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Some analysts

Merkel's reforms, change is unlikely in the

edly be worse without the existence of the

near future.

small private insurance sector. Although

blame price

small as a proportion of total health spend-

restrictions and

ing, private insurance puts competitive pres-

A Few Thoughts on Canada

reimbursement

sure on sickness funds, pushing them to

expand their quality and services. At one

rates for

time, CT scanners were even rarer in the pub-

Canada is another country that did not

increasing

lic system, available only under exceptional

make the top 20 health care systems in the

circumstances and after long waits, yet rela-

WHO rankings (it finished 30th), and few seri-

bureaucratic

tively common in the private sector.

ous advocates of universal health care look to

interference in

Competition forced the public sector to add

it as a model. As Jonathan Cohn puts it,

how German

more CT scanners.309

"Nobody in the United States seriously pro-

poses recreating the British and Canadian sys-

Some analysts blame price restrictions

physicians

tem here--in part because, as critics charge . . .

and reimbursement rates for increasing

practice

they really do have waiting lines."312 However,

bureaucratic interference in how German

medicine.

physicians practice medicine. Physicians try-

since the press still frequently cites it as an

ing to work within the maze of reimburse-

example, it is worth briefly examining.

ment caps and budget restrictions have no

Although Canada is frequently referred to

financial incentive to provide more than the

as having a "national health system," the sys-

minimally necessary care. That has led to

tem is actually decentralized with consider-

questions of quality assurance, and the gov-

able responsibility devolved to Canada's 10

ernment has responded with ever greater

provinces and 2 territories. It is financed

micromanagement of practice standards.

jointly by the provinces and the federal gov-

The result has been a huge increase in red

ernment, similar to the U.S. Medicaid pro-

tape for physicians and a general loss of inno-

gram. In order to qualify for federal funds,

vation.310

each provincial program must meet five crite-

ria: 1) universality--available to all provincial

Germans seem aware of the need to

residents on uniform terms and conditions;

reform their health care system. In a 2004

2) comprehensiveness--covering all medically

poll, 76 percent of Germans thought health

necessary hospital and physician services; 3)

care reform was "urgent," while an addition-

portability--allowing residents to remain cov-

al 14 percent thought it was "desirable."

ered when moving from province to province;

However, Germans are split nearly down the

4) accessibility--having no financial barriers

middle about what that reform should be.

to access such as deductibles or copayments;

Roughly 47 percent would like to see an

and 5) public administration--administered

increase in private health care spending,

by a nonprofit authority accountable to the

whereas 49 percent would not. Similarly, 45

provincial government.

percent of Germans believe that more patient

Federal financing comes from general tax

choice would improve health care quality,

revenue. The federal government provides a

whereas 50 percent do not. The reluctance to

block grant to each province which amounts

fully embrace market reforms undoubtedly

to around 16 percent of health care spend-

stems from a long-standing German belief in

ing. However, most funding comes from

social solidarity. By a margin of 81 to 18 per-

provincial taxes, primarily personal and cor-

cent, Germans believe that equal access to the

porate income taxes. Some provinces also use

same quality of care for everyone is more

funds from other financial sources like sales

important than their own access to the best

possible care.311

taxes and lottery proceeds. And some (British

Columbia, Alberta, and Ontario) charge pre-

Costs and demographics will eventually

miums, although health services cannot be

force changes in the German system.

denied because of inability to pay. The health

However, given the failure of Chancellor

31