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Expert answer:Healthcare Frameworks in Canada Vs United States P - Ray writers

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Instructions: This assignment must be done in APA format. A minimum word count of 300 words
(not including references) is required. A minimum of 3 references (with in-text citations) is required.
Please make sure that scholarly references are used. If you have any questions please feel free to ask.
Select a country to use for comparison of their healthcare policies and system to the United
States. Focus on policy first then operations.
Select a policy from each nation having a common goal. e.g access to healthcare, quality of care,
Compare these two policies.
What are the benefits of each?
What are the downsides of each.
What unintended consequences come from the implementation of each?
What policies or implementation practices could the US adopt from another country. Do not jump
to “universal care”. To understand why research key words like universal healthcare in the US,
why universal care won’t work in the US, cultural factors prohibit copying another nation etc.
Can countries with diverse often conflicting cultures really be compared as to success? Why or
why not?
Sample link: Malcolm Gladwell on Canadian
universal care vs US
Book Reference:
Morone, J. A., Litman, T. J., & Robins, L. S. (2009). Health politics and policy(4th ed.). Clifton Park, NY:
Cengage Learning.
Additional Readings:
Instructors Notes:

In professional writing avoid using first person “I” and third person “we”, as they detract from
the quality and turn professional researched statements into opinions. Instead of “I” use, for
example, use “the writer, the author or the researcher”.
Approved sources for this course include the course textbook and scholarly articles from the
Bethel library databases. No other source information is acceptable.
Chapter 23
American Health Care in
International Perspective
Joseph White
This chapter places American health care politics and policy in an international perspective—highlighting how our own system is unusual. The
chapter describes the “international standard” for organizing and financH
ing care by showing what most other health systems have in common.
The international perspective illuminates A
the underlying causes of our
problems (like high costs); it highlights the kind of health policies that
I to fail.
often succeed—and those that are more likely
Artists know that the appearance of a figure depends
Uin part
on the painting’s background, or setting. Within this book’s
analysis of American health policies, the purpose of thisAchapter
is to provide some background, or contrast, that can highlight
important aspects of the subject.
The proper background for this picture consists of other
“rich democracies”: countries that have large enough1per capita incomes and responsive enough political arrangements
0 so
that underlying economics and sociology enable similar poli5
cies, if the political systems so choose.1
While I will fill in some details later in this chapter,Tthe basic outline of the international backdrop to American
S medical care is clear enough. Other countries have national health
care or insurance systems that provide much more equitable
access at lower cost than in the United States. Hence the international background highlights how differently the United
States collects the money for health care (finance) and pays
the providers of care (payment). To a lesser extent, the background provides some contrasts to how Americans organize
care (delivery). Last, the background highlights aspects of US
health politics.
These international comparisons were evident to some of
the supporters of the 2010 health care reform legislation, and
one way to understand that legislation is by looking at to what
extent it would, if implemented, make the American health
care system like those in other countries.
9781305172005, Health Politics and Policy, Fifth Edition, Morone/Ehlke – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
CHAPTER 23 • American Health Care in International Perspective
What Can We Learn
From Comparison?
From a social scientific perspective, comparing countries is
a way to increase the number of cases for analysis. Just as
we can learn more about welfare-to-work policies by looking
at actions and results in 50 states than in one, we can learn
more about health policies by adding to American experience
the experience of the countries at comparable levels of economic development.2 We need to be careful because nations
may vary from each other in ways that states do not. YetHthat
should not scare us away. After all, Texas is very different from
International comparisons offer three kinds of information:
about possibilities, about cause-and-effect relationships, and
about preferences.
The more cases we look at, the more phenomena we might
see, so the more alternatives we might consider for changing our own system. For example, national health coverage
can be achieved in very different ways. Canada has governH
ment-sponsored insurance, but it is managed by the provinces
within broad national guidelines. France has a dominant
Anational insurer that covers most people but a series of smaller
N of
funds for other occupational groups. Japan has thousands
insurers, with membership determined by employmentI and
location. In the Netherlands, people are required to have inC
surance but can choose among funds. In Germany, about
80% of the population is required to join “sickness funds,”
but there too people choose their funds. In England, instead
of having insurance, citizens are given the right to use a state
bureaucracy, the National Health Service. Sweden alsoA
provides coverage through health services, but they are organized
and mainly funded at the county level. Australia has a version
of Medicare nationwide for ambulatory care, but hospital1care
is provided by state public hospitals. National Health Insur1
ance (NHI) turns out to include a very wide range of possible
5 in
Looking abroad can expand our sense of possibilities
other health policy areas as well. In 1990, for example,Tone
could see that in the United States care within hospitals
was basically supervised by admitting physicians, who S
practiced outside of the hospital as well. The full-time hospital
staff consisted mostly of trainees, interns, and residents. In
Germany, physicians with ambulatory care practices generally
did not have hospital privileges: Once a patient was admitted, their care was and is managed by full-time, fully trained,
hospital physicians. Each system has its own strengths and
weaknesses, but, since that time, the US system has moved
toward greater use of full-time “hospitalist” physicians.4 There
are many different ways to pay hospitals; in recent years, policymakers in other countries have to some extent adapted the
American Medicare method of payment by diagnosis, but in
a variety of forms and for a variety of purposes. Britain’s creation of a National Institute for Health and Clinical Excellence
(NICE) has inspired all sorts of proposals in other countries.
