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Sunday, March 10, 2019

Health insurance

From Wikipedia, the free encyclopedia

Health insurance is an insurance that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over a large number of persons. By estimating the overall risk of health care and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity. 

According to the Health Insurance Association of America, health insurance is defined as "coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment" (p. 225).

Background

A health insurance policy is:
  1. A contract between an insurance provider (e.g. an insurance company or a government) and an individual or his/her sponsor (e.g. an employer or a community organization). The contract can be renewable (e.g. annually, monthly) or lifelong in the case of private insurance, or be mandatory for all citizens in the case of national plans. The type and amount of health care costs that will be covered by the health insurance provider are specified in writing, in a member contract or "Evidence of Coverage" booklet for private insurance, or in a national health policy for public insurance.
  2. (US specific) Provided by an employer-sponsored self-funded ERISA plan. The company generally advertises that they have one of the big insurance companies. However, in an ERISA case, that insurance company "doesn't engage in the act of insurance", they just administer it. Therefore, ERISA plans are not subject to state laws. ERISA plans are governed by federal law under the jurisdiction of the US Department of Labor (USDOL). The specific benefits or coverage details are found in the Summary Plan Description (SPD). An appeal must go through the insurance company, then to the Employer's Plan Fiduciary. If still required, the Fiduciary's decision can be brought to the USDOL to review for ERISA compliance, and then file a lawsuit in federal court.
The individual insured person's obligations may take several forms:
  • Premium: The amount the policy-holder or their sponsor (e.g. an employer) pays to the health plan to purchase health coverage.
  • Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor's visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Furthermore, most policies do not apply co-pays for doctor's visits or prescriptions against your deductible.
  • Co-payment: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. For example, an insured person might pay a $45 co-payment for a doctor's visit, or to obtain a prescription. A co-payment must be paid each time a particular service is obtained.
  • Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-payment), the co-insurance is a percentage of the total cost that insured person may also pay. For example, the member might have to pay 20% of the cost of a surgery over and above a co-payment, while the insurance company pays the other 80%. If there is an upper limit on coinsurance, the policy-holder could end up owing very little, or a great deal, depending on the actual costs of the services they obtain.
  • Exclusions: Not all services are covered. Billed items like use-and-throw, taxes, etc. are excluded from admissible claim. The insured are generally expected to pay the full cost of non-covered services out of their own pockets.
  • Coverage limits: Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes have annual or lifetime coverage maxima. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.
  • Out-of-pocket maximum: Similar to coverage limits, except that in this case, the insured person's payment obligation ends when they reach the out-of-pocket maximum, and health insurance pays all further covered costs. Out-of-pocket maximum can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
  • Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer.
  • In-Network Provider: (U.S. term) A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider. Generally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the "usual and customary" charges the insurer pays to out-of-network providers.
  • Prior Authorization: A certification or authorization that an insurer provides prior to medical service occurring. Obtaining an authorization means that the insurer is obligated to pay for the service, assuming it matches what was authorized. Many smaller, routine services do not require authorization.
  • Explanation of Benefits: A document that may be sent by an insurer to a patient explaining what was covered for a medical service, and how payment amount and patient responsibility amount were determined.
Prescription drug plans are a form of insurance offered through some health insurance plans. In the U.S., the patient usually pays a copayment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan. Such plans are routinely part of national health insurance programs. For example, in the province of Quebec, Canada, prescription drug insurance is universally required as part of the public health insurance plan, but may be purchased and administered either through private or group plans, or through the public plan.

Some, if not most, health care providers in the United States will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn't pay. The insurance company pays out of network providers according to "reasonable and customary" charges, which may be less than the provider's usual fee. The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider's standard charges. It generally costs the patient less to use an in-network provider.

Comparisons

Health Expenditure per capita (in PPP-adjusted US$) among several OECD member nations. Data source: OECD's iLibrary
 
The Commonwealth Fund, in its annual survey, "Mirror, Mirror on the Wall", compares the performance of the health care systems in Australia, New Zealand, the United Kingdom, Germany, Canada and the U.S. Its 2007 study found that, although the U.S. system is the most expensive, it consistently under-performs compared to the other countries. One difference between the U.S. and the other countries in the study is that the U.S. is the only country without universal health insurance coverage. 

Life Expectancy of the total population at birth from 2000 until 2011 among several OECD member nations. Data source: OECD's iLibrary
 
The Commonwealth Fund completed its thirteenth annual health policy survey in 2010. A study of the survey "found significant differences in access, cost burdens, and problems with health insurance that are associated with insurance design". Of the countries surveyed, the results indicated that people in the United States had more out-of-pocket expenses, more disputes with insurance companies than other countries, and more insurance payments denied; paperwork was also higher although Germany had similarly high levels of paperwork.

Australia

The Australian public health system is called Medicare, which provides free universal access to hospital treatment and subsidised out-of-hospital medical treatment. It is funded by a 2% tax levy on all taxpayers, an extra 1% levy on high income earners, as well as general revenue. 

The private health system is funded by a number of private health insurance organizations. The largest of these is Medibank Private Limited, which was, until 2014, a government-owned entity, when it was privatized and listed on the Australian Stock Exchange

Australian health funds can be either 'for profit' including Bupa and nib; 'mutual' including Australian Unity; or 'non-profit' including GMHBA, HCF and the HBF Health Fund (HBF). Some, such as Police Health, have membership restricted to particular groups, but the majority have open membership. Membership to most health funds is now also available through comparison websites like moneytime, Compare the Market, iSelect Ltd., Choosi, ComparingExpert and YouCompare. These comparison sites operate on a commission-basis by agreement with their participating health funds. The Private Health Insurance Ombudsman also operates a free website which allows consumers to search for and compare private health insurers' products, which includes information on price and level of cover.

Most aspects of private health insurance in Australia are regulated by the Private Health Insurance Act 2007. Complaints and reporting of the private health industry is carried out by an independent government agency, the Private Health Insurance Ombudsman. The ombudsman publishes an annual report that outlines the number and nature of complaints per health fund compared to their market share.

The private health system in Australia operates on a "community rating" basis, whereby premiums do not vary solely because of a person's previous medical history, current state of health, or (generally speaking) their age (but see Lifetime Health Cover below). Balancing this are waiting periods, in particular for pre-existing conditions (usually referred to within the industry as PEA, which stands for "pre-existing ailment"). Funds are entitled to impose a waiting period of up to 12 months on benefits for any medical condition the signs and symptoms of which existed during the six months ending on the day the person first took out insurance. They are also entitled to impose a 12-month waiting period for benefits for treatment relating to an obstetric condition, and a 2-month waiting period for all other benefits when a person first takes out private insurance. Funds have the discretion to reduce or remove such waiting periods in individual cases. They are also free not to impose them to begin with, but this would place such a fund at risk of "adverse selection", attracting a disproportionate number of members from other funds, or from the pool of intending members who might otherwise have joined other funds. It would also attract people with existing medical conditions, who might not otherwise have taken out insurance at all because of the denial of benefits for 12 months due to the PEA Rule. The benefits paid out for these conditions would create pressure on premiums for all the fund's members, causing some to drop their membership, which would lead to further rises in premiums, and a vicious cycle of higher premiums-leaving members would ensue.

