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Benchmarks of Fairness for Health Care Reform added 4/08/01
by Norman Daniels, Donald W. Light, and Ronald
Caplan
Oxford University Press 1996
OCR from page 27 & 28
How equal must our rights to health care be? Specifically, must everyone receive exactly the same kinds of health care services and coverage, or is fairness in health care compatible with a "tiered" system? Around the world, even countries that offer universal health insurance differ in their answers to this question. In Canada and Norway, for example, no supplementary insurance is permitted. Everyone is served solely by the national health insurance schemes, though people who seek additional services or more rapid service may go elsewhere, as some Canadians do by crossing the border. In Britain, supplementary private insurance allows about 10 percent of the population to gain quicker access to services for which there is extensive queuing in the public system. Basing a right to health care on an obligation to protect equality of opportunity is compatible with the sort of tiering the British have, but it does not require it, and it imposes some constraints on the kind of tiering allowed.
Comment by a Canadian on April 10, 2001: "... In Canada, all medically necessary procedures are covered by provincially-run single-payer health insurance plans. However, it is also the case that provinces set how much physicians can bill for given procedures, so there is no need for "supplemental" insurance for these procedures, as all their costs are covered. There *are* expenses that aren't covered by the government-run system, such as private rooms, drug costs, and ambulance fees, as well as any extra costs of receiving health care abroad, and all of these costs *can* be covered by private health insurance plans.
I cannot imagine any scenario under the current system where Skyaid would be prohibited from operating in Canada due to health insurance restrictions. As I understand it, Skyaid is no different in principle than ground-based automated response systems, which are perfectly legal in Canada.
The primary social obligation is to assure everyone access to a tier of services that effectively promotes normal functioning and thus protects equality of opportunity. Since health care is not the only important good, resources to be invested in the basic tier are appropriately and reasonably limited, for example, by democratic decisions about how much to invest in education or job training as opposed to health care. Because of their high "opportunity costs," there will be some beneficial medical services that it will be reasonable not to provide in the basic tier, or to provide only on a limited basis, for example with queuing. To say that these services have "high opportunity costs" means that providing them consumes resources that would produce greater health benefits and protect opportunity more if used in other ways.
In a society that permits significant income and wealth inequalities, some people will want to buy coverage for these additional services. Why not let them? After all, we allow people to use their after-tax income and wealth as they see fit to pursue the "quality of live" and opportunities they prefer. The rich can buy special security systems for their homes, safer cars, and private schooling for their children. Why not allow them to buy supplementary health care for their families?
One objection to allowing a supplementary tier is that its existence might undermine the basic tier either economically or politically. It might attract better quality providers away from the basic tier, or raise costs in the basic tier, reducing the ability of society to meet its social obligations. The supplementary tier might weaken political support for the basic tier, for example, by undercutting the social solidarity needed if people are to remain committed to ensuring opportunity for all. These objections are serious, and where a supplementary tier takes away from the basic tier either economically or politically, priority must be given to protecting the basic tier. In principle, however, it seems possible to design a system in which the supplementary tier does not undermine the basic one. If that can be done, then a system that permits tiering avoids restricting liberty in ways that some find seriously objectionable.
The following chart from page 89 shows that the most expensive 1% of enrollees account for 30% of all health care costs
