It’s been said repeatedly that the healthcare systems used in other nations to provide universal healthcare to all citizens are “too foreign” to work in the United States. In other words: America is unique and, some would argue, superior–in a word, exceptional.
This is so, in the sense that every country is unique. And every country probably has some area in which it is (depending on your values) superior to other countries. Alas, in the area of taking care of our own, we are not doing all that well; which is why I believe we should take a serious and deep look at what other developed nations are doing for healthcare with the idea that we can do it just as well.
Let’s look at the four basic models of healthcare provision currently in use:
- The Bismarck Model, founded by Otto von Bismarck in Germany in the 19th century. This is a privatized but non-profit multiple-payer model. Sickness funds (think insurance companies) pay out, but the government negotiates prices. Providers are privately run.
- The Beveridge Model, invented by William Beveridge in Britain. This is a public service like the police and fire department, paid for by the government. Some hospitals and health groups are government run, but not necessarily all.
- The National Health Insurance Model, which has elements of both Bismarck and Beveridge systems. It has private providers, but government-run funds to pay out.
- The Out-of-Pocket Model, which is used in the developing world. Basically, the rich get medical care, the poor don’t. Pretty simple.
T.R. Reid, author of an in-depth exploration of global healthcare systems entitled The Healing of America, comments, “Of course the foreign models could work for Americans; they already do.” Each of these systems is in use in the US already and services some segment of our population. Even with the advent of the Affordable Care Act, we still have less a healthcare system as a patchwork quilt of different systems for different people.
For example, for people over 65, we’ve adapted the Canadian NHIS model and even used the same name the system’s inventor gave it: Medicare. For those of us who get care through an employer (I get mine through Jeff’s employer, Apple), we’re using the Bismarck system (Germany and Japan). For the rest of our population, we’re using the Purchase-Insurance-or-Pay-Out-of-Pocket-System (OOPS). Huh. Now there’s an appropriate acronym. “Oops, sorry. You fell through the cracks.”
Why doesn’t this work well? Because it’s chaotic and piecemeal. And because not every state got on board with it, the ACA is not implemented the same way in all parts of the country. Which is why some insurers pulled out of the market places (How’d you like to keep track of all the different levels of state participation?) and why healthcare continues to cost us more of our GDP than any other industrialized nation pays … and with worse outcomes.
Here’s the REALITY to go with the MYTH that “foreign” healthcare systems wouldn’t work for Americans: All healthcare systems are not the same.
There are a myriad variations on the basic theme. Some systems have co-pays, others don’t. Some have the bill footed by taxes, others have premiums. (Taiwan has both $13 co-pays and $150 per month premiums.) Most provide free care to pregnant women and newborns. Some offer yearly checkups, others take care of monitoring health levels at every visit. Some countries assign the healthcare premium as a percentage of income, others let the insurance plans set their own rates (with oversight, of course).
The overarching principle is: EVERYONE MUST BE CARED FOR. What varies from nation to nation is how financing and delivery is handled.
This is an essential point: What keeps our healthcare from being as good as we say we want it to be, is the delivery system. That’s what’s broken. Our medical care here is great. Our delivery system is broken. Think of a rail system. You can have the best, most beautiful train cars with state of the art everything, and grand, comfortable stations with all the amenities, but if the rails connecting those wonderful things to the people who need to use them are sub-par, none of that wonderfulness matters.
Reid suggests that by studying the above models and variations and exploring their strengths and weaknesses, we can learn how to create our own SYSTEM. A unified system of just about any kind will cost us—as a nation and as citizens—far less than what we’ve got now because of a set of central realities:
- A unified delivery system is far more efficient than a chaotic piecemeal one. This is true of any delivery system, not just healthcare. Look at industry: companies keep costs lower when they standardize. (This is also an argument for having a national system as opposed to a bunch of different state ones.)
- A unified system makes it much easier to use digital record-keeping. You’ve seen those commercials where the guy’s getting an exam in front of a whole hall full of docs whose experience with him is available on his current physician’s computer. They already have that in Japan, France, and Germany. I’ve experienced it twice here in California because of some ACA provisions our hospitals and medical groups adopted early on.
- A unified system eliminates the cost-shifting that a piecemeal system has. That is, if a hospital is underpaid by Medicare, it shifts the costs to other payers. With a unified system, there’s no need for this.
- A unified system creates incentives for preventive healthcare. If you’ve got to take everyone, you have a vested interest in keeping them healthy. You can’t just remove them from the rolls.
- A unified system is a powerful force for cost control. Reid notes that “Since the single healthcare system is the only buyer of medical services, it has enormous market clout.” (Evidence: An MRI costs $89 in Japan. It costs $1200 in the US or more.)
My personal take on this: I had brain surgery in 1992 which necessitated follow-up visits. My neurophysician had me getting MRIs at a facility attached to Davis University. When my employer switched insurance plans, they insisted I get my MRIs at a less expensive facility in our home town. Result? The inferior quality of the image from the portable MRI in Nevada City caused my doctor to have to schedule more MRIs and more frequent visits to get a baseline for comparison. So whatever money they saved with cheaper MRIs they spent in more frequent MRIs and visits to a high-end service provider. That’s the sort of inefficiency a piecemeal system can cause.
I’d like to close with this observation: The service is not the delivery system. Most countries rely on free-market service providers for healthcare, which the government pays for. The fundamental difference between our “system” and the ones used by other countries is that their health insurance plans exist only to pay people’s medical bills, NOT to make a profit or pay dividends to investors.
Food for thought: We have public policing, public fire departments, public schools. Why are we so averse to going public in one of the most crucial facets of our existence?