The Australian government has introduced a number of incentives to encourage adults to take out private hospital insurance. These include:
  • Lifetime Health Cover: If a person has not taken out private hospital cover by 1 July after their 31st birthday, then when (and if) they do so after this time, their premiums must include a loading of 2% per annum for each year they were without hospital cover. Thus, a person taking out private cover for the first time at age 40 will pay a 20 percent loading. The loading is removed after 10 years of continuous hospital cover. The loading applies only to premiums for hospital cover, not to ancillary (extras) cover.
  • Medicare Levy Surcharge: People whose taxable income is greater than a specified amount (in the 2011/12 financial year $80,000 for singles and $168,000 for couples) and who do not have an adequate level of private hospital cover must pay a 1% surcharge on top of the standard 1.5% Medicare Levy. The rationale is that if the people in this income group are forced to pay more money one way or another, most would choose to purchase hospital insurance with it, with the possibility of a benefit in the event that they need private hospital treatment – rather than pay it in the form of extra tax as well as having to meet their own private hospital costs.
    • The Australian government announced in May 2008 that it proposes to increase the thresholds, to $100,000 for singles and $150,000 for families. These changes require legislative approval. A bill to change the law has been introduced but was not passed by the Senate. An amended version was passed on 16 October 2008. There have been criticisms that the changes will cause many people to drop their private health insurance, causing a further burden on the public hospital system, and a rise in premiums for those who stay with the private system. Other commentators believe the effect will be minimal.
  • Private Health Insurance Rebate: The government subsidises the premiums for all private health insurance cover, including hospital and ancillary (extras), by 10%, 20% or 30%, depending on age. The Rudd Government announced in May 2009 that as of July 2010, the Rebate would become means-tested, and offered on a sliding scale. While this move (which would have required legislation) was defeated in the Senate at the time, in early 2011 the Gillard Government announced plans to reintroduce the legislation after the Opposition loses the balance of power in the Senate. The ALP and Greens have long been against the rebate, referring to it as "middle-class welfare".

Canada

As per the Constitution of Canada, health care is mainly a provincial government responsibility in Canada (the main exceptions being federal government responsibility for services provided to aboriginal peoples covered by treaties, the Royal Canadian Mounted Police, the armed forces, and Members of Parliament). Consequently, each province administers its own health insurance program. The federal government influences health insurance by virtue of its fiscal powers – it transfers cash and tax points to the provinces to help cover the costs of the universal health insurance programs. Under the Canada Health Act, the federal government mandates and enforces the requirement that all people have free access to what are termed "medically necessary services," defined primarily as care delivered by physicians or in hospitals, and the nursing component of long-term residential care. If provinces allow doctors or institutions to charge patients for medically necessary services, the federal government reduces its payments to the provinces by the amount of the prohibited charges. Collectively, the public provincial health insurance systems in Canada are frequently referred to as Medicare. This public insurance is tax-funded out of general government revenues, although British Columbia and Ontario levy a mandatory premium with flat rates for individuals and families to generate additional revenues - in essence, a surtax. Private health insurance is allowed, but in six provincial governments only for services that the public health plans do not cover (for example, semi-private or private rooms in hospitals and prescription drug plans). Four provinces allow insurance for services also mandated by the Canada Health Act, but in practice there is no market for it. All Canadians are free to use private insurance for elective medical services such as laser vision correction surgery, cosmetic surgery, and other non-basic medical procedures. Some 65% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers. Private-sector services not paid for by the government account for nearly 30 percent of total health care spending.

In 2005, the Supreme Court of Canada ruled, in Chaoulli v. Quebec, that the province's prohibition on private insurance for health care already insured by the provincial plan violated the Quebec Charter of Rights and Freedoms, and in particular the sections dealing with the right to life and security, if there were unacceptably long wait times for treatment, as was alleged in this case. The ruling has not changed the overall pattern of health insurance across Canada, but has spurred on attempts to tackle the core issues of supply and demand and the impact of wait times.

France

The national system of health insurance was instituted in 1945, just after the end of the Second World War. It was a compromise between Gaullist and Communist representatives in the French parliament. The Conservative Gaullists were opposed to a state-run healthcare system, while the Communists were supportive of a complete nationalisation of health care along a British Beveridge model. 

The resulting programme is profession-based: all people working are required to pay a portion of their income to a not-for-profit health insurance fund, which mutualises the risk of illness, and which reimburses medical expenses at varying rates. Children and spouses of insured people are eligible for benefits, as well. Each fund is free to manage its own budget, and used to reimburse medical expenses at the rate it saw fit, however following a number of reforms in recent years, the majority of funds provide the same level of reimbursement and benefits. 

The government has two responsibilities in this system.
  • The first government responsibility is the fixing of the rate at which medical expenses should be negotiated, and it does so in two ways: The Ministry of Health directly negotiates prices of medicine with the manufacturers, based on the average price of sale observed in neighboring countries. A board of doctors and experts decides if the medicine provides a valuable enough medical benefit to be reimbursed (note that most medicine is reimbursed, including homeopathy). In parallel, the government fixes the reimbursement rate for medical services: this means that a doctor is free to charge the fee that he wishes for a consultation or an examination, but the social security system will only reimburse it at a pre-set rate. These tariffs are set annually through negotiation with doctors' representative organisations.
  • The second government responsibility is oversight of the health-insurance funds, to ensure that they are correctly managing the sums they receive, and to ensure oversight of the public hospital network.
Today, this system is more or less intact. All citizens and legal foreign residents of France are covered by one of these mandatory programs, which continue to be funded by worker participation. However, since 1945, a number of major changes have been introduced. Firstly, the different health care funds (there are five: General, Independent, Agricultural, Student, Public Servants) now all reimburse at the same rate. Secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and who are not students, meaning the very rich or the very poor). This regime, unlike the worker-financed ones, is financed via general taxation and reimburses at a higher rate than the profession-based system for those who cannot afford to make up the difference. Finally, to counter the rise in health care costs, the government has installed two plans, (in 2004 and 2006), which require insured people to declare a referring doctor in order to be fully reimbursed for specialist visits, and which installed a mandatory co-pay of €1 for a doctor visit, €0.50 for each box of medicine prescribed, and a fee of €16–18 per day for hospital stays and for expensive procedures. 

An important element of the French insurance system is solidarity: the more ill a person becomes, the less the person pays. This means that for people with serious or chronic illnesses, the insurance system reimburses them 100% of expenses, and waives their co-pay charges.

Finally, for fees that the mandatory system does not cover, there is a large range of private complementary insurance plans available. The market for these programs is very competitive, and often subsidised by the employer, which means that premiums are usually modest. 85% of French people benefit from complementary private health insurance.

Germany

Germany has the world's oldest national social health insurance system, with origins dating back to Otto von Bismarck's Sickness Insurance Law of 1883.

Beginning with 10% of blue-collar workers in 1885, mandatory insurance has expanded; in 2009, insurance was made mandatory on all citizens, with private health insurance for the self-employed or above an income threshold. As of 2016, 85% of the population is covered by the compulsory Statutory Health Insurance (SHI) (Gesetzliche Krankenversicherung or GKV), with the remainder covered by private insurance (Private Krankenversicherung or PKV) Germany's health care system was 77% government-funded and 23% privately funded as of 2004. While public health insurance contributions are based on the individual's income, private health insurance contributions are based on the individual's age and health condition.

Reimbursement is on a fee-for-service basis, but the number of physicians allowed to accept Statutory Health Insurance in a given locale is regulated by the government and professional societies. 

Co-payments were introduced in the 1980s in an attempt to prevent over utilization. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the United States (5 to 6 days). Part of the difference is that the chief consideration for hospital reimbursement is the number of hospital days as opposed to procedures or diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).

Germans are offered three kinds of social security insurance dealing with the physical status of a person and which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance. Long-term care insurance (Gesetzliche Pflegeversicherung) emerged in 1994, but it is not mandatory. Accident insurance (gesetzliche Unfallversicherung) is covered by the employer and basically covers all risks for commuting to work and at the workplace.

Japan

There are two major types of insurance programs available in Japan – Employees Health Insurance (健康保険 Kenkō-Hoken), and National Health Insurance (国民健康保険 Kokumin-Kenkō-Hoken). National Health insurance is designed for people who are not eligible to be members of any employment-based health insurance program. Although private health insurance is also available, all Japanese citizens, permanent residents, and non-Japanese with a visa lasting one year or longer are required to be enrolled in either National Health Insurance or Employees Health Insurance.

