Transcript International Health Care Systems

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
Mostly
private
Mandated
insurance
Mostly public Public and
private
Mostly
private
U.S.
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%
Employersponsored
Uninsured
15%
18%
62%
Medicaid/other
public
Private nongroup
*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
1800 Kenpo
Associations
(large
companies)
Seikan
(small-mid
companies)
Elderly (Roken)
Self-employed,
retired, others
(Kokuho)
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
Industrial,
commerical,
government
6%
9%
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”
High-income may opt-out
of SHI and purchase
“voluntary health
insurance”
Free government care
9% 2%
SHI
Substitutive
VHI
89%
Free
government
care
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
Portability
Canada
Health
Act
of 1984
Accessibility
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