Sure, if you are rich and can afford to pick and choose from the vast array of expensive private health care providers and insurers, or if you are old and can avail oneself of the limited socialised Medicare system, then you can safely say that USA Healthcare is "the best in the world". Otherwise it is an unmitigated disaster that condemns tens of millions of citizens in the richest country on Earth to suffering and death from preventable or treatable causes. In spite of the vastly lower per patient administrative costs associated with government run Medicare insurance when compared to the private sector insurance system, and the overwhelmingly positive reviews it gets from the senior citizens served by it, political conservatives are utterly opposed to extending the plan to citizens under 65 because of a lack of cost controls. Meanwhile the liberals are complaining that women pay private health insurance premiums that are 115-120% the price paid by men, accurately pointing out that this is also roughly the share consumed for reproductive health (which is justifiably the economic responsibility of both genders equally), while at the same time seeming to ignore the statistics that show that adult American females of reproductive age consume health care services at a rate around 250% the cost of their adult male counterparts.
The American delivery system is a hodgepodge of taxable private hospitals, clinics, specialists, and research laboratories, non-taxable versions of the same facilities run by churches, medical schools, and charities, and government versions of the same facilities paid for with tax money. Overlaid on this is another patchwork quilt of insurance coverage for individuals, some for profit, some non-profit, and some government run and subsidised in whole or part by tax dollars. Oh and by the way did I mention that government institutions and insurance programmes include all levels of government, not just the Federal government, but each one of the individual 50 state governments, and each of the hundreds of county governments within those states, and often city governments as well? Well it does.
Apparently the only compromise between the advocates and opponents of extending the socialised insurance system to the whole population (nobody is seriously even contemplating a "government takeover of healthcare" delivery institutions), is to shove the whole problem onto employers. Well I am an employer, and I am not qualified to be making those decisions about the appropriate amount of medical insurance covering my employees. I have 15 employees, ranging in age from early twenties to late sixties, all of whom make over the statutory minimum wage even for my State, which has the highest wage standard of the fifty. About half of them are not covered by any form of health insurance and must pay full cost out of pocket for any care received (myself included). All of them already by law have a percentage of their wage deducted by me and delivered to the Medicare insurance system before they receive the balance of their pay. All of them are already covered for treatment and lost wages due to injuries suffered while on the job, paid to private insurers by me and factored into the price of everything that we sell. If any or all of these numbers need to be increased, be it the minimum wage, government insurance percentage of wages to be withheld, or the required amount of catastrophic coverage related to on-the-job injury, then we know how to make those changes relatively easily without adding much administrative overhead. If the costs become untenable, we will be able to see and show where and why.
Down here at the lower gross sales per employee end of the spectrum, where wages even at or near the minimum constitute 30-40% of gross revenues already due to heavy competition, we face a very different equation than the "small businesses" with millions or tens of millions of dollars in gross income per employee (such as financial planners, lawyers, or surgeons in private practice). High wage employees are used to having health insurance paid by their employer in lieu of higher wages as a tax dodge, and since they also probably have stock options they don't really mind that the company doesn't pay as much for this insurance as they would have in increased wages. This is the only source of "savings" that I can detect from employer issued insurance, and it goes to the shareholders. Effectively lowering wages in order to deliver insurance to employees would be illegal where those costs reduced compensation below minimum standards. The problem is that low wage workers cannot afford the costs of private insurance plans, so lower the costs of the plans, or mandate higher wages, but don't randomly put employers in the middle of that decision, if we aren't already health care experts then it is literally none of our business.
Zambian healthcare, such as there is of it, is almost entirely delivered by government and non-profits at this point in time, making it much simpler to impose a standard insurance framework than in the massively redundant (sorry, "competitive"), American marketplace. When I speak with German or Japanese nationals about health care in their countries, it all sounds very simple for the patients. There is a basic national system, everyone gets enrolled (in Germany 92% use national insurance, 8% purchase private plans or designate sufficient personal savings for health care), and goes to any health care delivery facility that is most convenient and/or appropriate to their immediate and preventative needs. Every visit to a facility incurs a cost based on the services performed, and the portion of that cost payable by the patient is dependent on their status as registered in the system. If they are employed in a high wage industry then they may pay all or almost all of the cost of their treatment (in addition to subsidising the system partially through their contribution to the income tax system). If they are employed in a low wage industry, then the amount payable from their disposable income is partially subsidised through the system (effectively reduced or fully offset by their contribution to the income tax system); and if they are unemployed or disabled or otherwise in need of health care beyond their economic means, or if the preventive nature of the treatment will benefit the society and reduce future health-related expenditures by the system, then all of the cost may be bourne by the system. The facility, whether public or private, is always compensated for the services they deliver in all three examples (with appropriate oversight for waste and/or fraud of course)[2,2a].
Such systems are not without their limits however, and the volume of emergency procedures, or the ratio of subsidised procedures overall may require higher patient contributions to and/or delay of less urgent or optional procedures, thereby placing some hardship on certain patients. It is unlikely however that those patients would have received faster or less expensive treatment under a different insurance system, unless they also have sufficient means to pay more than the average patient for procedures under a single-payer system. There may be a viable market for secondary private insurance to amortize the costs of copayment for those with consistent employment. Certain re-evaluations of health care priorities may be necessary as the overall health of the population increases, so as to avoid the circumstance of the US system, where with an aging population and a disproportionate share of the uninsured amongst the young, an ever increasing share of total health expenditures is being used during the last two months of elderly patient's lives .
