International Health Care Systems

1. International Health Care Systems Kao-Ping Chua Jack Rutledge Fellow, 2005-2006 American Medical Student Association

2. Structure of systems

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

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

5. Outline • U.S. • Japan • Germany • France • U.K. • Canada THINK BIG PICTURE!!!

6. U.S. WHO Ranking for Health Attainment: 24 WHO Overall Ranking: 37 % GDP spent on health care: 15% (OECD median 8.6%)

7. US: Organization* *This refers to the non-elderly population

8. 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

9. US: Problems • 45 million uninsured • Skyrocketing health care costs • Significant health disparities by race and income

10. Japan WHO Ranking for Health Attainment: 1 WHO Overall Ranking: 10 % GDP spent on health care: 7.9% (OECD median 8.6%)

11. Japan: organization

12. Japan: organization • Most providers and hospitals are in the private sector • Hospitals are the center of care

13. 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

14. Japan: problems/reforms • Kenpo associations in debt (cross-subsidizations); rapidly aging population • Over-prescription of drugs • High cost-sharing

15. France WHO Ranking for Health Attainment: 3 WHO Overall Ranking: 1 % GDP spent on health care: 10.1% (OECD median 8.6%)

16. 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

17. 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 cost-sharing (90% of the population)

18. 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

19. France: problems • Nursing and physician shortages • Increasing health expenditures, mainly from drugs (19% of all expenditures) • 90% of physician visits end up with prescriptions!

20. Germany WHO Ranking for Health Attainment: 22 WHO Overall Ranking: 25 % GDP spent on health care: 11.1% (OECD median 8.6%)

21. Germany: organization • Multi-payer system • “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” • Free government care

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

23. 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

24. Germany: problems/reforms • Expensive health care system • High cost-sharing • Excessive numbers of physicians (60% of areas are closed off to more doctors)

25. The United Kingdom WHO Ranking for Health Attainment: 14 WHO Overall Ranking: 18 % GDP spent on health care: 7.7% (OECD median 8.6%)

26. UK: organization • National health service (NHS): publicly financed and delivered • Supplemental private insurance for dental and eye care • Growing sector of substitutive private insurance

27. 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)

28. UK: problems • Underfunding: • Waiting lists • Health care delivery capacity is insufficient for many services • Facilities need updating

29. Canada WHO Ranking for Health Attainment: 12 WHO Overall Ranking: 30 % GDP spent on health care: 9.9% (OECD median 8.6%)

30. 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 pre-specified criteria

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

33. 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

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

35. 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

36. 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)

37. 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