How should society pay for the healthcare of its citizens? This has been a fiercely debated question for decades among health economists, public policy advocates, and public health administrators around the globe. Different countries have answered the question in different ways, applying their own unique blends of private and public funding. This has resulted in vastly different healthcare delivery systems in countries such as Canada, the United Kingdom, and the United States.
An in-depth analysis pertaining to the private and public funding of universal healthcare systems is discussed in Financing Health Care: New Ideas for a Changing Society, edited by Mingshan Lu and Egon Jonsson. This volume is the first in a new public health series, compiled by the Institute of Health Economics (IHE) in Edmonton, Canada. The book centers on the Canadian universal healthcare system. Economic concepts and principles are studied across different countries in order to contribute new health policy solutions for Canada. Each chapter is authored by a different leading expert within the field. Some sections are written with deep technical emphasis, others with high-level conceptual themes.
The first couple of chapters focus on public financing, prescription drug financing, and private financing. In public financing, the author explores the role of government in a universal healthcare system. He discusses how the high cost of treating diseases often exceeds the ability of a consumer to pay for the service and how a lack of information limits the consumer’s decision on “what to purchase.” For a system to be effective, the government needs to share the financial burden and reduce asymmetric information. These issues also open up further analysis in pharmaceutical financing, where the cost of drugs in an outpatient setting is often not included under a universal coverage plan. In consumer financing, the author touches upon issues associated with “opting-out” of universal coverage to accept “customized” private services. A detailed econometrics exercise is then performed to determine the impact of “de-listing” services from a universal health plan. Other issues, such as the allocation of a doctor’s time for private vs. public service and the ethics of private insurance marketing in a universal healthcare market, are covered as well.
The rest of the chapters focus on consumer directed healthcare (CDHC), medical savings accounts (MSAs), and economic incentives. With complex economic models, the author argues that high-deductible (HD) plans result in a stronger “illness prevention” behavior than a conventional plan. The author also highlights that individuals with low likelihood of illness are more likely to choose HD plans. The next chapter highlights the introduction of MSAs within the United States, Singapore, and China, and the role MSAs would play in public spending and saving in Canada. The concepts of “demand side incentives” and “supply side incentives” are introduced to highlight the role of patient and provider incentives. The book expands these concepts to include physician, health plan, and provider incentives. The author concludes that health services in Canada are, for the most part, equally balanced between poor and rich socioeconomic groups. However, for services not covered under the universal plan (i.e., dental), there is strong evidence that supports unequal coverage among socioeconomic groups, and despite equal coverage between socioeconomic groups, lower income populations are in worse health overall than higher income populations.
A particular strength of this work is its ease in organization. Each section is clearly titled and defined, allowing the reader to scan the book quickly to retrieve information of particular interest. The graphs, economic charts, and tables are clear and relevant, adding breadth to the text, which contains detailed, technical information to support the economic concepts.
A downside is the style of writing varies drastically from chapter to chapter. Some sections of chapters contain high level executive summaries that are clear and easy to read. Other sections dive deep into the underlying economic theory that supports the health policy, which could challenge any reader who hasn’t pursued advanced study in economics and/or mathematics.
An interesting surprise about this compilation is its focus around the Canadian universal healthcare system. The readings gave an interesting perspective about the potential inefficiencies and inequities of universal coverage or the role of non-covered services. However, I would have liked to have seen how the economic models discussed in the chapters on consumer directed healthcare (CDHC) would impact a privatized, fragmented healthcare system such as the United States. There is also the assumption that the reader already has a clear understanding of the Canadian healthcare system.
Financing Health Care: New Ideas for a Changing Society may not contain all the solutions needed to improve a universal healthcare system, but it does give strongly supported, economic frameworks to help the reader gain a deeper understanding of public vs. private financing, CDHCs, MSAs, and incentives among stakeholders in a universal healthcare system. It is an excellent resource for health economists and public policy advocates who wish to support their healthcare reform arguments with underlying economic theory, or the student who wishes to understand the underlying economics behind health reform policy in a universal coverage system. I would, however, recommend dusting off your favorite microeconomics textbook before diving in.