International Health Care Systems
Kao-Ping Chua Jack Rutledge Fellow, 2005-2006 American Medical Student Association
Structure of systems
Insurance Delivery Examples
National health service
Mostly public Mostly public U.K.
Entrepreneurial
Mandated insurance
Mostly private
Mostly private
U.S.
Mostly public Public and private
Germany
The influence of values on systems
European social ethic: public good, social solidarity
American individualistic ethic: individual good, social fragmentation
Three categories of analysis
Organization: insurance pools, public/private mix Quality, choice, and access Problems
Outline
I.
II.
III. IV. V. VI.
U.S. Japan Germany France U.K. Canada
THINK BIG PICTURE!!!
U.S.
WHO Ranking for Health Attainment: 24 WHO Overall Ranking: 37 % GDP spent on health care: 15% (OECD median 8.6%)
US: Organization*
5% 15% Employersponsored Uninsured Medicaid/other public Private nongroup
18%
62%
*This refers to the non-elderly population
US: Quality, choice, access
Quality: depends on plan – often gaps for prescription drugs, dental, vision Choice: Restricted choice of providers Access: Waiting lines relatively rare, huge amount of uninsurance
US: Problems
45 million uninsured
Skyrocketing health care costs
Significant health disparities by race and income
Japan
WHO Ranking for Health Attainment: 1 WHO Overall Ranking: 10 % GDP spent on health care: 7.9% (OECD median 8.6%)
Japan: organization
Japanese health care system
Employee health insurance
Elderly (Roken)
Self-employed, retired, others (Kokuho)
1800 Kenpo Associations (large companies)
Seikan (small-mid companies)
Kyosai (public employees and private-school teachers)
Japan: organization
Most providers and hospitals are in the private sector
Hospitals are the center of care
Japan: quality, choice, access
Quality: huge amount of technology, comprehensive benefits Choice: free choice of doctors and hospitals Access: few waiting lists except at the very best hospitals
Japan: problems/reforms
Kenpo associations in debt (crosssubsidizations); rapidly aging population Over-prescription of drugs High cost-sharing
France
WHO Ranking for Health Attainment: 3 WHO Overall Ranking: 1 % GDP spent on health care: 10.1% (OECD median 8.6%)
France: organization
Multi-payer system 3 main payers are the “Sickness Insurance Funds” (SIF’s) – cover most health care costs Profession determines which SIF a citizen is automatically enrolled in
6% 9% Industrial, commerical, government Farmers
85%
Professionals, small business, craftspeople
France: organization
Most ambulatory care physicians are in private practice
Sector I: charge at national fee schedule but get government benefits Sector II: charge above fee schedule but don’t get government benefits
Hospitals both private and public Complementary health insurance for costsharing (90% of the population)
France: quality, choice, access
Quality: very comprehensive, good safety net for the poor Choice: Free choice of doctors Access: Can usually see GP on same-day
France: problems
Nursing and physician shortages Increasing health expenditures, mainly from drugs (19% of all expenditures)
90% of physician visits end up with prescriptions!
Germany
WHO Ranking for Health Attainment: 22 WHO Overall Ranking: 25 % GDP spent on health care: 11.1% (OECD median 8.6%)
Germany: organization
Multi-payer system
“Social Health Insurance” (SHI) network made up of 192 private, occupationbased "sickness funds”
9% 2%
SHI
High-income may opt-out of SHI and purchase “voluntary health insurance” Free government care
Substitutive VHI Free government care
89%
Germany: organization
Ambulatory physicians are mostly private
Hospitals are both public and private
Germany: quality, choice, access
Quality: Extremely comprehensive benefits
Generous sick pay policies
Choice: Free choice of GP and specialists, must use closest hospital Access: Waiting times not usually a problem
Germany: problems/reforms
Expensive health care system High cost-sharing Excessive numbers of physicians (60% of areas are closed off to more doctors)
The United Kingdom
WHO Ranking for Health Attainment: 14 WHO Overall Ranking: 18 % GDP spent on health care: 7.7% (OECD median 8.6%)
UK: organization
National health service (NHS): publicly financed and delivered Supplemental private insurance for dental and eye care Growing sector of substitutive private insurance
UK: Quality, choice, access
Quality: Comprehensive except dental and eye Choice: Free choice of doctor Access: major problems with waiting lists
Specialist (2.5 months) Elective procedures (3 months)
UK: problems
Underfunding:
Waiting lists Health care delivery capacity is insufficient for many services Facilities need updating
Canada
WHO Ranking for Health Attainment: 12 WHO Overall Ranking: 30 % GDP spent on health care: 9.9% (OECD median 8.6%)
Canada: organization
Single-payer system 13 provincial/territorial governments administer health care plan (“Medicare”) Federal government regulates the provincial/territorial health care plans by offering “transfer payments” contingent upon prespecified criteria
Federal government
10 provinces
3 territories
Provincial health care plan
Territorial health Care plan
Universality
Comprehensive
Canada Health Act of 1984
Accessibility
Portability
Public administration
Canada: organization
Providers are mostly private; hospitals mostly public
Most Canadians have complementary private health insurance for non-covered services
Canada: Quality, choice, access
Quality: Coverage for “medically necessary” services
Gaps for dental care, long-term care, outpatient drugs complementary private insurance
Choice: Free to choose GP and hospital Access:
No waiting lists for GP visits or emergencies Waiting times can be problematic for certain ELECTIVE procedures
Canada: Problems/reforms
Underfunding Gaps in coverage Tension between provincial and central governments
Points to remember, part 1
Every country is dealing with increasing health care costs ANY system can have problems if it is underfunded, no matter how good it is theoretically Privatization exists to various degrees in each system…but no country allows private elements to price people out of health care
Points to remember, part 2
UHC can be achieved while maintaining:
Comprehensive benefits for everyone (every country but U.S.) Free choice of providers (every country but U.S.) High levels of technology (Japan, Germany) Few waiting lists (France, Germany, Japan)
Parting thought
The U.S. is the only industrialized country in the world without UHC… …but we can achieve high-quality, affordable health care for EVERYONE if we used the vast amounts of money in our system more efficiently