Two-tier healthcare is a situation in which a basic government-provided healthcare system provides basic care, and a secondary tier of care exists for those who can pay for additional, better quality or faster access. Most countries have both publicly and privately funded healthcare, but the degree to which it creates a quality differential depends on the way the two systems are managed, funded, and regulated. Some publicly funded universal healthcare systems deliver excellent service and the private system tends to be small and not highly differentiated. In other, typically poorer countries, the public health system is underfunded and overstretched, offering opportunities for private companies to deliver better-quality, albeit more expensive coverage.
Canada
In Canada, patients have freedom with regard to which doctors and facilities they use. Under Canada's single-payer system, all Canadian citizens have the right to access healthcare services governed by provincial and territorial authorities. Within a person's province of residence, where they pay taxes, they are able to access any doctor they choose for most basic and essential healthcare services free of charge. Both referrals to specialists and hospital visits are covered. The decentralized, universal, publicly-funded health system is called Canadian Medicare. The federal government distributes funds to the provinces for healthcare, providing that the provinces have designed their systems to meet certain criteria, which they all do at present. Most people receiving care in Canada do not pay for their care apart from prescriptions and certain procedures that are not covered, such as visits to dentists, optometrists, and some others. The healthcare system is financed primarily through tax revenue. Canadians can choose to purchase health insurance to cover some or all of the healthcare services that are not covered by the government. Medical providers are generally paid fixed fees depending on the type of visit. The average doctor is paid $258,049 a year for the care provided. In situations where a doctor is being paid by their respective provincial healthcare system, the law bans the medical provider from charging patients to supplement their income from Medicare. Canada technically does not have a two-tiered healthcare system. However, some services in Canada are covered not by government provided healthcare, but instead by the private sector (dentistry, laser eye surgery, most cosmetic plastic surgeries), while most basic essential services are provided by the public healthcare systems, which are primarily administered by the country's 13 provinces and territories. Each province and territory has their own insurance plan receiving federal funding on a per-capita basis. About 70% of Canada's healthcare spending is via the public system. The other 30% comes from private funding, divided approximately equally between out-of-pocket funding and private insurance, which may be complementary (meeting costs not covered by the public system such as the cost of prescription medicines, dental treatments, and copayments) or supplementary (adding more choice of provider or providing faster access to care). Financial disincentives are in place to make private medicine for services that are covered by Medicare less economical. Six of Canada's ten provinces used to ban private insurance for publicly insured services to inhibit queue jumping and so preserve fairness in the health care system. In 2005, the Supreme Court of Canada ruled that in Quebec, such bans are unconstitutional if the waiting period for care is excessively long. However, this ruling only applies within the Province of Quebec. A second court challenge to determine whether the prohibition of private parallel health care violates the patients' right to life, liberty, and security under Section 7 of the Canadian Charter of Rights and Freedoms was defeated by the Supreme Court of British Columbia in 2020. Some private hospitals operating at the time the national healthcare plan was being instituted (for example, the Shouldice Hernia Centre in Thornhill, Ontario) continue to operate, but they may not bill additional charges for medical procedures. The Shouldice Hospital, however, has mandatory additional room charges not covered by public health insurance. That effectively places it in the "upper tier" of a two-tier system. Welfare recipients, for example, cannot be referred there, as they would not be able to afford the extra costs. Clinics are usually private operations but may not bill additional charges. Private healthcare may also be supplied, both in uncovered fields and to foreigners.
Denmark Healthcare in Denmark, although primarily subsidised by the government at the county and the national levels health, is supported by complementary insurance plans to cover elective services not covered by the public system; they also help cover copayments.
France Healthcare in France is a system of private and public physicians, who largely draw their income from the government. There are public as well as private hospitals. Patients pay a small copayment for certain aspects of care, but many people choose to cover the costs by taking out supplemental health insurance for which a small premium is payable each year. Thus, France also has a mixed delivery system with complete patient freedom of supplier choice. There is a two-tier funding arrangement, with compulsory funding of core medical services from taxation, with optional private insurance for the cost of copayments.
Germany Healthcare in Germany has two branches of health insurance, public and private, with multiple insurers each, where the public ones are either publicly owned or not-for-profit mutuals. Membership in public health insurance is mandatory for most people, and only those with large incomes, public servants, and the self-employed in a list of particular occupations are eligible to opt out. Doctors are usually self-employed, and hospitals may be publicly owned, privately owned or non-profit.
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