# Health system: are people treated equal in your country?



## sokol

In Austria we have an obligatory national health insurance - health treatment basically is for free (you only have to pay small fees of a more symbolic nature).

But people aren't treated equal nevertheless: if you have an additional (private) health insurance you receive preferential treatment (you may be allowed to skip the queue*, or you may not have to wait as long as "normal" patients for surgery because there are long waiting lists for many treatments).
*) Even bullied to; a friend of mine with such an additional insurance told me that she wanted to wait, as everyone else did, but was told that she should skip the queue.

People who have this additional insurance also are insured through the national insurance system here in Austria: it only guarantees better covering of health insurance.
Those who are insured privately only - that is, "private patients" - are of course treated even better.

So in theory Austrian health care system is equal for everyone - it is (basically) free of charge and (virtually) everyone is insured - but treatment in fact is far from being equal.

Thus my question: how is it in your country?


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## Chaska Ñawi

Interesting .... our systems aren't as similar as I'd thought.

Here your extra health insurance gives you such things as a private or semi-private hospital room, or covers "peripheral" treatments such as chiropractic adjustments or physiotherapy.  To the best of my knowledge, it does not allow you to move up the line.

To do this, you go to a private clinic and pay a hefty additional amount.  This covers things like joint replacements, outpatient procedures, and other comparatively minor surgery.  The major complaint is that specialists make more money in private clinics than working for public health, so that resources are drawn away from the public sector.

The government has flirted with the idea of "parallel systems", but the collective outrage was significant.

I'm extremely grateful for our public health care, for all its wait times.  I sometimes read horror stories about lag times, but have never encountered anybody ... even second or third-hand.... who's experienced delay in getting life-threatening problems treated .  If I lived 15 km further south, on the other hand, I'd literally be dead, bankrupt, or both.

Hope that this isn't too confusing!


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## sokol

Well, technically moving up the line in public hospitals or also when you're visiting your general practicioner isn't exactly a right you are entitled to - in fact I think that this is not the case, by _regulations_. But it is very common _practice _to do so.
So it might be that Canadian and Austrian public health system aren't that different after all - and that only handling is different.

If you have an additional insurance you won't have to wait for surgery as long as you might have to without, and if you are a private patient you might not have to wait at all (depends on what surgery needs to be done of course: private clinics also may have waiting lists for all I know; I never went to a private clinic).

Also it is more likely to happen that you are told that your appointment for surgery has been put off - for "lack of capacity" or similar reasons - if you only have public health care insurance, and no additional insurance.
It happened to me once - and I was asked if I had additional insurance because they might find a place for me somewhere if I had. As I hadn't I had to make a new appointment.


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## wildan1

Well, I live below that border that Chaska mentions is only 15 km from her house, so I guess I'll make a few points here, too.

Health care in the US is completely inequitable. It is one of the hugest domestic problems we have in this country. If Obama can find a solution he will be a huge hero. (I wish him luck but am not too hopeful.)

We probably have the most advanced treatment facilities overall in the world, and lead in health research. Our government and the private sector both invest heavily in basic research, which benefits the whole world, but doesn't trickle down very well to everyman in this country.

The delivery of health care in Canada, admirable as it is, relies informally on the US system. Since 80% of Canadians live within 100 km of the US border, you will see a lot of them come to this side for convenience or quicker service (if they can afford it) or complex treatment which their own government doesn't have to provide because it can be bought on the US side.


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## Chaska Ñawi

wildan1 is correct, our health care structure does rely on the American one, at least in Ontario.  When there isn't the capacity to provide urgent care, patients are routinely shuttled across the border to have their babies or receive emergency treatment.  The costs to the health care system are substantial, and it is hard on the patients' families.

Then the complaints about our failing infrastructure get tossed around the legislature, the lack of funding is bemoaned, and the issue is allowed to die until the next crisis.


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## Athaulf

sokol said:


> Well, technically moving up the line in public hospitals or also when you're visiting your general practicioner isn't exactly a right you are entitled to - in fact I think that this is not the case, by _regulations_. But it is very common _practice _to do so.
> So it might be that Canadian and Austrian public health system aren't that different after all - and that only handling is different.



To be more precise, in Canada, health care is for the most part a responsibility of provincial governments, so the situation varies across the country. Also, the issue of what counts as "health care" is moot. For example, dental care (at least here in Ontario) is not at all covered by the government health insurance plan. 