Thus looking at other countries can increase the menu of
possible “solutions” to policy problems. Yet studying other
countries should also, sometimes, provide caution against
believing problems could be easily solved. If an undesirable
condition has never been solved in other countries, maybe
American failures are not due to American institutions. As my
mentor, Aaron Wildavsky, commented to me in 1993, “Even
Stalin and Beria couldn’t get doctors to move to the countryside.” In 2011 it was impossible to find countries that had
found ways to “pay for performance.” Comparison might give
us a more realistic sense of what is possible, not just a wider
range of options to consider.
Cause and Effect
Analysis of how systems work in other countries can also provide evidence about cause-and-effect relationships. For example, observation of the same relationship in multiple settings
may make it more credible. American evidence suggests that
an aging population per se is not nearly the most important
cause of increases in health care spending. The fact that evidence from other countries supports exactly the same conclusion should make this finding more convincing.5
Yet it is more difficult to use comparison to analyze causation than to survey possibilities, for a series of reasons. To
begin, it can be very hard to measure some effects. The controversies over assessing any new technology or drug make
that clear enough, as do the controversies over rating the performance of individual hospitals or health plans. The problem
is particularly severe if the goal is to compare the quality of
national health care systems.6 Measurement of the dependent
variable is less of a problem if the variable is health care costs
or the extent of insurance coverage. There can be some disagreement about what costs count or what benefits matter,
9781305172005, Health Politics and Policy, Fifth Edition, Morone/Ehlke – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
PART VII • The United States in International Context
but there is very little doubt that costs are much higher, and
a larger part of the population has no coverage, in the United
States than in other countries.
Even when outputs can be measured and causes identified,
doubts can be raised about the implication of that finding
for American policy choices. For example, there is no doubt
that when Canada moved to a system of NHI with stronger
capacity and payment regulations, the trend of spending increases, which had been quite similar to the United States
until then, substantially diminished. Yet critics could argue
the association between seeming cause and effect is H
because the better performance is due to some other, unmeaI not be
sured cause. Lower health care costs in Canada could
due to superior cost-control methods but due to Canadians
being healthier because of lower levels of poverty, crime, and
other problems. Or perhaps changing the policy (cause) will
have negative effects on some other valued output. Hence
S the
policies that lower Canadian costs may be claimed to have
unacceptable effects on quality. Also, perhaps intervening factors mean a policy would work differently in the United States
than in Canada. A friend of mine, for example, suggests
S that
the payment restrictions that work in Canada will not work
H law
as well in the United States because Canadians are more
abiding and Americans more likely to look for waysA
to cheat
the system. None of these objections are in fact compelling,
N benbut an analyst who argues that the United States would
efit from adopting Canadian-style insurance has to be
I able to
address them all.
Each nation has not only health care policies but health care
U fight
politics as well. Within that politics, groups define and
for their interests. Analysts identify “problems.” To most
A people, each of these processes may seem natural, but for political scientists they require explanation.
1 as
Why are some conditions put onto the political agenda
problems and others not? For example, how did “quality”
1 become an issue in the United States in the late 1990s?8
Why do some groups take stands that would seem contrary to their economic interests? For example, why5
do businesses that pay lots of money for health insurance not
Tturn to
the government, which seems to have more power to control
costs, and ask it to take over?
Do we decide which problems are most pressing based on
some objective measurement of their level? Or do problems
get prioritized based on the self-interested perspectives of
groups that try to sell those definitions to win changes that
serve their own purposes? Here an instance would be the frequent claim in the United States that there should be a greater
emphasis on “primary care” and less on “specialty care.”9
Is this claim clearly justifiable from data? Or is it predominantly a result of the social position of its advocates?
Comparison to other countries can give us a sense of the
answers to such questions. For example, if we find people
with the same backgrounds promoting the same problem
definitions in different countries, in spite of quite different circumstances, we may conclude that the preferences of these
groups (say, public-health professionals or physicians) are determined by socioeconomic aspects of health care. If a group
in one country takes different positions than similar groups in
other countries (such as American businessmen on the subject of compulsory health insurance), we might look for specific causes in that country.
In the rest of this chapter, I will identify some conclusions
about possibilities, cause and effect, and preferences that I
have drawn from my comparative studies of health policy.
The most obvious possibility, as mentioned previously, is to
provide a health insurance and health care system to all citizens. The fact that all other rich democracies do it strongly
suggests it is possible!
