There has been so much misinformation
about how health care systems work around the world, I felt that it was time to
explain the basics with regard to some of the other health care systems out
there.
The wingnuts like to throw around the
word "socialism," and characterize all universal health care systems
as such, but as you will see, it's simply incorrect. By the same token, some on
the left insinuate that all countries that provide universal health care do so
with a single-payer system, which is also not true.
The purpose of this column is simply to
provide information and clear up misconceptions, not to advocate for one
particular system over another. All of these systems have a strong public
component, but few have a single-payer system. Most have a strong private
insurance component, but – and this is an important distinction to be made with
regard to our internal health insurance debate -- none include a profit
component.
For the most part, the intent of this
post is to allow you to make up your own mind.
But I will say this; every single system below recognizes one basic fact
that our system does not. Health care is
a basic human right that all humans are entitled to. In every single country
mentioned below, the people have ascribed to the government a duty to make sure
everyone is covered and all bills are paid. Good basic health care is seen as
an investment in society; an investment that pays off in the long run, because
a healthy, productive society needs healthy productive participants.
Now, read and learn.
France
According to many measures, the French
health care system is considered to be among the best in the world. The health
insurance system is funded through taxes. French workers pay 20% of their gross
pay into the Social Security System, with the self-employed paying a little
more.
Now, that may sound like a lot, but
the Social Security tax includes health insurance, retirement support,
unemployment and welfare. For the sake of comparison, workers in the United
States pay nearly 9% of our gross pay just to Medicare and Social Security
alone. When you include employer contributions for those programs, those
programs cost us almost 16%. Add in the unemployment insurance and workers'
compensation payroll taxes paid on a worker's behalf, and we pay roughly the
same amount as the French, and even more to cover welfare and Medicaid. And we have to buy health insurance on top of
that.
The French system includes access to a wide choice of
general practitioners and healthcare specialists, and every single legal
resident of France has access to this care, because the law mandates universal
coverage. Everyone, regardless of
coverage, has the right to consult a doctor or specialist, and the right to
emergency treatment. The Social Security
system pays approximately 75% of the cost of medical treatment, with the
balance covered by private insurance or self-insurance. When you go to the
doctor, you or your insurance company pay the bill at the time of the visit.
Then, either you or your private insurance plan submit the bill to the state,
and you are reimbursed for 75% of that bill, usually within 10 days.
The
French government sees health care as a public safety issue, and that it
is charged with protecting patients' rights.
French health authorities plan the sizes and numbers of hospitals, and
they decide how to allocate technical equipment, so that everyone in the
country has adequate access to care, without creating an expensive glut of
unnecessary expensive machines. The
public sector accounts for 65% of hospital beds,
and they are responsible for ongoing care, teaching and training.
Private hospitals are operated for
profit, and they concentrate mostly on surgical procedures. By most accounts, there is no significant
difference between the quality of care in public and private hospitals.
Physicians and other health
professionals tend to work in both public and private hospitals, as well as
private practice. Approxmately 36% of physicians work in public hospitals or
clinics, and they're essentially public servants, and the amount they are paid
is determined by the government. However,
56% of physicians work in private practice.
The relative price of procedures is
determined by experts in the field, but are negotiated by physicians' unions and the public health
insurance funds themselves and set as "tariff references." More than
95% of practitioners conform to the tariff reference, and those who do not use
them are required to display their prices.
In some situations, medical practitioners with extra qualifications or
experience can charge more than the
tariff convention, but this is rare, and must be disclosed to patients
ahead of time.
The French health insurance system
does need some tweaking. It's expensive to maintain, and does run a deficit
currently. Of course, even with the obvious stresses on the French system, they
only spend 10% of GDP on health care and cover literally everyone, while we spend more than 16% of GDP on health care and,
well, don't cover everyone. Also, health
care costs rose just under 4% last year, while ours increased just under 12%.
The French set up their world class
health insurance system in 1945. There's been a lot of retooling and adjusting,
but at no point -- even when they were rules by right wing governments -- have the French people or the French government even attempted to
dismantle the mostly-socialized insurance system.
Germany
The German health insurance system is
a hybrid system, including both public and private components, although pretty
much all insurance is private.