A peculiarity of the Canadian system is that in the areas covered by the government plans, the laws of some provinces place unusually severe restrictions on the possibilities for private payment for health care. This is a major point of controversy in Canadian politics, and certain restrictions on private health care in Quebec were even struck down as unconstitutional by the Supreme Court a few years ago. 

Another important fact is that rich Canadians often travel to the U.S. for private treatments, so despite all the restrictions, private options are available in practice for those who can afford them. Occasionally, even politicians who advocate exclusive government health care fly to the U.S. for private treatment and get called for hypocrisy afterwards. There are also cases of ordinary people who spent their savings for a private treatment in the U.S. faced with long waiting times in Canada. Thus, a _de facto_ two-tier health care system definitely exists here.


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## sokol

Athaulf said:


> For example, dental care (at least here in Ontario) is not at all covered by the government health insurance plan.


As you mention dental care - well, here there are some peculiarities in the Austrian system too.

Dental health care also, in theory, is free, but public health care does not provide for:
- surgery considered "cosmetic", and this also includes dental braces: for those you have to pay full price; and for surgical correction of malocclusion you need a certificate (needs approvement by public health care) that surgery is absolutely necessary from a medical point of view;
- other fillings than amalgam (= the cheapest one) for molars; only for incisors white fillings are paid;
- local anesthesia only will be paid for endodontic therapy, for normal fillings you don't get one, or else you have to pay for it;
- prostetics: only a symbolic amount of money is paid for them by public health care (= the cost of the cheapest prostetics available, and even of those only a percentage).

So if you rely on public health care only when it comes to teeth you only get "minimal" surgery, so to speak.

[Technical terminology I took from Wikipedia, I only can hope I didn't make any grave errors there.]


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## Tagarela

Hi,

In Brazil, there is the public health system, its idea is very good, but it doesn't work as it should indeed. So, those who can afford for health insurance and private services are in much better situation. And doctors and other healthcare professional also tend to prefer work in private system, since the payments and work conditions are usually (not always) better. 

Therefore, the answer is clearly no!

Good bye.:


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## sokol

Thank you all for your contributions, very interesting insights. 

I've got to add something: today I asked my colleagues at work about moving up the line in case you've got an additional insurance.

They assured me that they think moving up the line - even though very common in Austria - is not at all part of additional insurance but is against our health systems regulations according to which everyone should wait his or her turn, without regard to additional insurance.

But of course they all knew that this is common practice nevertheless: you are somehow a second class patient if you rely on national health insurance only, here in Austria; still, for the most part you will receive the required treatment in time.


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## alexacohen

Hello Sokol,

In Spain the Public Health Service is quite good. All right, the waiting list for some services is long. But their services are still better than many private ones.

Public Health services don´t cover plastic surgery (except if it is necessary after an accident, for instance; but not straight noses and bigger breasts). I believe they do not cover either dental braces or dental implants. 

There is no usually jumping the queue for people who have private insurance; everyone must wait for their number to be called. Probably friends of the doctor do jump the queue. 

I have never known of anyone who was discriminated for any reason. When one of my twins was hospitalized for three weeks she shared a room with anther child. This child was a Romanian gypsy illegal inmigrant, whose parents very obviously had never paid any taxes. She received the same treatment my chid received, the same care, the same medicines and the same food (provided by the hospital).


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## PABLO DE SOTO

alexacohen said:


> Hello Sokol,
> 
> 
> . Probably friends of the doctor do jump the queue.
> 
> 
> .


 
This is absolutely true. Not only friends, family too.
I know it because I have had the chance of jumping the queue , thanks to some friends or even a friend of my sister, not mine.
So I suppose this is extremely common.


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## Tagarela

Hi,

In Brazil, if you have a private health insurance, you're not going to actually skip the queue of the public system, since the private and the public systems are somehow parallel things.  

Good bye.:


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## Wilma_Sweden

In the Swedish health care system, people are treated almost equal (I'll get to the inequalities later). Health care insurance is public only, there are no private medical insurances that I have heard of allowing you to jump queues. There are many private health care providers, but they work on a contractual basis within the public system, so you pay the same fee whether you go to a private or a public clinic, and regardless of your income.

If queues for certain procedures are too long locally, you may get treatment at an alternative location within the same county or elsewhere within Sweden, and in some cases your extra transport costs will be paid by the county council.

The inequality mentioned consists of a lot of red tape and limited health care for undocumented migrants, who risk having to pay full costs and also risk getting arrested and deported.

