In Western liberal democracies, society dictates what is valued when it comes to the balance between access to health care services and the pubic "cost" for that access. There is a large public financing cost that comes with unfettered access to health care services, so elected governments make decisions about what kinds of health care services to fund (breadth) and by how much (depth). This is a policy discussion, and these debates happen during elections and while negotiating national and state budgets within lawmaking bodies. Governments have policy making divisions staffed with analysts and strategists who review the health system and suggest ways to make it more effective and efficient. But their impact and control depends on the overall philosophy around whether health care should be treated as a public responsibility (taxpayer funded) or as a private business (individual pay-per-use).
An excellent World Health Organization paper on this subject describes this concept by using the analogy of a bucket. Depending on the dimensions of the bucket, it can be large, implying excellent access but at a large public financial burden, or very light, implying low or limited access but at a smaller public financial burden. Many societies try to find a balance based on the merits of keeping some health care services publicly financed and delivered while leaving the rest to the private market (where individuals pay "out-of-pocket" to access these services) in order to manage public spending on health care services. Using our analogy, governments will try to find a "bucket" of services with the "right dimensions", taking into account societal values on what is considered necessary access to health care services and for whom, while also considering the "weight" of this bucket, the public financial burden, based on those dimensions. In Canada, the health care system is mostly publicly financed, but there are certain services that are not included in that public financing—our "bucket"—like plastic surgery for cosmetic purposes, some dental care services and pharmaceutical costs, for example. And while access to health care services in Canada can be considered "universal", that does not mean that every health care service is paid for publicly.
The United States is an outlier among Western democracies in that it does not publicly deliver and fund, at least in the conventional sense, health care services. With the exception of Medicare and Medicaid, two publicly-funded programs that extend financial help only to those who are eligible and thus limits access, Americans must otherwise self-finance their access to health care services by either paying out-of-pocket when requiring specific health care services or by purchasing a health care insurance plan that offers coverage for a certain range of health care services (with many paying through employee sponsored health benefit plans.) Health care delivery facilities (hospitals, primary care clinics, long-term care centers, etc...) are also often privately owned and operated, with the rare exception among them that are publicly financed (for example, federally, like a veteran's hospital, or municipally, like the United Medical Center hospital in Washington D.C.)
In terms of how this all ties back to our conversation on the health care system, it’s important to understand that depending on the degree of public financing, a health care system may have a significant and active government presence in its administration, while countries whose health care systems are not significantly publicly financed may have a smaller (or largely absent) government role. Active public management may mean that governments and government-managed care providers contract directly with health providers, like physicians, to provide care, have direct and active input in the design of the health care system, create legislation that prevents certain health care services from being offered both privately and publicly, define where and when major health care facilities are built, and manage public expectations of service quality and access that may differ when compared to the market-managed delivery of health care services. But regardless of whether a society chooses a pure public, mixed, or pure private health care delivery system, most governments will legislate in order to instill confidence in their health care systems to the extent that is expected by the electorate and, at the most basic level, in terms of the quality and safety of the health care services provided (to prevent the delivery of "bogus" or high risk health care services that have little evidence of clinical success, for example.)
Policy gives structure and rules for how health care providers and facilities operate and under whose control (be it government controlled or privately delivered), and dictates what services are accessible to all by public expense versus those that need to be paid individually, out-of-pocket.
Next post, we'll talk about training.