HGov Research: Sick Around the World


Sick Around the World 1
Washington Post foreign correspondent T.R. Reid finds out how five capitalist democracies — the United Kingdom, Japan, Germany, Taiwan and Switzerland — deliver health care, and what the United States might learn from their successes and their failures.

The British system is socialized medicine because the government both provides and pays for health care. The British pay taxes for health care, and the government run National Health Service or NHS distributes those funds to health care providers. Hospital doctors are paid salaries while General Practitioners are paid based on the number of patients they see. A small number of specialists work outside the NHS and see private pay patients. Because the system is funded through taxes, administrative costs are low. There are no bills to collect or claims to review. Patients have a medical home with their General Practitioners, who also serves as a gatekeeper to the rest of the system. Patients must see their General Practitioners before going to a specialist. General Practitioners are paid a bonus for keeping their patients healthy and are instrumental in preventive care. Preventive care is an area in which Britain is a world leader.

The Japanese go to the doctor three times as often as Americans, have more than twice as many MRI scans, use more drugs, and spend more days in the hospital. Japan spends about half as much on health care per capita as the United States. Japan uses a social insurance system in which all citizens are required to have health insurance. The Japanese receive insurance either through their work or purchased from a community based plan. Those individuals who cannot afford the premiums receive public assistance. Most health insurance is private and cannot turn down a patient for a pre-existing illness, nor are they allowed to make a profit. Doctors and almost all hospitals are in the private sector. In Japan there are no gatekeepers. Having no gatekeepers means there’s no check on how often the Japanese use health care. The Japanese can go to any specialist when and as often as they like. Every two years the Ministry of Health negotiates with physicians to set the price for every procedure. This helps keeps costs down.  Japan has been so successful at keeping costs down that Japan now spends too little on health care. The result is half of the hospitals in Japan are operating in the red.

Germany, like Japan, uses a social insurance model. But unlike the Japanese, who get insurance from work or are assigned to a community fund, Germans are free to buy their insurance from one of more than 240 private, nonprofit sickness funds. For its 80 million people, Germany offers universal health care, including medical, dental, mental health, homeopathy and spa treatment. As in Japan, the poor receive public assistance to pay their premiums. Sickness funds are nonprofit and cannot deny coverage based on preexisting conditions; they compete with each other for members, and fund managers are paid based on the size of their enrollments. Germans can go straight to a specialist without first seeing a gatekeeper doctor, but they pay higher co-pay if they do. Like Japan, Germany is a single-payment system and medical providers must charge standard prices, but instead of the government negotiating the prices, the sickness funds bargain with doctors as a group. This keeps costs down, but it also means physicians in Germany earn between half and two-thirds as much as their U.S. counterparts. This system leaves some German doctors feeling underpaid. A family doctor in Germany makes about two-thirds as much as he or she would in America. However, German doctors pay much less for malpractice insurance, and many attend medical school for free. Germany also lets the richest 10 percent opt out of the sickness funds in favor of U.S.-style for-profit insurance. These patients are generally seen more quickly by doctors, because the for-profit insurers pay doctors more than the sickness funds.

In the 1990s, Taiwan researched many health care systems before settling on one where the government collects the money and pays providers. But the delivery of health care is left to the market. Taiwan adopted a National Health Insurance model in 1995 after studying other countries’ systems. Like Japan and Germany, all citizens must have insurance, but there is only one government-run insurer. Working people pay premiums split with their employers; others pay flat rates with government help; and some groups, like the poor and veterans, are fully subsidized. The resulting system is similar to Canada’s and the U.S. Medicare program. Taiwan’s new health system extended insurance to the 40 percent of the population that lacked it while actually decreasing the growth of health care spending. The Taiwanese can see any doctor without a referral. Every citizen in Taiwan has a smart card, which is used to store his or her relevant health information, medical history and bills the national insurer automatically. The system also helps public health officials monitor standards and effect policy changes nationwide. Thanks to this use of technology and the country’s single insurer, Taiwan’s health care system has the lowest administrative costs in the world. But the Taiwanese are spending too little to sustain their health care system and the government is borrowing from banks to pay what there isn’t enough to pay the providers. The problem is compounded by politics, because it is up to Taiwan’s parliament to approve an increase in insurance premiums, which it has only done once since the program was enacted.

Misc-05-june

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