Dental care is barely included, it's much less subsidised. This means that people on low income can't afford to see a dentist regularly. I find it extremely annoying that I have to pay SEK 2,200 for a root canal filling, while I can get open-heart surgery and around 25 days in hospital for that same price!

Some studies also suggest that there is gender inequality in some contexts, where men seem to get more hi-tech procedures and more expensive drugs than women for the same complaint, e.g. a heart attack.

Apart from these inequalities, I think the Swedish system has more pros than cons, and I can't see any reason to make major changes.

/Wilma


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## sokol

alexacohen said:


> Public Health services don´t cover plastic surgery (except if it is necessary after an accident, for instance; but not straight noses and bigger breasts). I believe they do not cover either dental braces or dental implants.
> 
> There is no usually jumping the queue for people who have private insurance; everyone must wait for their number to be called. Probably friends of the doctor do jump the queue.


That's quite interesting, Alexa - situation in Spain seems to be better than here in Austria. 

Even though I would consider our health system quite good in general it seems it can't compare to the Spanish one.
Jumping the queue of course also is possible if you're good friends with a doctor (even if you don't have additional insurance); as explained it is not supposed to happen in Austria but is very common nevertheless.

Concerning food and so: if you have an _additional _insurance you can choose between several menues, also you get a single room or at least a room with not too many beds - while if you don't have an additional insurance you cannot choose what to eat, you will be served the dinner of the day, and you might get a room with 5-10 beds (I don't think that there are still rooms with more than 10 beds in Austrian hospitals; I am not sure though).

Technically, if you have additional insurance the only privilege you "should" get here is a better room, better food and small luxuries (probably TV and computer in your room - I wouldn't know, I never saw one of those from the inside).
And then there are those additional privileges which you get in real life even though this isn't supposed to happen - like, first and foremost, jumping the queue.


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## Cabeza tuna

Here every month we have a discount in our salaries, is for "Health" the most of the the people use the public system called Fonasa, if you have fonasa you can pay to a private doctor, or wait months in the public system, but you also have the chance to pay more to some companies called Isapres, that companies have their own doctors and hospitals, as more you pay every month less are you going to pay when you go to the doctor.
A little example, once we have a we have a gardener in home, we have an accident he fall from a really tall tree, we take him to the next public hospital, we have to wait 2 or 3 hours before a doctor see him, in the waiting room you can find, people than is suffering heart attacks, with several injuries etc.
A few months ago I have an accident and I sprain my ankle, my step father take my to "Clinica Alemana" the best private hospital in Chile, we park in the front entry and a Valet, park the truck after that, a nurse was waiting with a wheel chair, and inside was a doctor waiting to attend me, all the rooms have an LCD tv, so you can watch TV as you wait, after a while they take me to x-rays and everything was really fast, even when I ask for the x-ray images they give me a cd, I was surprised.


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## alexacohen

sokol said:


> Concerning food and so: if you have an _additional _insurance you can choose between several menues, also you get a single room or at least a room with not too many beds - while if you don't have an additional insurance you cannot choose what to eat, you will be served the dinner of the day, and you might get a room with 5-10 beds (I don't think that there are still rooms with more than 10 beds in Austrian hospitals; I am not sure though).
> 
> Technically, if you have additional insurance the only privilege you "should" get here is a better room, better food and small luxuries (probably TV and computer in your room - I wouldn't know, I never saw one of those from the inside).


 
I haven´t checked all the public hospitals in Spain, of course. But I have lived in one for eighteen months when I had my babies. A public hospital.

I had to share a room, of course. Every room had a private bathroom but only two beds. Sometimes there was an extra bed and there were three people in the room, but that was a rare occurrence. Every room had a TV set (you had to insert coins to make it work) and a telephone. Broadband was available for free but you had to bring your own computer.

Every morning when the staff brought our trays with breakfast (fresh fruit, coffee and bread and butter) they left a printed sheet with next day´s menu (lunch and dinner). We were given three choices for starters, three choices for main dish and three choices for dessert. We could have tea if we wanted to (coffee and biscuits and tea and biscuits, no choosing). Of course special diets were available too (vegan, kosher, non gluten, low fat, I don´t remember exactly: but those had no three choices). 

The hospital did not provide accomodation for companions. If someone wanted to stay with you, he or she could sleep on a chair (there were two) or on the floor.

