Should healthcare be guaranteed for cancer but not diabetes? Andrew Jack, deputy editor of the Financial Times, writes in the BMJ 15th March: (BMJ 2014;348:g1812)
As healthcare costs spiral, debate is growing over whether countries should limit their healthcare coverage to certain medical conditions. Andrew Jack examines why Chile’s attempt is meeting a mixed reception and looks at the other options
Ten years ago Chile introduced a groundbreaking health insurance system designed to improve access, quality, and speed of medical treatment for its citizens. Auge (the Spanish acronym for Universal Access with Explicit Guarantees) offered legally enshrined coverage for several medical conditions.
Today, that system—like its equivalents in other countries around the world—is generating both interest and criticism as policy makers seek ways to balance ever rising demands for better and fairer access to healthcare against intensifying pressures on costs.
Auge, approved under Chile’s socialist president Ricardo Lagos in 2004, sought to expand coverage across the country with a pioneering system that incorporates the principles of access, quality, opportunity, and financial protection, funded through a mixture of taxes and copayments by patients. The scheme lists the conditions that will be covered, which now number about 80, ranging from breast cancer to hepatitis C.1
This has triggered criticism that it discriminates against people with conditions outside the defined categories. “On the positive side, it has created in public opinion a consciousness of the importance of health as a right,” says Vivienne Bachelet, editor in chief of Medwave, a Chilean medical journal.
“But Auge has come to the detriment of those conditions that are not covered, and in order to meet treatment guarantees it has forced providers to outsource the covered conditions to the private sector at four to ten times the cost. It has led to the impoverishment of the public health system.”
Inclusion or exclusion?
Chile is not alone. It is one of several countries that are debating or experimenting with an “inclusion list” of reimbursed …”
The article ends with a comment on increased efficiency. “The Nuffield Trust’s report rejected the idea of an explicit national health benefits package for England, but argued for the establishment of a formal list of principles including cost-effectiveness, transparent decision making, and ways to encourage patients to make the right choices through more public information.
Improvements in efficiency will cause pain but offer prospects for gains that could be better spent on improved health. Discussions over different approaches are set to provoke fierce debate. Yet greater use of assessments that will narrow the conditions, subgroups of patients, or interventions offered are only set to grow. The alternatives risk being still more painful, divisive, and inequitable.”
NHSreality feels that increasing efficiencies without overt rationing, will lead to an increasingly and covertly rationed post-coded health service, in which the best care is often available only to the assertive or well informed…… I wonder if Andrew Jack has Private Medical Insurance?
The article comments “some opinion polls suggest those taking responsibility for their own health through improved lifestyles – such as not smoking, keeping fit, and healthy eating – are reluctant to pay more to subsidise people who do not.”
This suggestion is that the South East of England resents subsidising the poorer people – and it should be nonsense. The whole idea of a mutual is that we are all in it together for the greater good. England has already hived off Wales, N Ireland and Scotland from its mutual, so now the Welsh “valleys” and the Glasgow “deep-fried mars bar eaters” are no longer subsidised by the home counties. But there are poorer areas even in the South East, and breaking up the mutual into smaller and smaller ones will only make it weaker, and the costs per head higher – look at the State of Wales. Wales response is an emphasis on spiritual rather than physical care!
What more could the insurance world want than smaller and smaller units, so that in the end there is no benefit and individuals pay – at great cost.