The second and equally obvious background fact is that
other countries spend much less money on health care than
the United States does. Figure 23-1 reports that in 2008, the
United States spent 16% of its gross domestic product (GDP)
on health care. The second highest spender as a share of its
economy was France, at 11.2%; most countries clustered in a
range from 9 to 11%. Thus, the United States spent at least
a 40% larger share of its economy than other countries. The
first column in the table provides another comparison: spending in terms of purchasing power (national currency adjusted
for national prices). By this standard, the United States spent
half again more ($7,538) than the next most expensive country, Norway ($5,003).
If we look behind the statistics, we can see nearly as stark
differences in policies between the United States and other rich
democracies. Although their policies differ in many ways, they
share aspects that can be called an international standard.
9781305172005, Health Politics and Policy, Fifth Edition, Morone/Ehlke – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
CHAPTER 23 • American Health Care in International Perspective
G Israel Germany France United
G 2008 1998
Figure 23-1 Health Care Spending as Share of GDP, 1998 and 2008
Note: Based on OECD 2010, countries with national per capita incomes over $25,000 per year in 2009.
© Cengage Learning®. All Rights Reserved.
GDP is a standard measure of the size of an economy. The ratio of health spending to GDP depends not just on the trend in
health spending but on the trend of GDP. Thus, some of the changes over time in this data are partly due to different levels of
economic growth, with slow increases in the ratio tending to occur in countries with high growth rates.
All other rich democracies provide virtually universal
coverage—about 99% or more of the legal population. But
they do not provide complete equity of access, nor do they all
cover the same set of services.
Governments create universal coverage by compelling people
to contribute to the system. Germany is the exception: About
20% of the population, those with higher incomes or particular
jobs, are not compelled to participate in the sickness fundUsystem. But some of those people (such as civil servants) have other
automatic coverage; all have high enough incomes to afford in-
portion of more privileged people can buy extra access or better amenities.
surance; and all are given strong financial incentives to buy it.
The difference between the United States and other countries therefore is not the existence of inequality per se. The
difference is that in other countries everyone is guaranteed
decent standard coverage, and some have more. In the United
States, hardly anyone under age 65 is guaranteed anything;
most people have decent coverage, but a large segment has
much less. In other countries, there are “escape valves” for
the well-to-do. In the United States, there is a ragged “safety
net” for the poor.
Each country covers its own definition of all “medically
necessary” hospital and physician services. Each provides
pharmaceutical benefits for the poor and elderly, and some
make that coverage universal. In all cases, the definition
0 of
medically necessary excludes extras such as cosmetic sur5
gery and private rooms, which are more available to people
with more resources. There are other inequalities, partlyTdue
to factors such as geography and patients’ knowledge. S
areas can never have the same access to services as urban areas, and immigrants who do not speak the national language
will always be at some disadvantage. In all systems, some
With limited exceptions (Switzerland, Holland to some extent, and Germany for some people), the main coverage in
other countries is not a good that people purchase on a market. Instead, people contribute to a system. Whether people
pay a payroll contribution (a proportion of wages, like Social
Security) or spending is financed from government general
revenues, payments are in rough proportion to ability to pay.
They are not related to need for care. The basic principle
is that contributions should be a fairly steady share of income
through your life, regardless of how much health care you
or those on whose behalf you contribute need.
9781305172005, Health Politics and Policy, Fifth Edition, Morone/Ehlke – © Cengage Learning. All rights reserved. No distribution allowed without express authorization.
PART VII • The United States in International Context
In the United States, private insurers charge according to
the perceived risks of individuals or groups, so they charge
more to those who need more, regardless of their income.
Insurance companies and purchasers, which normally means
employers, negotiate over the terms of insurance, so that coverage differs according to the price that the purchaser feels
able to pay. Therefore, there are thousands of different combinations of benefit terms and provider networks. In most other
countries, coverage is much more standard, even if (as in the
Netherlands) insurers can compete for customers. Variation
occurs mainly due to markets for additional gap or parallel
As mentioned earlier in the chapter, compulsory Icoverage
can be organized and financed in many ways. Inequalities
based on the financing system (rather than on, say, geograG
phy or social connections) then can take a variety of forms. In
England, a person might “jump the queue” with private
S care
financed by private, parallel insurance. In France, some people
have a wider choice of physicians because they pay extra for
“Sector 2” doctors. In Germany, people with private insurance
may have quicker or at least more personal service. InS
some people have better gap insurance (e.g., for pharmaceutical or dental benefits) than other people. Yet the basicHguarantee in all these cases remains solid and relatively equitable,
A at
least, compared to the United States.
Managers of insurance companies or hospitals in other
I scope
countries may have entrepreneurial instincts, but the
for entrepreneurship is limited. Other countries’ experiences
show that universal insurance can include private insurers.
Their experience suggests it is not possible, if youQ
want to
cover everybody, to allow insurers to pursue profitU
being very heavily r …
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