There is ample evidence that the confidence citizens of countries with national insurance systems have that their needs will be adequately covered correlates with relatively lower reported stress over medical issues being suffered by patients or their relations. This is also true of American seniors on Medicare and high earners with "Cadillac" private insurance plans when compared to their uninsured or underinsured fellow citizens. According to Vermont's Governor, Peter Shumlin, the State is moving to a single payer system as the best means to contain costs . Perhaps the voters of Vermont are just idealistic, but they apparently would rather have a system concentrated on enabling doctors and nurses to focus treating patients with the resources on hand, instead of worrying about which patients can pay for what level of care, or how much more care they could deliver if only their patients were richer. I strongly doubt that doctors and nurses currently working or aspiring to work in Zambia chose to do so in order to become obscenely rich. I think that most of us want such persons to be prosperous and comfortable in their home lives, and nobody on either side wants there to be a lack of trust between patients and health care providers.
There is no profit motive at the heart of health care delivery. Certainly it is a capitalist, market-oriented world that allows for various medical suppliers and innovators to outcompete their fellows through productivity, economy of scale, and alternative methodologies. There is no need for that natural competition on the periphery of the doctor-patient relationship to intrude into actual delivery, and I certainly cannot identify any actual benefit provided by private insurance other than to high wage earners and stockholders who would rather pay a large amount to a private insurer than the same or smaller amount in additional income taxes. The logical presumption is that such persons intend to make use of additional, expensive private health care services without making use of the government insurance system, and therefore want to avoid any contribution to a national plan. For richer Zambians already accustomed to traveling abroad for private care, any contribution to domestic health delivery may seem like an unnecessary additional expense. This is similar to many attitudes of some parents who send their children to expensive private schools in reaction to initiatives to improve universal public education delivery, and equally self-defeating since their own children's prospects are still tied to the national situation as a whole. Children trained in the best of private schools can still benefit a great deal both economically and culturally from life amongst a better educated general population, and will have a much better chance of being accepted as a leader by their fellow citizens if there is no barrier of resentment between them from the start.
One primary insurance plan, with simple earnings based patient co-payment of fee-for-service health delivery at any licensed facility, is a proven way to provide reliable health care universally to citizens at a resource level determined by the average income of the patient base. Only those with no reasonable means of payment are not required to contribute at the point of service, thereby reducing the burden on the general revenue of the government, and providing reassurance to the higher income elements of society that they will not be disproportionately burdened by "freeloaders". Keep in mind that even though two consumers may be asked to pay the same 50,000 kwacha price for a 25 Kg bag of mealie meal in the market, if the first consumer takes home 500,000 kwacha per month then the bag costs 10% of their income, while if the second consumer takes home 5 million kwacha per month then that same bag is only 1% of their income. The first consumer can only cover one-sixth of the JCTR monthly basic needs basket for a family of six, and will need to combine their income with that of other household members in order to afford the full basket, while the second consumer can afford it all and still have nearly half their take home pay left for other things even if no other household members produce earnings . This is known as "relative poverty", and it means that the cost of basic needs like food or healthcare are effectively much higher for poor people than richer people can easily perceive.
I strongly advise against Zambia adopting any portion of the health insurance system used by the USA. A diversified market of delivery facilities is welcome, especially given the general lack of facilities in the nation at present, and a reliable single-payer insurance system can provide the industry with a level playing field and predictable reimbursement rates for services delivered in good faith for the benefit of citizen's health. The wealthiest can and will always seek their own exclusive arrangements individually or collectively, and don't need the whole system to be geared to their expectations. There is no advantage to be gained by involving employers in the process other than for the purpose of ensuring that wages are high enough to allow wage earners to contribute to their own health care, account for liabilities accrued due to workplace injuries and/or hazardous working conditions, or to facilitate tax collection through income withholding from paychecks.
 "Gender Differences in Health Care Expenditures, Resource Utilization, and Quality of Care", Dr. Gary M. Owens, MD, Supplement to Journal of Managed Care Pharmacy, April 2008, Vol. 14, No. 3, pp 52-56 (PDF 285 KB), http://www.amcp.org/data/jmcp/JMCPSupp_April08_S2-S6.pdf
 "Insights From Health Care in Germany", Christa Attenstetter, PhD, American Journal of Public Health, January 2003, Vol. 93, No. 1, (PDF 136 KB), http://ajph.aphapublications.org/cgi/reprint/93/1/38
[2a] "Health Care Reform In Japan: The Virtues Of Muddling Through", Naoki Ikegami and John Creighton Campbell, Health Affairs, 1999, Vol. 18, No. 3 pp. 56-75, (PDF 328 KB), http://content.healthaffairs.org/content/18/3/56.full.pdf
Sixty Minutes, (CBS), "The Cost of Dying: End-of-Life Care", http://www.cbsnews.com/stories/2010/08/05/60minutes/main6747002.shtml
Vermont State Governor Peter Shumlin on The Rachel Maddow Show, http://www.msnbc.msn.com/id/26315908/vp/44544269#42773328
JCTR Basic Needs Basket, http://www.jctr.org.zm/bnbasket.html
The above post was written by our resident contributor - L Yakima.
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