can drink or the number of cars they can drive simultaneously, there is obviously no natural limit for the consumption of health services. Everybody will agree that your health can always be improved. Especially doctors will always find a way how to sell additional services regardless whether they are good for their customers or not. There is obviously not a strong correlation how much people spend on health care and their actual health. France is spending about 40% less per capita for health care than Germany. The result:people in France live in average 1 year (men) or 3 years (women) longer than people  in Germany. In addition to life expectancy (around 80  years in the European Union) the number of healthy life years (around 60 years in the EU) is interesting.   USA spends more money on health care than any other country with rather poor results.  Certainly the country specific income of health care personnel results in different cost of health services. Therefore health expenditures are mostly measured in percent of the GDP – again with US leading.  It is well known that in Germany the cost of health care is directly related to the number of doctors in an area. This is probably also the case in US. Obviously the health care system (public and private) allows the doctors the cash in regardless what they achieve.

The problem is that denial of health services is considered amoral. Everybody has an example of a poor sick child which does nor get the treatment it deserves because the parents cannot pay the cost of treatment. However, these cases are statistically irrelevant and should be solved individually by welfare. The real problem is, that the majority of people with advice of their doctors eagerly consumes health services which are not really needed. A sustainable public health system must have a good strategy and a strong stand in saying NO.  By the way this is true not only for public health care systems but also for private health care systems based on health insurance.

There is an easy way to say NO at all needy people. This is certainly not a solution for a modern society. Now it is interesting to see how different systems limit the amount of health services by using following schemes:

1. No public health insurance. (Does not automatically reduce the cost of healthcare for individuals).
2. Cost sharing. Patient have to pay x % of their individual health cost up to a certain limit e.g. 10% of their income/year
3. Patient Base Barrier. The insurance pays for health cost only above a certain limit. This is combined with lower cost of health insurance using a bonus system.
4. Limiting the type of services e.g. only well established medical methods and (low cost) drugs)
5. Service limitations similiar to method 3 but the real restrictions are hidden in the terms of the insurance contract ( a system favored by American health insurers).
6. Limiting the number of hospitals and doctors (a system favored by the English public care system)
7. Low quality of public health care services (very often combined with method 5)
8. Low salaries for doctors and health care personnel making health care unattractive.

Most public health care system use a combination of above methods. There are also interesting special solutions e.g. I found a system in China where patients can collect bonus points if they pay for health services on their own. The bonus points could be used when they really got seriously ill to chose a superior hospital to be treated. This worked very well because Chines people are used to care for themselves in the future.

Organizations and politicians proposing public health care systems shy away from the “What’s enough?” question because saying NO is never popular. However, any public health care system (but also private insurance) must clearly define the limits where health care cost can be shared. It is an illusion that these barriers can be stretched and redefined arbitrarily without breaking the system. However the public must be made aware of this crucial question and should participate in the discussions. Sorry politicians – there is no easy way out.