The misinformation about how health care systems work around the world has been so bad coming from both sides of the aisle, I decided it was time to clear up a few things. Most universal health care systems are not "socialist," as the right wing likes to characterize everything coming from Europe and Asia. But just as importantly, most are also not single-payer systems, contrary to what many on the far left would have you believe, and very few have a "public option" for anyone who isn't on public assistance.
The system created under Obamacare, the Affordable Care Act is under attack precisely because the right wing and left wing both seem to hate the bill. Because of this, polls keep showing that a plurality of Americans want the bill to go away, even though they overwhelmingly favor most of its provisions. Rachel Maddow showed this quite well on her program the other night. No on Obamacare, but yes on most of its provisions is an indication that the progressive message is being lost, again, because the loudest of us don't seem to understand that, when you yell "(insert anything here) sucks!" and then go into a nuanced explanation of why you think it sucks, the only message that actually gets out is the "sucks" part.
Right wingers hate Obamacare because they don't want insurance to be regulated, and they don't want President Obama to accomplish anything. But many on the far left, especially the professional left, also seem to hate the concept of the law, because of an irrational devotion to abstract concepts like "public options" and "single payer," rather than "universal health care." The problem is, all most voters hear is that "everyone agrees" that "Obamacare sucks."
As progressives, our goal should be universal health care. Single payer and a public option are methods for paying for universal health care; they are not equivalent to universal health care itself. The main purpose for a universal system of health insurance is to make sure everyone who needs it get health care, and that everyone participates in helping pay the bills. There are many ways to do this, as the list of countries below demonstrates. Few have single payer, and few have a public insurance component, except for the elderly and unemployed. The vast majority of these systems are relatively close to the model in the Affordable Care Act. And all provide what is most important; universal health care. They all see good basic health care as an investment in society; an investment that pays off in the long run, because a healthy, productive society needs healthy productive participants.
As you'll see, Obamacare draws from many of the best aspects of all universal health care systems, and not one of these systems is as "perfect" as many progressives seem to demand from Democrats here.
Set up in 1945 and constantly tweaked by the French govenment, according to many measures, the French health care system is recognized as being 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. The Social Security tax includes health insurance, retirement support, unemployment and welfare.
If that sounds like a lot, consider that workers in the United States pay 7.65% of our gross pay into the Medicare and Social Security trust funds, and when employer contributions for those programs are added, we're paying 15.3%. Add in the unemployment insurance and workers' compensation payroll taxes paid on our behalf, and we pay nearly as much as the French, and even more to cover welfare and Medicaid. And that's before we pay for health insurance.
French law mandates universal coverage, so every legal resident of France has access to a wide choice of general practitioners and healthcare specialists. The Social Security system pays about 75% of the cost of medical treatment, with the balance covered by private insurance or self-insurance. When you go to a doctor, either you or your private insurance company pay the bill at the time of the visit. You are then reimbursed for 75% of that bill within 10 days.
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 currently runs a deficit. But even with the obvious stresses on the French system, they only spend 10% of GDP on health care, compared to the 16% of a much larger GDP we spend on health care, even though we don't cover everyone. Also, their health care inflation rate has traditionally been less than 4%, whereas ours averaged more than three times that.
The German health insurance system, which has been around since Otto von Bismarck passed the Health Insurance Act of 1883, 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 insurance premium is 14.9% of gross salary, with the worker paying 51% of the premium and the 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. German children are officially considered "national treasures" and an investment in the country's future and as such receive coverage by the government out of general revenues.
The German system is not 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 health care financing system. The funds are then redistributed to 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 based on that person's actuarial risk. 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.
A certain minimum level of coverage must be provided by any insurance company. Coverage is constant, there are no "pre-existing conditions" and there are no exclusions. And while most insurance services are provided by private companies, there is no profit element in the system.
Australia's Medicare system, created in 1975, is a public system with 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 system is not all public. Private, non-profit insurance plays a significant role in the Australian system, because 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 accommodations, 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.
Canada's Medicare system is a universal single-payer system that covers about 70% of the country's health care expenses. 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.
Though the insurance system is mostly public, the Canadian health care system itself is not "socialized medicine." Most of the delivery system is private, not public. While the federal government provides provinces with money to finance health care, 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. 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.
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 of this, there is a shortage of physicians in the country, which causes some folks to have to drive a long way to see a doctor, and waiting times are a significant problem in some areas. That said, Canadians for the most part love their system. It 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, even that isl far less than the 16% of GDP the United States spends, and they cover everyone.
The United Kingdom is the exception when it comes to universal health care, in that it's the only system of truly "socialized" medicine in the bunch. 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 developing a completely socialized system, or even a single-payer 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. While private health care is available in England, only about 8% of the population uses it. 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 "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.