I never saw anyone discriminated and I can tell you that I saw all kinds of people walk in and walk out of my rooms. Sometimes there was an uproar when the nurses forced someone to wash before accepting her in the ward - and the soap provided by the hospital was one of those with disinfectant. 

Some of the women who were washed and cleaned against their will were very angry indeed and cried "racism" and "crime against my cuture". But I was grateful.

You have no idea what it is to share a room with someone who has never washed her feet during her entire life. I do.


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## sokol

I am a 100% sure, Alexa, that Austrian hospitals also wouldn't tolerate unwashed feet, for hygienic reasons obviously. 

But most public hospital bedrooms I have seen have more beds - 4-6 typically, I'd say (some have less, few have more); 2 beds bedrooms are rare, in my experience. Except of course for those who have additional insurance and get single bedrooms or rooms with 2 beds only: we call them "Klasse-Patienten" = "class patients" (just as in "first class"  - the ones mentioned in my posts above).

Concerning equal treatment I haven't noticed any unequal treatments myself except that moving up the line is possible for those with additional insurance, as mentioned above: the hospital staff, at least in theory, of course _should _treat all patients equally.
(Except for "class patients" of course who pay extra (with their additional insurance) for better treatment.)

And as for Cabeza tuna's story: in Austria a doctor _must _see a patient immediately if a serious accident happened - the doctor then will evaluate if the case is urgent (then treatment will begin immediately) or if it is not so urgent which would mean that the patient has to wait.
A "class patient" with additional insurance however most likely will walk straight through to the doctor in case of an emergency (or even in not very urgent cases).


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## wildan1

sokol said:


> And as for Cabeza tuna's story: in Austria a doctor _must _see a patient immediately if a serious accident happened - the doctor then will evaluate if the case is urgent (then treatment will begin immediately) or if it is not so urgent which would mean that the patient has to wait.
> A "class patient" with additional insurance however most likely will walk straight through to the doctor in case of an emergency (or even in not very urgent cases).


 
In the emergency department in a US hospital you are first sent to _"triage"_ where a nurse takes down your symptoms and evaluates the seriousness of your condition. Nobody sees a physician (M.D.) right away.

If it is serious, you will immediately see a doctor, or pretty soon if you are in serious pain. 

If you have something non life-threatening, you can sit for a long time in the waiting room until they have time to see you. So it's not about your insurance nor how long you have been waiting, but the seriousness of what brought you there.

I recently went personally because I had food poisoning one long weekend and I wanted to get some lab tests done so I could get treatment if needed. (I have a good, private insurance policy so I guess if I were in Austria, I would be a ,Klasse' patient!)

I was immediatly evaluated and told I would see someone shortly. Then a man came in by ambulance with a heart attack; another arrived a bit later with a broken and bleeding leg; and then a third person arrived in a wheelchair who had been vomiting blood.

So I sat there for three hours... It was inconvenient because I felt bad, but I didn't really think it was unfair.


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## sokol

wildan1 said:


> I recently went personally because I had food poisoning one long weekend and I wanted to get some lab tests done so I could get treatment if needed. (I have a good, private insurance policy so I guess if I were in Austria, I would be a ,Klasse' patient!)
> 
> I was immediatly evaluated and told I would see someone shortly. Then a man came in by ambulance with a heart attack; another arrived a bit later with a broken and bleeding leg; and then a third person arrived in a wheelchair who had been vomiting blood.


Yes, you would be considered a "Klasse" patient here in Austria then, that's for sure.

But still, in Austria _real _emergencies like the ones described by you would come first: that is, the heart attack, the broken/bleeding leg, and the guy vomitting blood surely would receive treatment first.
But you would be for certain the first one treated of the "non-urgent" cases (except if several "Klasse" patients would be in line already, of course).


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## alexacohen

Of course a public hospital would attend to an emergency first in Spain too. But our health system is a bit different.

Usualy people with private insurance go to private hospitals, not public ones. In a public hospital it does not matter at all if the patient has private insurance or not, because the doctors, the medicines, the nurses, the food, are paid entirely with our taxes. 

So, unless patients find a doctor or a head nurse who can be bribed, they will not get any room of their own or any privileges whatsoever. 

Having said so, I have to confess that I jumped the queue more than one time. I had been a long time in patient, and I ended up knowing every doctor and every nurse and every cleaning woman by their first names, and vice-versa. So whenever analysis or x-rays were required there was no queuing for me.

