International Health Care Systems Kao-Ping Chua Jack Rutledge Fellow, American Medical Student Association

Structure of systems InsuranceDeliveryExamples National health service Mostly public U.K. Entrepre- neurial Mostly private U.S. Mandated insurance Mostly public Public and private Germany

The influence of values on systems European social ethic: public good, social solidarity European social ethic: public good, social solidarity American individualistic ethic: individual good, social fragmentation American individualistic ethic: individual good, social fragmentation

Three categories of analysis Organization: insurance pools, public/private mix Organization: insurance pools, public/private mix Quality, choice, and access Quality, choice, and access Problems Problems

Outline I. U.S. II. Japan III. Germany IV. France V. U.K. VI. 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* *This refers to the non-elderly population

US: Quality, choice, access Quality: depends on plan – often gaps for prescription drugs, dental, vision Quality: depends on plan – often gaps for prescription drugs, dental, vision Choice: Restricted choice of providers Choice: Restricted choice of providers Access: Waiting lines relatively rare, huge amount of uninsurance Access: Waiting lines relatively rare, huge amount of uninsurance

US: Problems 45 million uninsured 45 million uninsured Skyrocketing health care costs Skyrocketing health care costs Significant health disparities by race and income 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 1800 Kenpo Associations (large companies) Seikan (small-mid companies) Kyosai (public employees and private-school teachers) Elderly (Roken) Self-employed, retired, others (Kokuho)

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 Quality: huge amount of technology, comprehensive benefits Choice: free choice of doctors and hospitals Choice: free choice of doctors and hospitals Access: few waiting lists except at the very best hospitals Access: few waiting lists except at the very best hospitals

Japan: problems/reforms Kenpo associations in debt (cross- subsidizations); rapidly aging population Kenpo associations in debt (cross- subsidizations); rapidly aging population Over-prescription of drugs Over-prescription of drugs High cost-sharing 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 Multi-payer system 3 main payers are the “Sickness Insurance Funds” (SIF’s) – cover most health care costs 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 Profession determines which SIF a citizen is automatically enrolled in

France: organization Most ambulatory care physicians are in private practice Most ambulatory care physicians are in private practice Sector I: charge at national fee schedule but get government benefits Sector I: charge at national fee schedule but get government benefits Sector II: charge above fee schedule but don’t get government benefits Sector II: charge above fee schedule but don’t get government benefits Hospitals both private and public Hospitals both private and public Complementary health insurance for cost- sharing (90% of the population) Complementary health insurance for cost- sharing (90% of the population)

France: quality, choice, access Quality: very comprehensive, good safety net for the poor Quality: very comprehensive, good safety net for the poor Choice: Free choice of doctors Choice: Free choice of doctors Access: Can usually see GP on same-day Access: Can usually see GP on same-day

France: problems Nursing and physician shortages Nursing and physician shortages Increasing health expenditures, mainly from drugs (19% of all expenditures) Increasing health expenditures, mainly from drugs (19% of all expenditures) 90% of physician visits end up with prescriptions! 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 Multi-payer system “Social Health Insurance” (SHI) network made up of 192 private, occupation- based "sickness funds” “Social Health Insurance” (SHI) network made up of 192 private, occupation- based "sickness funds” High-income may opt-out of SHI and purchase “voluntary health insurance” High-income may opt-out of SHI and purchase “voluntary health insurance” Free government care Free government care

Germany: organization Ambulatory physicians are mostly private Ambulatory physicians are mostly private Hospitals are both public and private Hospitals are both public and private

Germany: quality, choice, access Quality: Extremely comprehensive benefits Quality: Extremely comprehensive benefits Generous sick pay policies Generous sick pay policies Choice: Free choice of GP and specialists, must use closest hospital Choice: Free choice of GP and specialists, must use closest hospital Access: Waiting times not usually a problem Access: Waiting times not usually a problem

Germany: problems/reforms Expensive health care system Expensive health care system High cost-sharing High cost-sharing Excessive numbers of physicians (60% of areas are closed off to more doctors) 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 National health service (NHS): publicly financed and delivered Supplemental private insurance for dental and eye care Supplemental private insurance for dental and eye care Growing sector of substitutive private insurance Growing sector of substitutive private insurance

UK: Quality, choice, access Quality: Comprehensive except dental and eye Quality: Comprehensive except dental and eye Choice: Free choice of doctor Choice: Free choice of doctor Access: major problems with waiting lists Access: major problems with waiting lists Specialist (2.5 months) Specialist (2.5 months) Elective procedures (3 months) Elective procedures (3 months)

UK: problems Underfunding: Underfunding: Waiting lists Waiting lists Health care delivery capacity is insufficient for many services Health care delivery capacity is insufficient for many services Facilities need updating 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 Single-payer system 13 provincial/territorial governments administer health care plan (“Medicare”) 13 provincial/territorial governments administer health care plan (“Medicare”) Federal government regulates the provincial/territorial health care plans by offering “transfer payments” contingent upon pre- specified criteria Federal government regulates the provincial/territorial health care plans by offering “transfer payments” contingent upon pre- specified criteria Federal government 10 provinces Provincial health care plan 3 territories Territorial health Care plan

Canada Health Act of 1984 UniversalityAccessibility Public administration PortabilityComprehensive

Canada: organization Providers are mostly private; hospitals mostly public Providers are mostly private; hospitals mostly public Most Canadians have complementary private health insurance for non-covered services Most Canadians have complementary private health insurance for non-covered services

Canada: Quality, choice, access Quality: Coverage for “medically necessary” services Quality: Coverage for “medically necessary” services Gaps for dental care, long-term care, outpatient drugs  complementary private insurance Gaps for dental care, long-term care, outpatient drugs  complementary private insurance Choice: Free to choose GP and hospital Choice: Free to choose GP and hospital Access: Access: No waiting lists for GP visits or emergencies No waiting lists for GP visits or emergencies Waiting times can be problematic for certain ELECTIVE procedures Waiting times can be problematic for certain ELECTIVE procedures

Canada: Problems/reforms Underfunding Underfunding Gaps in coverage Gaps in coverage Tension between provincial and central governments Tension between provincial and central governments

Points to remember, part 1 Every country is dealing with increasing health care costs 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 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 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: UHC can be achieved while maintaining: Comprehensive benefits for everyone (every country but U.S.) Comprehensive benefits for everyone (every country but U.S.) Free choice of providers (every country but U.S.) Free choice of providers (every country but U.S.) High levels of technology (Japan, Germany) High levels of technology (Japan, Germany) Few waiting lists (France, Germany, Japan) 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