Netherlands

In 2006, a new system of health insurance came into force in the Netherlands. This new system avoids the two pitfalls of adverse selection and moral hazard associated with traditional forms of health insurance by using a combination of regulation and an insurance equalization pool. Moral hazard is avoided by mandating that insurance companies provide at least one policy which meets a government set minimum standard level of coverage, and all adult residents are obliged by law to purchase this coverage from an insurance company of their choice. All insurance companies receive funds from the equalization pool to help cover the cost of this government-mandated coverage. This pool is run by a regulator which collects salary-based contributions from employers, which make up about 50% of all health care funding, and funding from the government to cover people who cannot afford health care, which makes up an additional 5%.

The remaining 45% of health care funding comes from insurance premiums paid by the public, for which companies compete on price, though the variation between the various competing insurers is only about 5%. However, insurance companies are free to sell additional policies to provide coverage beyond the national minimum. These policies do not receive funding from the equalization pool, but cover additional treatments, such as dental procedures and physiotherapy, which are not paid for by the mandatory policy.

Funding from the equalization pool is distributed to insurance companies for each person they insure under the required policy. However, high-risk individuals get more from the pool, and low-income persons and children under 18 have their insurance paid for entirely. Because of this, insurance companies no longer find insuring high risk individuals an unappealing proposition, avoiding the potential problem of adverse selection.

Insurance companies are not allowed to have co-payments, caps, or deductibles, or to deny coverage to any person applying for a policy, or to charge anything other than their nationally set and published standard premiums. Therefore, every person buying insurance will pay the same price as everyone else buying the same policy, and every person will get at least the minimum level of coverage.

New Zealand

Since 1974, New Zealand has had a system of universal no-fault health insurance for personal injuries through the Accident Compensation Corporation (ACC). The ACC scheme covers most of the costs of related to treatment of injuries acquired in New Zealand (including overseas visitors) regardless of how the injury occurred, and also covers lost income (at 80 percent of the employee's pre-injury income) and costs related to long-term rehabilitation, such as home and vehicle modifications for those seriously injured. Funding from the scheme comes from a combination of levies on employers' payroll (for work injuries), levies on an employee's taxable income (for non-work injuries to salary earners), levies on vehicle licensing fees and petrol (for motor vehicle accidents), and funds from the general taxation pool (for non-work injuries to children, senior citizens, unemployed people, overseas visitors, etc.)

Rwanda

Rwanda is one of a handful of low income countries that has implemented community-based health insurance schemes in order to reduce the financial barriers that prevent poor people from seeking and receiving needed health services. This scheme has helped reach 90% of the country's population with health care coverage.

Switzerland

Healthcare in Switzerland is universal and is regulated by the Swiss Federal Law on Health Insurance. Health insurance is compulsory for all persons residing in Switzerland (within three months of taking up residence or being born in the country). It is therefore the same throughout the country and avoids double standards in healthcare. Insurers are required to offer this basic insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans.

The universal compulsory coverage provides for treatment in case of illness or accident and pregnancy. Health insurance covers the costs of medical treatment, medication and hospitalization of the insured. However, the insured person pays part of the costs up to a maximum, which can vary based on the individually chosen plan, premiums are then adjusted accordingly. The whole healthcare system is geared towards to the general goals of enhancing general public health and reducing costs while encouraging individual responsibility.

The Swiss healthcare system is a combination of public, subsidised private and totally private systems. Insurance premiums vary from insurance company to company, the excess level individually chosen (franchise), the place of residence of the insured person and the degree of supplementary benefit coverage chosen (complementary medicine, routine dental care, semi-private or private ward hospitalisation, etc.).

The insured person has full freedom of choice among the approximately 60 recognised healthcare providers competent to treat their condition (in their region) on the understanding that the costs are covered by the insurance up to the level of the official tariff. There is freedom of choice when selecting an insurance company to which one pays a premium, usually on a monthly basis. The insured person pays the insurance premium for the basic plan up to 8% of their personal income. If a premium is higher than this, the government gives the insured person a cash subsidy to pay for any additional premium.

The compulsory insurance can be supplemented by private "complementary" insurance policies that allow for coverage of some of the treatment categories not covered by the basic insurance or to improve the standard of room and service in case of hospitalisation. This can include complementary medicine, routine dental treatment and private ward hospitalisation, which are not covered by the compulsory insurance.

As far as the compulsory health insurance is concerned, the insurance companies cannot set any conditions relating to age, sex or state of health for coverage. Although the level of premium can vary from one company to another, they must be identical within the same company for all insured persons of the same age group and region, regardless of sex or state of health. This does not apply to complementary insurance, where premiums are risk-based.

Switzerland has an infant mortality rate of about 3.6 out of 1,000. The general life expectancy in 2012 was for men 80.5 years compared to 84.7 years for women. These are the world's best figures.

United Kingdom

The UK's National Health Service (NHS) is a publicly funded healthcare system that provides coverage to everyone normally resident in the UK. It is not strictly an insurance system because (a) there are no premiums collected, (b) costs are not charged at the patient level and (c) costs are not pre-paid from a pool. However, it does achieve the main aim of insurance which is to spread financial risk arising from ill-health. The costs of running the NHS (est. £104 billion in 2007-8) are met directly from general taxation. The NHS provides the majority of health care in the UK, including primary care, in-patient care, long-term health care, ophthalmology, and dentistry.

Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services. There are many treatments that the private sector does not provide. For example, health insurance on pregnancy is generally not covered or covered with restricting clauses. Typical exclusions for Bupa schemes (and many other insurers) include:
... ageing, menopause and puberty; AIDS/HIV; allergies or allergic disorders; birth control, conception, sexual problems and sex changes; chronic conditions; complications from excluded or restricted conditions/ treatment; convalescence, rehabilitation and general nursing care ; cosmetic, reconstructive or weight loss treatment; deafness; dental/oral treatment (such as fillings, gum disease, jaw shrinkage, etc); dialysis; drugs and dressings for out-patient or take-home use; experimental drugs and treatment; eyesight; HRT and bone densitometry; learning difficulties, behavioural and developmental problems; overseas treatment and repatriation; physical aids and devices; pre-existing or special conditions; pregnancy and childbirth; screening and preventive treatment; sleep problems and disorders; speech disorders; temporary relief of symptoms.
There are a number of other companies in the United Kingdom which include, among others, ACE Limited, AXA, Aviva, Bupa, Groupama Healthcare, WPA and PruHealth. Similar exclusions apply, depending on the policy which is purchased.

Recently (2009) the main representative body of British Medical physicians, the British Medical Association, adopted a policy statement expressing concerns about developments in the health insurance market in the UK. In its Annual Representative Meeting which had been agreed earlier by the Consultants Policy Group (i.e. Senior physicians) stating that the BMA was "extremely concerned that the policies of some private healthcare insurance companies are preventing or restricting patients exercising choice about (i) the consultants who treat them; (ii) the hospital at which they are treated; (iii) making top up payments to cover any gap between the funding provided by their insurance company and the cost of their chosen private treatment." It went in to "call on the BMA to publicise these concerns so that patients are fully informed when making choices about private healthcare insurance." The practice of insurance companies deciding which consultant a patient may see as opposed to GPs or patients is referred to as Open Referral. The NHS offers patients a choice of hospitals and consultants and does not charge for its services. 

The private sector has been used to increase NHS capacity despite a large proportion of the British public opposing such involvement. According to the World Health Organization, government funding covered 86% of overall health care expenditures in the UK as of 2004, with private expenditures covering the remaining 14%.

Nearly one in three patients receiving NHS hospital treatment is privately insured and could have the cost paid for by their insurer. Some private schemes provide cash payments to patients who opt for NHS treatment, to deter use of private facilities. A report, by private health analysts Laing and Buisson, in November 2012, estimated that more than 250,000 operations were performed on patients with private medical insurance each year at a cost of £359 million. In addition, £609 million was spent on emergency medical or surgical treatment. Private medical insurance does not normally cover emergency treatment but subsequent recovery could be paid for if the patient were moved into a private patient unit.

