1. Health Care–Lessons from Abroad
Peter C. Damiano
Director, Public Policy Center
Professor, College of Dentistry
University of Iowa
Iowa City Foreign Relations Council
August 24, 2017

2. Today The US health care “system” International health system overview
England
Canada
Netherlands
Japan
Characteristics and Outcomes of international systems
Health vs health care
Discussion

3. Three issues driving policy
Cost
Quality/Outcomes
Access

4. Cost of care in the US

5. What do we spend on health care in US?
$500 Billion
$1 Trillion
$3 Trillion
$10 Trillion

6. Cost to health care purchasers
Employers
Especially large employers
Government
Consumers

7. Where do we spend our money
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.

8. Health Care Spending Population Expenditures 1% 27% 55% 5% 10% 69%
Berk and Monheit. The Concentration of Health Care Expenditures, Revisited. Health Affairs. 2001;20(2):9-18.

9. Access to Care

10. Access to care Set of dimensions describing the fit
between the patient and the health care system
Penchansky and Thomas, 1981

11. Access (insurance coverage)
28 million uninsured (10.4%)
Children 5.1%
Adults 12.4%
50 million uninsured pre ACA (16.3%)
Up 13 million in previous 10 years
25-34 y.o. twice as likely as y.o.
25 million underinsured
Source: CDC: National Health Interview Survey, released March 2017

12. Uninsured by income in US Pre-ACA
Uninsured > one year:
41% of lower income
4% of higher income

13. Insurance coverage in US over time: Filling the gaps
1941
•Adults, some dependents working for large employers
•Tax incentive added
Employer sponsored insurance (ESI)
1965
•Some parents
•Poor kids (0-133% FPL)
•Disabled
•Seniors
Medicare and Medicaid
1997
•Children of working poor ( % FPL)
Children’s Health Insurance Program
ACA •Poor single adults (0-133% FPL* (Medicaid-IHAWP) •Pre-exist conditions •Individual and small group insurance GC

14. Question
Does the United States have a health care “system”?

15. International health systems
Many variations
All have universal “access” (cost) except US
Canada, Holland and Japan
Private delivery system
Public insurance program
England
Public delivery and insurance programs

16. Canada Public health insurance program
Operated at provincial level under federal guidance
Guaranteed by the Canadian Health Act of 1984
“universal, accessible, comprehensive, portable and publicly administered health insurance system.”

17. Criteria of Canada Health Act
1. Public administration: non-profit basis by a public authority;
2. Comprehensiveness: all medically necessary services must be insured;
3. Universality: all entitled to public health insurance coverage on uniform terms and conditions;
4. Portability: coverage must be maintained when an insured person moves; and
Accessibility: reasonable access by insured persons to medically necessary hospital and physician services must be unimpeded by financial or other barriers.

18. Canadian health insurance
Covered persons :
"a person lawfully entitled to be or to remain in Canada who makes his home and is ordinarily present in the province, but does not include a tourist, a transient or a visitor to the province.”
Excluded persons include:
members of the Canadian Forces, RCMP,
persons serving a term of imprisonment within a federal penitentiary, and
persons who have not completed a minimum period of residence in a province or territory (a period that must not exceed three months)

19. Covered services: Canadian insurance
Insured health services
medically necessary hospital, physician and surgical-dental
Insured hospital services
medically necessary in- and out-patient services
accommodation and meals at standard or ward level
preferred accommodation if medically required;
nursing service;
laboratory, radiological and other diagnostic procedures,
drugs, biologicals and related preparations in hospital;
use of operating room, case room and anesthetic facilities
medical and surgical equipment and supplies;
use of radiotherapy and physiotherapy facilities;

20. Holland health insurance
Everyone receives a basic insurance package
Additional package can be purchased by either an employer or the individual from a set of options
Health care providers are primarily private employees operating in private facilities
Fees are set for all services and negotiated annually between providers and government

21. Levels of Health Insurance in Holland
Name
AWBZ
Basic Insurance
Supplementary insurance
Type
Public
Public or Private*
Private
Coverage
Catastrophic
Basic services
Supplementary services
Government influence
+ + + ++ +
Who?
Every Dutch citizen
Voluntary
*Depending on income

22. Health Insurance in Holland (continued..)
Name
AWBZ
Public
Private
Payer
Government
Government for the unemployed and elderly who were in public insurance before age 65
Employer and payroll tax for basic for employed population
Employee for supplemental
Individual
Who is covered
Every Dutch citizen
The majority of adults and children based on income (63% of population)
Higher income adults and children
Who provides policy
Private companies
Covered services
Established by gov’t
Basic established by government
Supplemental options established by company

23. England National Health Services (NHS)
Established in 1948 to provide free healthcare for all.
With about one million employees, the U.K.'s health service is said to be the world's biggest nonmilitary employer after the Indian railways.

