Private Hospitals in Public Health Systems

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The mixed health care system of the U.S. has raised many questions of the proper relationship between private and public health This paper is concerned with the same problem, but from a European perspective, where the situation involves not public activity in a predominantly private system, but quite the reverse, that is, the introduction of private hospitals in a totally or predominantly public health care system. For our purposes here, private will refer to a hospital owned by private investors and operated for profit, whose patients are not totally or primarily funded by public moneys. Among the countries in Europe that have seen a rise in the private health care sector, Denmark and England are prominent. Denmark has operated a public free-for-all system of health care since the mid-1960s, thereby securing a high level of primary and hospital care to all citizens. There are waiting lists for certain treatments, including hip replacements and cardiac surgery, and purely cosmetic surgery is not covered by the public system. The objective results of the system in terms of neonatal mortality, healing rates for specific diseases or similar measurements are very high and not declining. But the subjective satisfaction of the users is at a low point, mainly due to the fact that no single doctor is your' doctor during a hospital stay. It is not unusual to be attended and/or treated by ten different physicians during a two-week stay. The waiting lists and dissatisfaction have led to the establishment of two private hospitals. The same development is seen in Norway and Sweden. Typically, the private hospitals are explicitly profit-seeking enterprises established close to major cities. Many Danes see this development as highly undesirable. The sentiment is shared by some political parties, particularly the Social Democratic Party Denmark's largest) and those to its left, who have called for a prohibition of private hospitals by the Danish Parliament. They are chiefly concerned that such hospitals will be an intrusion into a health care system that has been managed in a quasi-socialist way. They fear, moreover, that private hospitals may obstruct progress toward further socialization. The arguments offered against private hospitals fall in two main groups: those concerned with the inequality that private hospitals create, allowing the rich to secure better health care more quickly; and those concerned with the effects that private hospitals have on the public health care system and society as a whole. Both are important, but the arguments concerned with inequality touch the basic rationale for a public health care system. The reasons for creating comprehensive free-for-all health care systems of the type seen in many European countries are diverse, but two of the major ones are evident in the original proposal for the British National Health Service. The first is a belief that society should provide health care for all citizens, the second a belief that access to health care and the quality of care received should be equal for all.1 Though initially grounded in solidarity between classes, these have evolved into a belief in a broad light to health care. Will growth of private hospitals in a public health system create such gross inequalities that, considered as a question of distributive justice, this should be prevented? Are the consequences of introducing private hospitals so damaging to the public health care system as to be a reason to prohibit them? Private-System Inequities The introduction of private hospitals must necessarily cause some new inequalities, or at least perceived inequalities. In a market economic system, where one of two comparable goods is priced to zero the other good can only be sold if it is perceived to contain some important advantage. The inequalities introduced can be of several types: inequality of amenities, relative inequality of access, absolute inequality of access, and inequality of quality. …