United States

Short Term Health Insurance

On the 1st of August, 2018 the DHHS issued a final rule which made federal changes to Short-Term, Limited-Duration Health Insurance (STLDI) which lengthened the maximum contract term to 364 days and renewal for up to 36 months. This new rule, in combination with the expiration of the penalty for the Individual Mandate of the Affordable Care Act, has been the subject of independent analysis.

The United States health care system relies heavily on private health insurance, which is the primary source of coverage for most Americans. As of 2012 about 61% of Americans had private health insurance according to the Centers for Disease Control and Prevention. The Agency for Healthcare Research and Quality (AHRQ) found that in 2011, private insurance was billed for 12.2 million U.S. inpatient hospital stays and incurred approximately $112.5 billion in aggregate inpatient hospital costs (29% of the total national aggregate costs). Public programs provide the primary source of coverage for most senior citizens and for low-income children and families who meet certain eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors and certain disabled individuals; and Medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families. Together, Medicare and Medicaid accounted for approximately 63 percent of the national inpatient hospital costs in 2011. SCHIP is a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals.

In the late 1990s and early 2000s, health advocacy companies began to appear to help patients deal with the complexities of the healthcare system. The complexity of the healthcare system has resulted in a variety of problems for the American public. A study found that 62 percent of persons declaring bankruptcy in 2007 had unpaid medical expenses of $1000 or more, and in 92% of these cases the medical debts exceeded $5000. Nearly 80 percent who filed for bankruptcy had health insurance. The Medicare and Medicaid programs were estimated to soon account for 50 percent of all national health spending. These factors and many others fueled interest in an overhaul of the health care system in the United States. In 2010 President Obama signed into law the Patient Protection and Affordable Care Act. This Act includes an 'individual mandate' that every American must have medical insurance (or pay a fine). Health policy experts such as David Cutler and Jonathan Gruber, as well as the American medical insurance lobby group America's Health Insurance Plans, argued this provision was required in order to provide "guaranteed issue" and a "community rating," which address unpopular features of America's health insurance system such as premium weightings, exclusions for pre-existing conditions, and the pre-screening of insurance applicants. During 26–28 March, the Supreme Court heard arguments regarding the validity of the Act. The Patient Protection and Affordable Care Act was determined to be constitutional on 28 June 2012. The Supreme Court determined that Congress had the authority to apply the individual mandate within its taxing powers.

History and evolution

In the late 19th century, "accident insurance" began to be available, which operated much like modern disability insurance. This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance.

Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident insurance in the U.S. by 1866, but the industry consolidated rapidly soon thereafter. While there were earlier experiments, the origins of sickness coverage in the U.S. effectively date from 1890. The first employer-sponsored group disability policy was issued in 1911.

Before the development of medical expense insurance, patients were expected to pay health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle-to-late 20th century, traditional disability insurance evolved into modern health insurance programs. One major obstacle to this development was that early forms of comprehensive health insurance were enjoined by courts for violating the traditional ban on corporate practice of the professions by for-profit corporations. State legislatures had to intervene and expressly legalize health insurance as an exception to that traditional rule. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and most prescription drugs (but this is not always the case).

Hospital and medical expense policies were introduced during the first half of the 20th century. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations. The predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in 1929, through the 1930s and on during World War II.

The Employee Retirement Income Security Act of 1974 (ERISA) regulated the operation of a health benefit plan if an employer chooses to establish one, which is not required. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) gives an ex-employee the right to continue coverage under an employer-sponsored group health benefit plan.

Through the 1990s, managed care insurance schemes including health maintenance organizations (HMO), preferred provider organizations, or point of service plans grew from about 25% US employees with employer-sponsored coverage to the vast majority. With managed care, insurers use various techniques to address costs and improve quality, including negotiation of prices ("in-network" providers), utilization management, and requirements for quality assurance such as being accredited by accreditation schemes such as the Joint Commission and the American Accreditation Healthcare Commission.

Employers and employees may have some choice in the details of plans, including health savings accounts, deductible, and coinsurance. As of 2015, a trend has emerged for employers to offer high-deductible plans, called consumer-driven healthcare plans which place more costs on employees; some employers will offer multiple plans to their employees.

Philosophy of healthcare

From Wikipedia, the free encyclopedia


The philosophy of healthcare is the study of the ethics, processes, and people which constitute the maintenance of health for human beings. (Although veterinary concerns are worthy to note, the body of thought regarding their methodologies and practices is not addressed in this article.) For the most part, however, the philosophy of healthcare is best approached as an indelible component of human social structures. That is, the societal institution of healthcare can be seen as a necessary phenomenon of human civilization whereby an individual continually seeks to improve, mend, and alter the overall nature and quality of their life. This perennial concern is especially prominent in modern political liberalism, wherein health has been understood as the foundational good necessary for public life.

The philosophy of healthcare is primarily concerned with the following elemental questions:
  • Who requires and/or deserves healthcare? Is healthcare a fundamental right of all people?
  • What should be the basis for calculating the cost of treatments, hospital stays, drugs, etc.?
  • How can healthcare best be administered to the greatest number of people?
  • What are the necessary parameters for clinical trials and quality assurance?
  • Who, if anybody, can decide when a patient is in need of "comfort measures" (allowing a natural death by providing medications to treat symptoms related to the patient's illness)?
However, the most important question of all is 'what is health?'. Unless this question is addressed any debate about healthcare will be vague and unbounded. For example, what exactly is a health care intervention? What differentiates healthcare from engineering or teaching, for example? Is health care about 'creating autonomy' or acting in people's best interests? Or is it always both? A 'philosophy' of anything requires baseline philosophical questions, as asked, for example, by philosopher David Seedhouse.

Ultimately, the purpose, objective and meaning of healthcare philosophy is to consolidate the abundance of information regarding the ever-changing fields of biotechnology, medicine, and nursing. And seeing that healthcare typically ranks as one of the largest spending areas of governmental budgets, it becomes important to gain a greater understanding of healthcare as not only a social institution, but also as a political one. In addition, healthcare philosophy attempts to highlight the primary movers of healthcare systems; be it nurses, doctors, allied health professionals, hospital administrators, health insurance companies (HMOs and PPOs), the government (Medicare and Medicaid), and lastly, the patients themselves.

President Johnson signing the U.S. Medicare bill. Harry Truman and his wife, Bess, are on the far right. (1965)

Ethics of healthcare

Hippocrates, the ancient Greek physician, considered the father of Western medicine.
 
The ethical and/or moral premises of healthcare are complex and intricate. To consolidate such a large segment of moral philosophy, it becomes important to focus on what separates healthcare ethics from other forms of morality. And on the whole, it can be said that healthcare itself is a "special" institution within society. With that said, healthcare ought to "be treated differently from other social goods" in a society. It is an institution of which we are all a part whether we like it or not. At some point in every person's life, a decision has to be made regarding one's healthcare. Can they afford it? Do they deserve it? Do they need it? Where should they go to get it? Do they even want it? And it is this last question which poses the biggest dilemma facing a person. After weighing all of the costs and benefits of her healthcare situation, the person has to decide if the costs of healthcare outweigh the benefits. More than basic economic issues are at stake in this conundrum. In fact, a person must decide whether or not their life is ending or if it is worth salvaging. Of course, in instances where the patient is unable to decide due to medical complications, like a coma, then the decision must come from elsewhere. And defining that "elsewhere" has proven to be a very difficult endeavor in healthcare philosophy.