24. England Organization Secretary of state for health
Department of Health Strategic health authorities
Primary and secondary health services trusts

25. England Secretary of state for health
This is the government minister responsible for the NHS in England and is answerable to Parliament
Department of Health
responsible for the overall planning, regulation and inspection of the health service. It develops policies and decides the general direction of healthcare.

26. England 28 Strategic health authorities Regionally established.
Oversee healthcare of their region.
Link between the Department of Health and the NHS.
Make sure that national health priorities (such as cancer programs) are integrated into local health plans.

27. Private health care in the UK
More employers are offering membership
Often used for:
Diagnostic tests
One-off specialist treatment, such as visiting a dermatologist
Specific operations in a private hospital
Non-essential treatment such as cosmetic surgery
Treatment for addiction or rehabilitation

28. Private health care in the UK
Private hospitals:
over 300 private hospitals in England
Private hospitals are provided by six organizations:
the NHS, which runs a number of private patient units within its hospitals
five private hospital groups:
BMI Healthcare,
BUPA,
Nuffield Hospitals,
Capio Healthcare UK and
HCA International.

29. Japan
Similar to Canada-public health insurance with mainly private providers.
Universal public health insurance with comprehensive coverage
Only modest cost sharing by patients
Mainly private providers paid mainly by fee-for-service.

30. Japan Might expect high healthcare costs
The share of population that is elderly is above average
Volume of health care is high
Physician visits
Pharmaceutical use
Hosp admissions low but length of stay high
Physician numbers are relatively low
Efficient doctors offering ambulatory care
Outcomes-quality vs quantity?

31. Cost comparisons

32. Health Care Spending per Capita, 2008 Adjusted for Differences in Cost of Living
Dollars
* 2007.
Source: OECD Health Data 2010 (Oct. 2010).

33. International Comparison of Spending on Health, 1980–2008
Average spending on health per capita ($US PPP)
Total expenditures on health as percent of GDP
Source: OECD Health Data 2010 (Oct. 2010).

34. Health Care Spending per Capita by Source of Funding, 2010 Adjusted for Differences in Cost of Living
Dollars ($US)
8,233
5,269
4,463
4,445
4,338
3,974
3,758
3,670
3,433
3,035
3,022
THE
COMMONWEALTH
FUND
* 2009.
Source: OECD Health Data 2012.

35. Mortality Amenable to Health Care
Deaths per 100,000 population*
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S.
THE
COMMONWEALTH
FUND
Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income Nations,” Health Policy, published online Sept. 12, 2011.

36. Why higher costs

37. Disease burden is higher in the U.S. than in comparable countries
Age standardized disability adjusted life year (DALY) rate per 100,000 population, 2010
Source: Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2010 (GBD 2010) Data Downloads, available here:

38. Though disease burden is decreasing in many countries, the gap has widened slightly
Age standardized disability adjusted life year (DALY) rate per 100,000 population,
Source: Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2010 (GBD 2010) Data Downloads, available here:

39. Cancer and circulatory diseases are the leading causes of death in the U.S.
Age standardized death rate per 100,000 population, both sexes, 2010
Source: Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2010 (GBD 2010) Data Downloads, available here:

40. Mental health and circulatory disorders are the leading causes of disease burden in the U.S.
Age standardized disability adjusted life years (DALYs) rate per 100,000 population, both sexes, 2010
Source: Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2010 (GBD 2010) Data Downloads, available here:

41. Other countries have seen improvement in similar areas as U. S
Other countries have seen improvement in similar areas as U.S., but some at faster rates
Percent change in age standardized disability adjusted life year (DALY) rate per 100,000 population,
Source: Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2010 (GBD 2010) Data Downloads, available here:

42. Hospital Discharges per 1,000 Population, 2010
THE
COMMONWEALTH
FUND
* 2009.
** 2008.
Source: OECD Health Data 2012.

43. Average Annual Number of Physician Visits per Capita, 2010
THE
COMMONWEALTH
FUND
* 2009.
** 2008.
Source: OECD Health Data 2012.