German residents are required to carry
health insurance if they are working. If you make less than €4,050 gross salary
per month, you are a mandatory enrollee of the public German health insurance
system. The premium is standardized, at
14.9% of gross salary, with you paying 51% of the premium and your employer
paying 49%. Non-working spouses are automatically covered by an employee's
policy.
Those who lose their job are covered
by unemployment insurance, which includes health coverage, so those who lose
their job do not lose their insurance. Children are officially considered
"national treasures" and an investment in the country's future and as
such are covered by the government out of general revenues.
The German system is not, however, a
single-payer system; it's more like a single-collector system. Premiums are
collected in a government-run central fund that pools risk for the entire
system, but they are redistributed to one of the nearly 200 independent,
non-profit, competitive, non-governmental "sickness funds," that each
German is free to choose for coverage. When a person chooses a particular sick
fund, the central fund will pay that particular sick fund a capitation payment
that uses more than 80 variables to determine that person's actuarial risk. The
same amount would be made, regardless of which fund that particular person
chose.
Put simply, the German government is
not the insurer. The government collects the money, based on the individual's
income, while private, non-profit insurance concerns actually cover the
insured. Usually, the employer will automatically sign a new worker up with an
insurance company, but sometimes the employee is asked if they have a preferred
insurance company.
The public insurance system covers
about 90% of the population. If you are earning more than the threshold amount
of €4,050 gross salary per month, you can choose to leave the public health
insurance system, and pay for your own private health insurance directly. One reason only 10% of the population opts
out of the public system is because it tends to be far more expensive to go
with private insurance, and figuring the premiums is often so complicated as to
require assistance from a broker. But
regardless of whether the coverage is public or private, a certain minimum level
of coverage must be provided. Coverage is constant, there are no
"pre-existing conditions" and there are no exclusions. There is also
no profit element in the system.
The German public system has been
around since Otto von Bismarck passed the Health Insurance Act of 1883. And in
that time, coverage has only been expanded, not contracted, and not once has
anyone in Germany tried to eliminate it.
Australia
Australia's Medicare system is a
public system, that is ably assisted by
a strong private component. Every legal resident of Australia has basic
coverage by virtue of living there, which means they have free access to the
extensive public hospital system, and receive a 75% reimbursement for
outpatient medical treatment to those doctors with a Medicare number. To pay
for this, every working person pays a 1.5% tax on all income, although those
with incomes over $70,000 pay an extra 1% if they don't have
"adequate" private coverage. The bottom line is, regardless of means,
every Australian is entitled to receive treatment in a public hospital free of
charge, and has most of their primary care covered.
But the system is not all public.
Private (non-profit) insurance also plays a significant role in the Australian
system, as it takes a lot of the pressure off of the public system. It also keeps the Medicare income tax low, as
a portion of private insurance premiums
goes to Commonwealth-State Health Care Agreements, to defray the cost of
"free" hospital care.
Approximately 43" of Australians
carry private insurance, and there are many reasons for residents to do so. In
fact the government encourages it.
Though many have cited the program as unfair to those who can't afford
private insurance, those with private policies receive a government rebate of
up to 30% of their premiums (up to 40% if they're over 65). There are shorter
waiting lists for many procedures in private hospitals; there is a wider
selection of doctors; and while medical facilities are more extensive in the
Australian public system, private hospitals offer more personalized
accommodation facilities, such as private rooms. Many also choose private
insurance so as to have more treatment choices, such as dental, optical,
chiropractic or holistic care, for which coverage is either limited or
nonexistent under Medicare.
The government of Australia has
recognized every human's right to medical care, and since the national health
care system was created in 1975, no one has tried to get rid of it, although
the "encouragement" to push more Australians toward private insurance
came mostly from the right-leaning Howard government. They were unsuccessful.
Canada
Canada's Medicare system is a
universal single-payer system that covers about 70% of all health care expenses
in the country. The Canada Health Act
requires that all insured are fully insured for hospitalization and basic
health care. About 91% of hospital costs and 99% of physician services are
financed by the public sector.
Contrary to what some would have you
believe, the Canadian health care system is not "socialized
medicine." Most of the delivery system is private, not public. The federal
government provides provinces with money to finance health care, but it doesn't
pay the salaries of medical professionals, and it doesn't make treatment
decisions. It merely makes sure they get paid.