Medical ethics

Whereas bioethics tends to deal with more broadly-based issues like the consecrated nature of the human body and the roles of science and technology in healthcare, medical ethics is specifically focused on applying ethical principles to the field of medicine. Medical ethics has its roots in the writings of Hippocrates, and the practice of medicine was often used as an example in ethical discussions by Plato and Aristotle. As a systematic field, however, it is a large and relatively new area of study in ethics. One of the major premises of medical ethics surrounds "the development of valuational measures of outcomes of health care treatments and programs; these outcome measures are designed to guide health policy and so must be able to be applied to substantial numbers of people, including across or even between whole societies." Terms like beneficence and non-maleficence are vital to the overall understanding of medical ethics. Therefore, it becomes important to acquire a basic grasp of the varying dynamics that go into a doctor-patient relationship.

Nursing ethics

Like medical ethics, nursing ethics is very narrow in its focus, especially when compared to the expansive field of bioethics. For the most part, "nursing ethics can be defined as having a two-pronged meaning," whereby it is "the examination of all kinds of ethical and bioethical issues from the perspective of nursing theory and practice." This definition, although quite vague, centers on the practical and theoretical approaches to nursing. The American Nurses Association (ANA) endorses an ethical code that emphasizes "values" and "evaluative judgments" in all areas of the nursing profession. The importance of values is being increasingly recognized in all aspects of healthcare and health research. And since moral issues are extremely prevalent throughout nursing, it is important to be able to recognize and critically respond to situations that warrant and/or necessitate an ethical decision.

Business ethics

Balancing the cost of care with the quality of care is a major issue in healthcare philosophy. In Canada and some parts of Europe, democratic governments play a major role in determining how much public money from taxation should be directed towards the healthcare process. In the United States and other parts of Europe, private health insurance corporations as well as government agencies are the agents in this precarious life-and-death balancing act. According to medical ethicist Leonard J. Weber, "Good-quality healthcare means cost-effective healthcare," but "more expensive healthcare does not mean higher-quality healthcare" and "certain minimum standards of quality must be met for all patients" regardless of health insurance status. This statement undoubtedly reflects the varying thought processes going into the bigger picture of a healthcare cost-benefit analysis. In order to streamline this tedious process, health maintenance organizations (HMOs) like BlueCross BlueShield employ large numbers of actuaries (colloquially known as "insurance adjusters") to ascertain the appropriate balance between cost, quality, and necessity in a patient's healthcare plan. A general rule in the health insurance industry is as follows:
The least costly treatment should be provided unless there is substantial evidence that a more costly intervention is likely to yield a superior outcome.
This generalized rule for healthcare institutions "is perhaps one of the best expressions of the practical meaning of stewardship of resources," especially since "the burden of proof is on justifying the more expensive intervention, not the less expensive one, when different acceptable treatment options exist." And lastly, frivolous lawsuits have been cited as major precipitants of increasing healthcare costs.

Political philosophy of healthcare

In the political philosophy of healthcare, the debate between universal healthcare and private healthcare is particularly contentious in the United States. In the 1960s, there was a plethora of public initiatives by the federal government to consolidate and modernize the U.S. healthcare system. With Lyndon Johnson's Great Society, the U.S. established public health insurance for both senior citizens and the underprivileged. Known as Medicare and Medicaid, these two healthcare programs granted certain groups of Americans access to adequate healthcare services. Although these healthcare programs were a giant step in the direction of socialized medicine, many people think that the U.S. needs to do more for its citizenry with respect to healthcare coverage. Opponents of universal healthcare see it as an erosion of the high quality of care that already exists in the United States.

U.S. Medicare (2008)

Patients' Bill of Rights

In 2001, the U.S. federal government took up an initiative to provide patients with an explicit list of rights concerning their healthcare. The political philosophy behind such an initiative essentially blended ideas of the Consumers' Bill of Rights with the field of healthcare. It was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the healthcare industry. Standardizing the nature of healthcare institutions in this manner proved provocative. In fact, many interest groups, including the American Medical Association (AMA) and Big Pharma came out against the congressional bill. Basically, having hospitals provide emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the two biggest stumbling blocks for the bill. As a result of this intense opposition, the initiative eventually failed to pass Congress in 2002.

Health insurance

Tommy Douglas' (centre left) number one concern was the creation of Canadian Medicare. In the summer of 1962, Saskatchewan became the centre of a hard-fought struggle between the provincial government, the North American medical establishment, and the province's physicians, who brought things to a halt with a doctors' strike.
 
Health insurance is the primary mechanism through which individuals cover healthcare costs in industrialized countries. It can be obtained from either the public or private sector of the economy. In Canada, for example, the provincial governments administer public health insurance coverage to citizens and permanent residents. According to Health Canada, the political philosophy of public insurance in Canada is as follows:
The administration and delivery of health care services is the responsibility of each province or territory, guided by the provisions of the Canada Health Act. The provinces and territories fund these services with assistance from the federal government in the form of fiscal transfers.
And the driving force behind such a political philosophy in Canada was democratic socialist politician Tommy Douglas.

Contrasting with the U.S., but similar to Canada, Australia and New Zealand have universal healthcare systems known as Medicare and ACC (Accident Compensation Corporation), respectively.

Australian Medicare originated with Health Insurance Act 1973. It was introduced by Prime Minister (PM) Gough Whitlam's Labor Government, and was intended to provide affordable treatment by doctors in public hospitals for all resident citizens. Redesigned by PM Bob Hawke in 1984, the current Medicare system permits citizens the option to purchase private health insurance in a two-tier health system.

Research and scholarship

Considering the rapid pace at which the fields of medicine and health science are developing, it becomes important to investigate the most proper and/or efficient methodologies for conducting research. On the whole, "the primary concern of the researcher must always be the phenomenon, from which the research question is derived, and only subsequent to this can decisions be made as to the most appropriate research methodology, design, and methods to fulfill the purposes of the research." This statement on research methodology places the researcher at the forefront of his findings. That is, the researcher becomes the person who makes or breaks his or her scientific inquiries rather than the research itself. Even so, "interpretive research and scholarship are creative processes, and methods and methodology are not always singular, a priori, fixed and unchanging." Therefore, viewpoints on scientific inquiries into healthcare matters "will continue to grow and develop with the creativity and insight of interpretive researchers, as they consider emerging ways of investigating the complex social world."

Clinical trials

Clinical trials are a means through which the healthcare industry tests a new drug, treatment, or medical device. The traditional methodology behind clinical trials consists of various phases in which the emerging product undergoes a series of intense tests, most of which tend to occur on interested and/or compliant patients. The U.S. government has an established network for tackling the emergence of new products in the healthcare industry. The Food and Drug Administration (FDA) does not conduct trials on new drugs coming from pharmaceutical companies. Along with the FDA, the National Institutes of Health sets the guidelines for all kinds of clinical trials relating to infectious diseases. For cancer, the National Cancer Institute (NCI) sponsors a series or cooperative groups like CALGB and COG in order to standardize protocols for cancer treatment.

Quality assurance

The primary purpose of quality assurance (QA) in healthcare is to ensure that the quality of patient care is in accordance with established guidelines. The government usually plays a significant role in providing structured guidance for treating a particular disease or ailment. However, protocols for treatment can also be worked out at individual healthcare institutions like hospitals and HMOs. In some cases, quality assurance is seen as a superfluous endeavor, as many healthcare-based QA organizations, like QARC, are publicly funded at the hands of taxpayers. However, many people would agree that healthcare quality assurance, particularly in the areas cancer treatment and disease control are necessary components to the vitality of any legitimate healthcare system. With respect to quality assurance in cancer treatment scenarios, the Quality Assurance Review Center (QARC) is just one example of a QA facility that seeks "to improve the standards of care" for patients "by improving the quality of clinical trials medicine."

