Discussions with the US about the American health care system often counterpose the well-known issues of the US health care system (high costs, lack of health insurance, unequal access to care, lower health outcomes than many other high-income countries) with a nebulous alternative often called “national health insurance, like all the other countries in the world” or sometimes “Medicare for all.” I refer to the alternatives as “nebulous” because the suggestion seems to be that these alternative plans offer all the health care demanded, with all or the vast majority of costs covered by someone else.
But more than half the recipients of Medicare, for example, now have their benefits managed by a “Medicare Advantage” or Part C plan, in which the government makes a risk-adjusted payment to a private health insurance company to provide care. The traditional Medicare plan, in which the federal government makes direct payments to providers, also includes insurance premiums, co-pays and deductibles, to the extent that many users of traditional Medicare also purchase a “Medigap” health insurance plan to cover the risk of high out-of-pocket payments and uncovered services. Most of those who name-check “Medicare for all” do not seem to be envisioning health insurance partially paid for by the government, together with out-of-pocket payments, and a continued central role for private health insurance companies. Moreover, the long-term projections under existing law for future Medicare payments over the next 75 years are a cool $60 trillion or so bigger than the long-term projections for Medicare revenues. It might be prudent to address the long-term solvency of Medicare as it current exists before touting it as a solution.
When it comes to broad statements about national health insurance, it’s also important to specify what national models you have in mind–because national health insurance systems vary substantially across high=income countries. The Commonwealth Fund has recently published a webpage offering “International Health Care System Profiles” for 31 countries. Many of the countries are high-income: the US, Canada, ten countries in Europe, Japan, Australia, Taiwan, Israel. But there also a selection of other large economies around the world: China, India, Brazil, Nigeria, Ethiopia, Indonesia, Phillippines, and others. Each country health care profile runs about 20 pages: that, is the Commonwealth Fund is trying to ride the thin line between a reasonably in-depth overview and information overload.
When comparing the health care systems of other countries to the US health care system, the most common comparisons I hear are other English-speaking countries, and in particular Canada and England. Both countries have 100% population coverage for national health insurance, and both spend about 11% of GDP on health care, as opposed to 18% of GDP going to health care spending in the US. On one hand, the lower health care spending in those countries seems attractive, allowing for additional consumption of other goods and services; on the other hand, I suspect that concrete and specific American proposal to cut total health care spending by one-third–to the UK and Canada level–would go down in flaming defeat.
Moreover, the Canadian and English systems are quite different from one another. In Canada, 69% of people have private health insurance to complement the public program; in the UK, only about 12% have private health insurance. In Canada, the national health care system is organized on the provincial level–rather like giving all 50 US states the lead authority for organizing health insurance–while the British system is nationally organized. As a result, determination of wages for health care providers looks different: most British physicians are on salary, with most specialists paid directly by the National Health Service, while a number of Canadian physicians still work on a fee-for-service basis.
In short, it’s not enough just to bewail the US health care and health insurance system. Other national models differ substantially among themselves. Indeed, Germany, Netherlands, and Switzerland have organized their national health insurance systems around individual-level health insurance, combined with regulated competition among insurers. A serious discuss of US health care reform has a number of lessons to learn from other countries, but the healtgh care systems of other countries differ substantially, and a serious discussion needs to dig into the details. The national-level profiles from the Commonwealth Fund are a useful starting point on the journey to literacy in the choices of health care policy.
