Saturday, June 20, 2009

Separate is Not Equal: Two Tiers in Healthcare

People get healthcare in Canada--Canada is committed to it, and is pretty successful at it. The vast majority of medical treatment--diagnostic, prescriptive, inoculations, etc.--are delivered regularly and well to just about everyone who needs them. As for the resource-intensive 5% (which account for nearly 95% of costs)--transplants, reconstructive surgeries, machine-therapies--Canadian healthcare by and large delivers that too. But the system feels the stretch of resource limitations. Canada considers healthcare everyone’s equal right, to the full measure that resources allow. One tier for everyone.
Some people want more than this equal level of care. They would like more additional personal service (private rooms), additional services (collagen treatments) or more speed (appointment now, not Thursday). And so people speak of a “Second Tier.”
Most often, this is seen as “cut to the front of the line,” which is a commodification of healthcare that runs counter to the idea of healthcare as an equal right. Some have proffered the idea of an alternative, more expensive system. On both sides of the border, separate is not considered equal. What to do then?
But Canada has an answer. What services National resources cannot support for everyone are available to those who want it through secondary insurance. Many employers provide their people such supplementary coverage as an option. Better rooms? Supplement to cover the difference between the core services and the “preferred.” Extra dental? Supplement. Employee premiums are well under $100/month with varying options of deductibles and partial payments (80/20, for example). This would seem to be a de facto two-tier system.
Canada has moved past the issue of healthcare access and is now confronting the difficulties of delivering with limited resources, and increasing expectations from users. There are still only so many operating rooms, so many organs available and so many MRIs. But what of those things of which there are extras? In the efforts to deliver a baseline of healthcare to all members of society, over-stocking and over-provision create excess capacity. Could such excess capacities be used as a different kind of “second tier?” Could a clinic charge a premium for a 6pm appointment with a doctor working hours above his “core” commitment that week? And could this premium revenue be used to expand general resources?
Excesses cannot be planned, and an immediate concern would be the redirection of funds to create excesses instead of enabling services to all. But it is a thought. And if these excesses (an ENT’s hours, a bed in a 30-day rehab facility, late-night imaging) were paid for as “premium,” could they then be offered to US citizens? And billed to US healthcare payers? And as the overheads of billing and collections of these services would be aggregated (and as these services are already lower in cost than in the US), could they be competitively priced? Perhaps passing the savings to the patient as $0 co-pays instead of the usual $25?

Now there’s a thought…