Birth and death

Reproductive rights

The ecophilosophy of Garrett Hardin is one perspective from which to analyze the reproductive rights of human beings. For the most part, Hardin argues that it is immoral to have large families, especially since they do a disservice to society by consuming an excessive amount of resources. In an essay titled The Tragedy of the Commons, Hardin states,
To couple the concept of freedom to breed with the belief that everyone born has an equal right to the commons is to lock the world into a tragic course of action.
By encouraging the freedom to breed, the welfare state not only provides for children, but also sustains itself in the process. The net effect of such a policy is the inevitability of a Malthusian catastrophe

Hardin's ecophilosophy reveals one particular method to mitigate healthcare costs. With respect to population growth, the fewer people there are to take care of, the less expensive healthcare will be. And in applying this logic to what medical ethicist Leonard J. Weber previously suggested, less expensive healthcare does not necessarily mean poorer quality healthcare.

Birth and living

The concept of being "well-born" is not new, and may carry racist undertones. The Nazis practiced eugenics in order to cleanse the gene pool of what were perceived to be unwanted or harmful elements. This "race hygiene movement in Germany evolved from a theory of Social Darwinism, which had become popular throughout Europe" and the United States during the 1930s. A German phrase that embodies the nature of this practice is lebensunwertes Leben or "life unworthy of life."

In connection with healthcare philosophy, the theory of natural rights becomes a rather pertinent subject. After birth, man is effectively endowed with a series of natural rights that cannot be banished under any circumstances. One major proponent of natural rights theory was seventeenth-century English political philosopher John Locke. With regard to the natural rights of man, Locke states,
If God's purpose for me on Earth is my survival and that of my species, and the means to that survival are my life, health, liberty and property — then clearly I don't want anyone to violate my rights to these things.
Although partially informed by his religious understanding of the world, Locke's statement can essentially be viewed as an affirmation of the right to preserve one's life at all costs. This point is precisely where healthcare as a human right becomes relevant.

The process of preserving and maintaining one's health throughout life is a matter of grave concern. At some point in every person's life, his or her health is going to decline regardless of all measures taken to prevent such a collapse. Coping with this inevitable decline can prove quite problematic for some people. For Enlightenment philosopher René Descartes, the depressing and gerontological implications of aging pushed him to believe in the prospects of immortality through a wholesome faith in the possibilities of reason.

Death and dying

One of the most basic human rights is the right to live, and thus, preserve one's life. Yet one must also consider the right to die, and thus, end one's life. Often, religious values of varying traditions influence this issue. Terms like "mercy killing" and "assisted suicide" are frequently used to describe this process. Proponents of euthanasia claim that it is particularly necessary for patients suffering from a terminal illness. However, opponents of a self-chosen death purport that it is not only immoral, but wholly against the pillars of reason.

In a certain philosophical context, death can be seen as the ultimate existential moment in one's life. Death is the deepest cause of a primordial anxiety (Die Anfechtung) in a person's life. In this emotional state of anxiety, "the Nothing" is revealed to the person. According to twentieth-century German philosopher Martin Heidegger,
The Nothing is the complete negation of the totality of beings.
And thus, for Heidegger, humans finds themselves in a very precarious and fragile situation (constantly hanging over the abyss) in this world. This concept can be simplified to the point where at bottom, all that a person has in this world is his or her Being. Regardless of how individuals proceed in life, their existence will always be marked by finitude and solitude. When considering near-death experiences, humans feels this primordial anxiety overcome them. Therefore, it is important for healthcare providers to recognize the onset of this entrenched despair in patients who are nearing their respective deaths. 

Other philosophical investigations into death examine the healthcare's profession heavy reliance on science and technology (SciTech). This reliance is especially evident in Western medicine. Even so, Heidegger makes ang allusion to this reliance in what he calls the allure or "character of exactness." In effect, people are inherently attached to "exactness" because it gives them a sense of purpose or reason in a world that is largely defined by what appears to be chaos and irrationality. And as the moment of death is approaching, a moment marked by utter confusion and fear, people frantically attempt to pinpoint a final sense of meaning in their lives.

Aside from the role that SciTech plays in death, palliative care constitutes a specialized area of healthcare philosophy that specifically relates to patients who are terminally ill. Similar to hospice care, this area of healthcare philosophy is becoming increasingly important as more patients prefer to receive healthcare services in their homes. Even though the terms "palliative" and "hospice" are typically used interchangeably, they are actually quite different. As a patient nears the end of his life, it is more comforting to be in a private home-like setting instead of a hospital. Palliative care has generally been reserved for those who have a terminal illness. However, it is now being applied to patients in all kinds of medical situations, including chronic fatigue and other distressing symptoms.

Role development

The manner in which nurses, physicians, patients, and administrators interact is crucial for the overall efficacy of a healthcare system. From the viewpoint of the patients, healthcare providers can be seen as being in a privileged position, whereby they have the power to alter the patients' quality of life. And yet, there are strict divisions among healthcare providers that can sometimes lead to an overall decline in the quality of patient care. When nurses and physicians are not on the same page with respect to a particular patient, a compromising situation may arise. Effects stemming from a "gender gap" between nurses and doctors are detrimental to the professional environment of a hospital workspace.

Perennial philosophy

From Wikipedia, the free encyclopedia

Perennial philosophy is a perspective in modern spirituality that views all of the world's religious traditions as sharing a single, metaphysical truth or origin from which all esoteric and exoteric knowledge and doctrine has grown.

Perennialism has its roots in the Renaissance interest in neo-Platonism and its idea of The One, from which all existence emanates. Marsilio Ficino (1433–1499) sought to integrate Hermeticism with Greek and Jewish-Christian thought, discerning a Prisca theologia which could be found in all ages. Giovanni Pico della Mirandola (1463–94) suggested that truth could be found in many, rather than just two, traditions. He proposed a harmony between the thought of Plato and Aristotle, and saw aspects of the Prisca theologia in Averroes (Ibn Rushd), the Quran, the Kabbalah and other sources. Agostino Steuco (1497–1548) coined the term philosophia perennis.

A more popular interpretation argues for universalism, the idea that all religions, underneath seeming differences, point to the same Truth. In the early 19th century the Transcendentalists propagated the idea of a metaphysical Truth and universalism, which inspired the Unitarians, who proselytized among Indian elites. Towards the end of the 19th century, the Theosophical Society further popularized universalism, not only in the western world, but also in western colonies. In the 20th century universalism was further popularized in the English-speaking world through the neo-Vedanta inspired Traditionalist School, which argues for a metaphysical, single origin of the orthodox religions, and by Aldous Huxley and his book The Perennial Philosophy, which was inspired by neo-Vedanta and the Traditionalist School.

Definition

Renaissance

The idea of a perennial philosophy originated with a number of Renaissance theologians who took inspiration from neo-Platonism and from the theory of Forms. Marsilio Ficino (1433–1499) argued that there is an underlying unity to the world, the soul or love, which has a counterpart in the realm of ideas. According to Giovanni Pico della Mirandola (1463–1494), a student of Ficino, truth could be found in many, rather than just two, traditions. According to Agostino Steuco (1497–1548) there is "one principle of all things, of which there has always been one and the same knowledge among all peoples."

Traditionalist School

The contemporary, scholarly oriented Traditionalist School continues this metaphysical orientation. According to the Traditionalist School, the perennial philosophy is "absolute Truth and infinite Presence." Absolute Truth is "the perennial wisdom (sophia perennis) that stands as the transcendent source of all the intrinsically orthodox religions of humankind." Infinite Presence is "the perennial religion (religio perennis) that lives within the heart of all intrinsically orthodox religions." The Traditionalist School discerns a transcendent and an immanent dimension, namely the discernment of the Real or Absolute, c.q. that which is permanent; and the intentional "mystical concentration on the Real."

According to Soares de Azevedo, the perennialist philosophy states that the universal truth is the same within each of the world's orthodox religious traditions, and is the foundation of their religious knowledge and doctrine. Each world religion is an interpretation of this universal truth, adapted to cater for the psychological, intellectual, and social needs of a given culture of a given period of history. This perennial truth has been rediscovered in each epoch by mystics of all kinds who have revived already existing religions, when they had fallen into empty platitudes and hollow ceremonialism.

