The Public-Private Mix for Health
The Nuffield Trust
The Public-Private Mix for Health
Edited by Alan Maynard
This book, written over 20 years after the publication of a similar collection of essays, examines again the complexities, frustrations and progress of healthcare systems in a leading group of rich countries. Like its predecessor, it offers few panaceas, but the insights of its authors show that the political and economic challenges of healthcare reform are now better articulated, if still largely unmet. The resilience of some of the obstacles to efficient reform articulated over 20 years ago and examined here again demonstrates the power of public and private interest groups in resisting changes that will benefit the patient. The ongoing battle between funders, providers and consumers is the business of healthcare, like many other markets. The characteristic of healthcare, however, is its resistance to change and the preservation of inefficient practices by management techniques appropriate for Dickensian times.
Despite differences in culture, history and resourcing, the nature and performance of healthcare systems worldwide are very similar. Political debates about healthcare reform are dominated by covert ideological arguments, and the policies these debates produce are generally ill-focused in terms of resolving well-evidenced common performance and incentive problems. As a consequence, the political necessity is created for the next often-irrelevant ‘redisorganisation’ of structures, epitomised nicely in the behaviour of successive Dutch and British governments, both having adopted, abandoned and readopted reforms in the past 15 years. Such changes usually fail to define the causes of inefficiencies in performance and pay scant attention to how better systems of incentives can be implemented to remedy performance problems.
http://www.radcliffe-oxford.com/books/bookdetail.asp?ISBN=1+85775+701+7
Comment: If you wish to be a serious participant in the national dialogue on health care reform, this book is an absolute must-read.
The United States has a unique position amongst the wealthier nations. We have the most expensive health care system, yet we are the least effective in ensuring affordable access to care. Everyone agrees that we need change, but we fail to move forward with reform because we are locked up in the debate as to whether the private or public sector would serve us better.
Before this book discusses the relative roles of the public and private sectors in the health systems of various nations, it discusses the pervasive role of ideology in the optimization of the public-private mix. Although the debate over the public-private mix is often framed as a linear spectrum with libertarians and authoritarians at either end, the authors instead describe the libertarian-egalitarian polarity. Much of the political process of reform is driven by these ideological positions.
The problem is that the debate over ideology is the wrong debate. Instead the dialogue should be over the best mechanisms to provide efficiency, control of expenditures, and ensuring equity in funding and access. No system will be purely public or private, so decisions should be made on changes that will improve the functioning of the system based on understanding of the impact of various well-described policies. Effective solutions would invariably have the support or opposition of ideologues, but the ideology should not control the process. Health policy science has advanced dramatically in the past couple of decades, and we have the knowledge on how to make the systems work.
Many lessons of the public-private mix can be learned from the discussions in this book of the systems of the United Kingdom, United States, Canada, France, Scandinavia, Germany, New Zealand and Australia. Single payer supporters will be particularly interested in the chapters on the United States by Uwe Reinhardt and on Canada by Robert Evans. But we should not allow our egalitarian, single payer ideology to deter us from reading the other chapters which help to clarify the advantages and the deficiencies of various government and market solutions.
As Professor Maynard states, “Political debates about healthcare reform are dominated by covert ideological arguments, and the policies these debates produce are generally ill-focused in terms of resolving well-evidenced common performance and incentive problems.”
It’s time to end our policies of “redisorganization” and move forward with rational reform. Optimizing patient care is too important of a process to worry about the response of ideologues, whether or not they’re pleased with the results.