44. Number of Practicing Physicians per 1,000 Population, 2010
THE
COMMONWEALTH
FUND
* 2009.
Source: OECD Health Data 2012.

45. Cervical Cancer Screening Rates, 2010
Percent of women screened
THE
COMMONWEALTH
FUND
Note: Norway, UK, NZ, Denmark, and Australia based on program data; all other countries based on survey data.
* 2009.
** 2008.
Source: OECD Health Data 2012.

46. Diabetes Lower Extremity Amputation Rates per 100,000 Population, 2009
THE
COMMONWEALTH
FUND
* 2008.
** 2007.
Source: OECD Health Data 2011.

47. Hospital Spending per Discharge, 2010 Adjusted for Differences in Cost of Living
Dollars
THE
COMMONWEALTH
FUND
* 2009.
** 2008.
Source: OECD Health Data 2012.

48. Diagnostic Imaging Prices, 2011
MRI scanning and imaging fees
CT scanning and imaging fees (head)
We also may seem to pay more for diagnostic imaging than in other countries.
This data is from an annual analysis of health care prices put out by the International Federation of Health Plans.
It shows the average price for MRI and CT scans charged to U.S. commercial payers is higher than in Switzerland, Germany, and France.
THE
COMMONWEALTH
FUND
Note: MRI refers to magnetic resonance imaging; CT refers to computed tomography.
Source: International Federation of Health Plans, 2011 Comparative Price Report.

49. Physician Incomes, 2008 Adjusted for Differences in Cost of Living
Dollars
Orthopedic surgeons
Primary care doctors
THE
COMMONWEALTH
FUND
Source: M. J. Laugesen and S. A. Glied, “Higher Fees Paid to U.S. Physicians Drive Higher Spending for Physician Services Compared to Other Countries,” Health Affairs, Sept (9):1647–56.

50. Outcomes of care

51. Rank of health indicators for the G7
Country
Health spending
Female life expectancy
Male life expectancy
Infant mortality US 1 7
Germany 2 5 6 3
France
Canada 4 4=
Italy
Japan UK
Kingsfund.org.uk, 2001

52. Cost/outcomes of US system

53. Blendon et al. Health Affairs, 22(3) 2003

55. Determinants of Health

56. Health vs. health care
Many determinants of our health best addressed by those outside the direct delivery of health care services
Requires integration

57. Determinants of health
What affects our health
Lifestyle factors-51%
Environmental factors-19%
Human biology-20%
Health care delivery-10%
Where does US invest
Lifestyle factors-1.2%
Environmental factors-1.8%
Human biology-7%
Health care delivery-90%

58. Broad determinants of health
Early childhood development
Education
Employment and working conditions
Food security
Health services
Housing
Income and income distribution
Social exclusion
The social safety net
Unemployment and job insecurity
*Centre for Social Justice: Social Determinants of Health for a Life Span Conference, Nov. 2002

59. Ratio of Social to Health Spending
Source: Elizabeth Bradley-Plenary session, NASHP annual meeting, October 6, 2014

60. Social Service vs Health Care Spending
US:
For $1 spent on health care, $0.90 spent on social services
OECD:
For $1 spent on health care, $2 is spent on social services
Source: Elizabeth Bradley-Plenary session, NASHP annual meeting, October 6, 2014

61. Obesity (BMI>30) Prevalence Among Adult Population, 2010
Percent
Measured
Self-reported
Note: Body-mass index (BMI) estimates based on national health interview surveys (self-reported data) are usually significantly lower than estimates based on actual measurements.
THE
COMMONWEALTH
FUND
* 2009.
** 2008.
Source: OECD Health Data 2012.

62. Adults Who Report Being Daily Smokers, 2010
Percent
THE
COMMONWEALTH
FUND
* 2009.
Source: OECD Health Data 2012.

63. Interactive comparison tool
Commonwealth Fund:

64. Summary US spends much more than other countries per capita
Health benefits unclear
Beware of simple international comparisons Health care systems
Health insurance systems
Cultural issues
Important lesson from other countries much beyond how to provide insurance or deliver health care

65. Summary regarding ACA implications
What is important is HEALTH not health care
Impacted by public health and determinants of health
Issues beyond the health care delivery system
We fund these at a much lower level
Cultural aspects must be considered when thinking about whether options are transferable to the US

66. Questions
Vinny