Shipley further notes that the Traditionalist School is oriented on orthodox traditions, and rejects modern syncretism and universalism, which creates new religions from older religions and compromise the standing traditions.

Aldous Huxley and mystical universalism

One such universalist was Aldous Huxley, who propagated a universalist interpretation of the world religions, inspired by Vivekananda's neo-Vedanta. According to Aldous Huxley, who popularized the idea of a perennial philosophy with a larger audience,
The Perennial Philosophy is expressed most succinctly in the Sanskrit formula, tat tvam asi ('That thou art'); the Atman, or immanent eternal Self, is one with Brahman, the Absolute Principle of all existence; and the last end of every human being, is to discover the fact for himself, to find out who he really is.
In Huxley's 1944 essay in Vedanta and the West, he describes The Minimum Working Hypothesis; the basic outline of the perennial philosophy found in all the mystic branches of the religions of the world:
That there is a Godhead or Ground, which is the unmanifested principle of all manifestation.
That the Ground is transcendent and immanent.
That it is possible for human beings to love, know and, from virtually, to become actually identified with the Ground.
That to achieve this unitive knowledge, to realize this supreme identity, is the final end and purpose of human existence.
That there is a Law or Dharma, which must be obeyed, a Tao or Way, which must be followed, if men are to achieve their final end.

Origins

The perennial philosophy originates from a blending of neo-Platonism and Christianity. Neo-Platonism itself has diverse origins in the syncretic culture of the Hellenistic period, and was an influential philosophy throughout the Middle Ages.

Classical world

Hellenistic period: religious syncretism

During the Hellenistic period, Alexander the Great's campaigns brought about exchange of cultural ideas on its path throughout most of the known world of his era. The Greek Eleusinian Mysteries and Dionysian Mysteries mixed with such influences as the Cult of Isis, Mithraism and Hinduism, along with some Persian influences. Such cross-cultural exchange was not new to the Greeks; the Egyptian god Osiris and the Greek god Dionysus had been equated as Osiris-Dionysus by the historian Herodotus as early as the 5th century BC.

Roman world: Philo of Alexandria

Philo of Alexandria (c.25 BCE – c.50 CE) attempted to reconcile Greek Rationalism with the Torah, which helped pave the way for Christianity with Neo-Platonism, and the adoption of the Old Testament with Christianity, as opposed to Gnostic Marcion roots of Christianity.[citation needed] Philo translated Judaism into terms of Stoic, Platonic and Neopythagorean elements, and held that God is "supra rational" and can be reached only through "ecstasy." He also held that the oracles of God supply the material of moral and religious knowledge.

Neo-Platonism

Neoplatonism arose in the 3rd century CE and persisted until shortly after the closing of the Platonic Academy in Athens in AD 529 by Justinian I. Neoplatonists were heavily influenced by Plato, but also by the Platonic tradition that thrived during the six centuries which separated the first of the Neoplatonists from Plato. The work of Neoplatonic philosophy involved describing the derivation of the whole of reality from a single principle, "the One." It was founded by Plotinus, and has been very influential throughout history. In the Middle Ages, Neoplatonic ideas were integrated into the philosophical and theological works of many of the most important medieval Islamic, Christian, and Jewish thinkers.

Renaissance

Ficino and Pico della Mirandola

Marsilio Ficino (1433–1499) believed that Hermes Trismegistos, the supposed author of the Corpus Hermeticum, was a contemporary of Mozes and the teacher of Pythagoras, and the source of both Greek and Jewish-Christian thought. He argued that there is an underlying unity to the world, the soul or love, which has a counterpart in the realm of ideas. Platonic Philosophy and Christian theology both embody this truth. Ficino was influenced by a variety of philosophers including Aristotelian Scholasticism and various pseudonymous and mystical writings. Ficino saw his thought as part of a long development of philosophical truth, of ancient pre-Platonic philosophers (including Zoroaster, Hermes Trismegistus, Orpheus, Aglaophemus and Pythagoras) who reached their peak in Plato. The Prisca theologia, or venerable and ancient theology, which embodied the truth and could be found in all ages, was a vitally important idea for Ficino.

Giovanni Pico della Mirandola (1463–94), a student of Ficino, went further than his teacher by suggesting that truth could be found in many, rather than just two, traditions. This proposed a harmony between the thought of Plato and Aristotle, and saw aspects of the Prisca theologia in Averroes, the Koran, the Cabala among other sources. After the deaths of Pico and Ficino this line of thought expanded, and included Symphorien Champier, and Francesco Giorgio.

Steuco

De perenni philosophia libri X
The term perenni philosophia was first used by Agostino Steuco (1497–1548) who used it to title a treatise, De perenni philosophia libri X, published in 1540. De perenni philosophia was the most sustained attempt at philosophical synthesis and harmony. Steuco represents the liberal wing of 16th-century Biblical scholarship and theology, although he rejected Luther and Calvin. De perenni philosophia, is a complex work which only contains the term philosophia perennis twice. It states that there is "one principle of all things, of which there has always been one and the same knowledge among all peoples." This single knowledge (or sapientia) is the key element in his philosophy. In that he emphasises continuity over progress, Steuco's idea of philosophy is not one conventionally associated with the Renaissance. Indeed, he tends to believe that the truth is lost over time and is only preserved in the prisci theologica. Steuco preferred Plato to Aristotle and saw greater congruence between the former and Christianity than the latter philosopher. He held that philosophy works in harmony with religion and should lead to knowledge of God, and that truth flows from a single source, more ancient than the Greeks. Steuco was strongly influenced by Iamblichus's statement that knowledge of God is innate in all, and also gave great importance to Hermes Trismegistus.
Influence
Steuco's perennial philosophy was highly regarded by some scholars for the two centuries after its publication, then largely forgotten until it was rediscovered by Otto Willmann in the late part of the 19th century. Overall, De perenni philosophia wasn't particularly influential, and largely confined to those with a similar orientation to himself. The work was not put on the Index of works banned by the Roman Catholic Church, although his Cosmopoeia which expressed similar ideas was. Religious criticisms tended to the conservative view that held Christian teachings should be understood as unique, rather than seeing them as perfect expressions of truths that are found everywhere. More generally, this philosophical syncretism was set out at the expense of some of the doctrines included within it, and it is possible that Steuco's critical faculties were not up to the task he had set himself. Further, placing so much confidence in the prisca theologia, turned out to be a shortcoming as many of the texts used in this school of thought later turned out to be bogus. In the following two centuries the most favourable responses were largely Protestant and often in England.

Gottfried Leibniz later picked up on Steuco's term. The German philosopher stands in the tradition of this concordistic philosophy; his philosophy of harmony especially had affinity with Steuco's ideas. Leibniz knew about Steuco's work by 1687, but thought that De la Verite de la Religion Chretienne by Huguenot philosopher Phillippe du Plessis-Mornay expressed the same truth better. Steuco's influence can be found throughout Leibniz's works, but the German was the first philosopher to refer to the perennial philosophy without mentioning the Italian.

Popularisation

Transcendentalism and Unitarian Universalism

Ralph Waldo Emerson (1803–1882) was a pioneer of the idea of spirituality as a distinct field. He was one of the major figures in Transcendentalism, an early 19th-century liberal Protestant movement, which was rooted in English and German Romanticism, the Biblical criticism of Herder and Schleiermacher, and the skepticism of Hume. The Transcendentalists emphasised an intuitive, experiential approach of religion. Following Schleiermacher, an individual's intuition of truth was taken as the criterion for truth. In the late 18th and early 19th century, the first translations of Hindu texts appeared, which were also read by the Transcendentalists, and influenced their thinking. They also endorsed universalist and Unitarianist ideas, leading to Unitarian Universalism, the idea that there must be truth in other religions as well, since a loving God would redeem all living beings, not just Christians.