Unfair, maybe. But human.


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## Lugubert

Wilma_Sweden said:


> In the Swedish health care system, people are treated almost equal (I'll get to the inequalities later). Health care insurance is public only, there are no private medical insurances that I have heard of allowing you to jump queues. There are many private health care providers, but they work on a contractual basis within the public system, so you pay the same fee whether you go to a private or a public clinic, and regardless of your income.


There are private insurance policies (although I don't know any person who has one). Those thus insured, as stated, can't jump queues. They probably will be treated at clinics outside the public system. Such clinics will probably have no or very short queues, because they're much more expensive than the public system.



> If queues for certain procedures are too long locally, you may get treatment at an alternative location within the same county or elsewhere within Sweden, and in some cases your extra transport costs will be paid by the county council.


In some cases, you might be allowed to have treatment in another EU country. I don't know the mechanisms of that procedure, but I think that you might have to pay yourself to be fully reimbursed at home.



> Some studies also suggest that there is gender inequality in some contexts, where men seem to get more hi-tech procedures and more expensive drugs than women for the same complaint, e.g. a heart attack.


At least the problem is recognized, and some doctors specialize in looking into the complex. It includes the fact that many studies have concentrated on men, meaning for example that standard dosage might not be optimal for women.



> Apart from these inequalities, I think the Swedish system has more pros than cons, and I can't see any reason to make major changes.


 
True.


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## Wilma_Sweden

Lugubert said:


> There are private insurance policies (although I don't know any person who has one). Those thus insured, as stated, can't jump queues. They probably will be treated at clinics outside the public system. Such clinics will probably have no or very short queues, because they're much more expensive than the public system.


Hopefully, there are not too many Swedes with access to private health care, because I seriously believe that there would be a huge public outcry if this started happening more frequently. The system is still geared towards 'same fee for everyone' and 'you can't buy better care with more money'.

/Wilma


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## Lugubert

Wilma_Sweden said:


> Hopefully, there are not too many Swedes with access to private health care, because I seriously believe that there would be a huge public outcry if this started happening more frequently. The system is still geared towards 'same fee for everyone' and 'you can't buy better care with more money'.
> 
> /Wilma


I think private insurances are mostly for high level executives or other key persons, paid by their companies. Such policies will in all probability guarantee fastest possible care anywhere in the world, because the absence of such people will cost their companies too much. One big bonus for us others is that they don't occupy slots in the queues (if any) that we face. Nothing wrong in them buying better care, they already buy better cars, better houses and whatever. I'm not envious. I wouldn't want their jobs and responsibilities, and their choices don't affect me.


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## sokol

I think it is necessary to repeat again how our system here in Austria works: because, in theory, it is just like in Sweden - you can't "buy" yourself the first place in a queue, everyone in theory *should *get treated equal.

And no politician would dare to claim that even though all patients were equal, some were "more equal". Nevertheless the latter is true - in real life: some people indeed are "more equal" here in Austria.

I've recently had the chance to talk this over with some people, and the gist of this was that there even were a "three-class-system" here, all of which however use the same facilities (so, no "double system" of private and public clinics - but public clinics for all of us, except for a very few private hospitals which treat only a very small percentage of the whole population):
- "economy class" = the standard public health insurance
- "business class" = pulbic health insurance for civil servants and a very few other people
- "first class" = private (additional) insurances

Jumping the queue is something done on a regular basis even though it is supposed _not _to happen. 
Also everyone is _supposed _to get the same treatment.

Nevertheless, this also is not always the case. Take the hip joint: if someone needs an artificial hipbone replacement at age 65 and then again at 80 he or she might be told that, at 75, that the second (artificial) hipbone won't be paid by common public health insurance - which would affect hugely your daily routines even though it isn't a severe risk to your health.

And the difference is that a "business class" patient _might _not have that problem, and that a "first class" patient certainly won't.

Or another example - gallstone treatment through ultrasound (without needing to operate) wasn't provided for "business class" patients in Austria about 10 years or so ago (I don't know the exact dates), only after continuous protests of doctors and patients alike the treatment was included in our public health insurance: ultrasound treatment is more expensive than an operation, but the risk to the patient as well as the post-operative pain is much less than with an operation.

So the difference might be in treatments not considered "vital" or "urgent"; or in the application of new technologies.

Moving "class" patients up the line is just something provided by doctors on a "voluntary" basis: rightfully they shouldn't do this.


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