The Canadian Medicare system actually
consists of 10 regional systems, and represents a model of administrative
simplicity. Doctors treat and the system
pays the bill. Everyone in Canada is covered for basic health care. Their
coverage is not affected by changing or losing jobs, there is no such thing as
a "pre-existing condition" and there is no lifetime limit to costs. Most physicians receive a set fee, at rates
negotiated annually by the provincial governments and the medical associations
within the province. No physician can charge more than the negotiated rate --
even to privately insured individuals -- unless they opt out of the public
system altogether. Pharmaceutical costs are set by government price controls.
Because there are no deductibles or co-pays on basic health care, costs are
very predictable for patients. Also, because private insurance is a very small
part of the system, there is little or no advertising or promotion necessary.
Most Medicare money is collected through income taxes, although three
provinces also impose a small fixed monthly premium, which is waived for
low-income Canadians. Approximately 65%
of Canadians also carry supplemental private insurance, most of which they
receive through employers. Private
insurance covers elective medical
services, as well as those services not covered, or not completely covered by
Medicare, such as pharmaceutical drugs, dental and ophthalmological
services.
The Canadian system is not perfect;
there are some flaws. They could stand to spend more money recruiting and
training medical professionals, because
there is a shortage of physicians in the country. This causes some folks to
have to drive a long way to see a doctor, and waiting times are a significant
problem in some areas. But if you are a Canadian resident, you can show up at a
hospital or a doctor with your Care Card , you will be treated, and little or
no money will change hands. Everyone gets the same high level of treatment,
regardless of their station in life.
Universal, single-payer health care
began in Saskatchewan in 1946, and in that time the concept has only expanded,
never contracted. Canadians, for the most part, love their system, even if they
find some aspects of the system irritating, such as the occasional long wait
times. But their system covers everyone
completely, and while health care represents 10.7% of their GDP as of 2008,
which is above average for Organisation
for Economic Co-operation and Development (OECD) countries, that's still far
less than the United States spends as a percentage of GDP.
United Kingdom.
While many opponents of universal
health insurance love to throw around the term "socialized medicine,"
you can see that few countries actually have a socialized medical system. In
fact, of the countries we've looked at so far, the United Kingdom is the
exception. There is a lot to like about
the UK health care system, but the NHS systems (England, Northern Ireland,
Scotland and Wales actually have
different systems, although they use similar approaches) also contain a
seriously cautionary tale when it comes to relying on a completely socialized
system.
All four NHS systems are publicly
funded systems that provide almost all health services for UK residents.
Services such as primary care, in-patient and long term care, and all are free
to all patients at the time of delivery.
Some health care sectors, such as ophthalmology, dentistry and
prescription drugs incur small charges. For example, prescription drugs in
England are free for people under 16 and over 59, others will pay a flat fee of
£7.20 per drug. There are, however, exemptions for low income individuals, and
those with chronic conditions, such as cancer and diabetes. In Northern Ireland, the charge is £6.85; in
Scotland, it's £4, and in Wales, all prescription drug charges were abolished
in 2007. In all four systems, prescribed contraception is free of charge.
The English NHS is run according to the NHS Constitution for
England, which guarantees the rights and obligations of everyone involved in
the system, including patients and medical professionals. Medical professionals
who are signed up with England NHS are considered government employees. Private health care is not illegal in
England, but only about 8% of the population uses the private system. In fact,
NHS has begun using the private system a bit, in order to increase capacity, but
the public has expressed their overwhelming opposition to such involvement.
The NHS systems were created in 1948,
and while there are often complaints about quality of care in the system, the
biggest problem seems to stem from the fact that the system is completely
government run, and is therefore subject to the whims and fancies of those
running the show. Therein lies the
"cautionary tale."
The system suffered greatly under the
"conservative" governments, to the point that is almost collapsed
under its own weight back in the 1970s and 1980s, as these
"conservatives" withheld funding, and ordered unrealistic changes in
the system under the guise of "efficiency." During the Thatcher
years, only about 6% of GDP was expended on health care, and resulted in an
extremely high level of dissatisfaction with the system. Since then, subsequent
governments have increased funding greatly, bringing spending levels up to 8.4% of GDP, which is just slightly below the
8.9% average of OECDs, and about 1% below the
EU average, and you'd be hard pressed to find a poll in which the
British express overwhelming dissatisfaction with NHS.