Theosophical Society

By the end of the 19th century, the idea of a perennial philosophy was popularized by leaders of the Theosophical Society such as H. P. Blavatsky and Annie Besant, under the name of "Wisdom-Religion" or "Ancient Wisdom". The Theosophical Society took an active interest in Asian religions, subsequently not only bringing those religions under the attention of a western audience but also influencing Hinduism and Buddhism in Sri Lanka and Japan.

Neo-Vedanta

Many perennialist thinkers (including Armstrong, Huston Smith and Joseph Campbell) are influenced by Hindu reformer Ram Mohan Roy and Hindu mystics Ramakrishna and Swami Vivekananda, who themselves have taken over western notions of universalism. They regarded Hinduism to be a token of this perennial philosophy. This notion has influenced thinkers who have proposed versions of the perennial philosophy in the 20th century.

The unity of all religions was a central impulse among Hindu reformers in the 19th century, who in turn influenced many 20th-century perennial philosophy-type thinkers. Key figures in this reforming movement included two Bengali Brahmins. Ram Mohan Roy, a philosopher and the founder of the modernising Brahmo Samaj religious organisation, reasoned that the divine was beyond description and thus that no religion could claim a monopoly in their understanding of it.

The mystic Ramakrishna's spiritual ecstasies included experiencing the sameness of Christ, Mohammed and his own Hindu deity. Ramakrishna's most famous disciple, Swami Vivekananda, travelled to the United States in the 1890s where he formed the Vedanta Society.

Roy, Ramakrishna and Vivekananda were all influenced by the Hindu school of Advaita Vedanta, which they saw as the exemplification of a Universalist Hindu religiosity.

Traditionalist School

The Traditionalist School was a group of 20th century thinkers concerned with what they considered to be the demise of traditional forms of knowledge, both aesthetic and spiritual, within Western society. The principal thinkers in this tradition are René Guénon, Ananda Coomaraswamy and Frithjof Schuon. Other important thinkers in this tradition include Titus Burckhardt, Martin Lings, Jean-Louis Michon, Marco Pallis, Huston Smith, Hossein Nasr, Jean Borella, Elémire Zolla and Julius Evola. According to the Traditionalist School, orthodox religions are based on a singular metaphysical origin. According to the Traditionalist School, the "philosophia perennis" designates a worldview that is opposed to the scientism of modern secular societies and which promotes the rediscovery of the wisdom traditions of the pre-secular developed world. This view is exemplified by Rene Guenon in his magnum opus and one of the founding works of the traditionalist school, The Reign of Quantity and the Signs of the Times

According to Frithjof Schuon:
It has been said more than once that total Truth is inscribed in an eternal script in the very substance of our spirit; what the different Revelations do is to "crystallize" and "actualize", in different degrees according to the case, a nucleus of certitudes which not only abides forever in the divine Omniscience, but also sleeps by refraction in the "naturally supernatural" kernel of the individual, as well as in that of each ethnic or historical collectivity or of the human species as a whole.

Aldous Huxley

The term was popularized in more recent times by Aldous Huxley, who was profoundly influenced by Vivekananda's Neo-Vedanta and Universalism. In his 1945 book The Perennial Philosophy he defined the perennial philosophy as:
... the metaphysic that recognizes a divine Reality substantial to the world of things and lives and minds; the psychology that finds in the soul something similar to, or even identical to, divine Reality; the ethic that places man's final end in the knowledge of the immanent and transcendent Ground of all being; the thing is immemorial and universal. Rudiments of the perennial philosophy may be found among the traditional lore of primitive peoples in every region of the world, and in its fully developed forms it has a place in every one of the higher religions.
In contrast to the Traditionalist school, Huxley emphasized mystical experience over metaphysics:
The Buddha declined to make any statement in regard to the ultimate divine Reality. All he would talk about was Nirvana, which is the name of the experience that comes to the totally selfless and one-pointed [...] Maintaining, in this matter, the attitude of a strict operationalist, the Buddha would speak only of the spiritual experience, not of the metaphysical entity presumed by the theologians of other religions, as also of later Buddhism, to be the object and (since in contemplation the knower, the known and the knowledge are all one) at the same time the subject and substance of that experience.
According to Aldous Huxley, in order to apprehend the divine reality, one must choose to fulfill certain conditions: "making themselves loving, pure in heart and poor in spirit." Huxley argues that very few people can achieve this state. Those who have fulfilled these conditions, grasped the universal truth and interpreted it have generally been given the name of saint, prophet, sage or enlightened one. Huxley argues that those who have, "modified their merely human mode of being," and have thus been able to comprehend "more than merely human kind and amount of knowledge" have also achieved this enlightened state.

New Age

The idea of a perennial philosophy is central to the New Age Movement. The New Age movement is a Western spiritual movement that developed in the second half of the 20th century. Its central precepts have been described as "drawing on both Eastern and Western spiritual and metaphysical traditions and infusing them with influences from self-help and motivational psychology, holistic health, parapsychology, consciousness research and quantum physics". The term New Age refers to the coming astrological Age of Aquarius.

The New Age aims to create "a spirituality without borders or confining dogmas" that is inclusive and pluralistic. It holds to "a holistic worldview", emphasising that the Mind, Body and Spirit are interrelated and that there is a form of monism and unity throughout the universe. It attempts to create "a worldview that includes both science and spirituality" and embraces a number of forms of mainstream science as well as other forms of science that are considered fringe.

Academic discussions

Mystical experience

The idea of a perennial philosophy, sometimes called perennialism, is a key area of debate in the academic discussion of mystical experience. Huston Smith notes that the Traditionalist School's vision of a perennial philosophy is not based on mystical experiences, but on metaphysical intuitions. The discussion of mystical experience has shifted the emphasis in the perennial philosophy from these metaphysical intuitions to religious experience and the notion of nonduality or altered state of consciousness

William James popularized the use of the term "religious experience" in his The Varieties of Religious Experience. It has also influenced the understanding of mysticism as a distinctive experience which supplies knowledge. Writers such as WT Stace, Huston Smith, and Robert Forman argue that there are core similarities to mystical experience across religions, cultures and eras. For Stace the universality of this core experience is a necessary, although not sufficient, condition for one to be able to trust the cognitive content of any religious experience.

Wayne Proudfoot traces the roots of the notion of "religious experience" further back to the German theologian Friedrich Schleiermacher (1768–1834), who argued that religion is based on a feeling of the infinite. The notion of "religious experience" was used by Schleiermacher to defend religion against the growing scientific and secular critique. It was adopted by many scholars of religion, of which William James was the most influential.

Critics point out that the emphasis on "experience" favours the atomic individual, instead of the community. It also fails to distinguish between episodic experience, and mysticism as a process, embedded in a total religious matrix of liturgy, scripture, worship, virtues, theology, rituals and practices. Richard King also points to disjunction between "mystical experience" and social justice:
The privatisation of mysticism - that is, the increasing tendency to locate the mystical in the psychological realm of personal experiences - serves to exclude it from political issues such as social justice. Mysticism thus comes to be seen as a personal matter of cultivating inner states of tranquility and equanimity, which, rather than serving to transform the world, reconcile the individual to the status quo by alleviating anxiety and stress.

Religious pluralism

Religious pluralism holds that various world religions are limited by their distinctive historical and cultural contexts and thus there is no single, true religion. There are only many equally valid religions. Each religion is a direct result of humanity's attempt to grasp and understand the incomprehensible divine reality. Therefore, each religion has an authentic but ultimately inadequate perception of divine reality, producing a partial understanding of the universal truth, which requires syncretism to achieve a complete understanding as well as a path towards salvation or spiritual enlightenment.

Although perennial philosophy also holds that there is no single true religion, it differs when discussing divine reality. Perennial philosophy states that the divine reality is what allows the universal truth to be understood. Each religion provides its own interpretation of the universal truth, based on its historical and cultural context. Therefore, each religion provides everything required to observe the divine reality and achieve a state in which one will be able to confirm the universal truth and achieve salvation or spiritual enlightenment.

Inequality (mathematics)

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