Particular attention should be paid to ethical choices in the financing and delivery of medical services, since these services account for a large portion of most countries's total healthcare spending (Organization for the Economic Cooperation and Development [OECD]). The provision of medical-care services requires policymakers to debate myriad ethical values and conflicts, and each country's medical-care system reflects its choices about underlying ethical matters.
Unlike public health activities, which are considered to benefit all members of society, medical-care services are generally considered as private goods, since it is the individual who benefits directly from them. Some countries consider access to medical care a merit good—a good that, although private, benefits society as well. Health insurance is a major determinant of access to care. In most industrialized countries health insurance coverage is universal. In the United States, however, 14 percent of Americans did not have health insurance in 2000 (Mills).
Similar value choices are exemplified by the benefits package that countries's health systems offer. Some coun-tries's health systems cover only hospital and physician care, while others include such items as long-term care, drugs, dental care, home health services, and eyeglasses (Healy). In addition, many European countries incorporate housekeeping, spa vacations and social services into their provision of healthcare services. Cultural norms also affect countries's health systems. Japan, for example, did not establish a formal system of long-term care until recently, in part because of the tradition that the eldest son and his wife have had responsibility for the son's parents (Campbell and Ikegami).
Countries's decisions about government involvement in provider issues can highlight conflicts between the individual liberty of providers and patients's access to care. Some countries, such as Israel, have adopted policies that restrict providers's ability to practice in areas that exceed a certain physician-population ratio and have developed policies that encourage them to operate in underserved locations (Anderson and Antebi). Other policies may limit the total income that can be generated by health professionals, either through restrictions on the salaries that physicians can earn or by limiting the volume of services the physicians may provide (White). In addition, some countries, such as the United Kingdom, permit providers to operate publicly (through a national health service) and have a private practice (Healy). Other countries, like most of the provinces in Canada, require a provider to work completely in the publicly financed plan or completely in the privately financed sector (Flood and Archibald).
Countries use three basic mechanisms, in addition to out-of-pocket payments, to finance medical-care services. One option is to use general tax revenues. With this method, citizens pay for medical services based on the structure of the overall tax system. This option is considered by economists to be the most progressive. For economists, progressive means that the income tax rate increases as the taxpayer's income rises. A second basic method to generate funds for medical-care services is through a payroll tax earmarked for the health system. This is referred to as a proportional or flat tax since the tax rate does not vary with income. The third basic method to finance medical-care services is through health-insurance premiums. This method is considered to be regressive by economists because the rate falls as income rises.
A related financing and access issue is that of the cost sharing by individuals. Cost sharing, such as coinsurance, copayments, and deductibles, is introduced when health insurance systems want to give patients a financial incentive not to use certain health services—especially services they believe to be only marginally beneficial. However, the patients' ability to make appropriate choices is debatable especially when they are poor (Fuchs). Poor patients's demand for care depends more on whether they have money at the time than on their own judgment of the seriousness of the condition (White). Some countries, such as the United Kingdom, Canada, and Germany, operate with no or nominal deductibles and coinsurance (Glaser, U.S. General Accounting Office 1991a, 1991b). Other countries have substantial cost-sharing requirements. For example, 10 to 20 percent coinsurance requirements are typical in the United States and France, and 20 to 30 percent coinsurance requirements are typical in Japan and Korea (U.S. General Accounting Office 1991b, Anderson).
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