Discussions with the US about the American health care system are often against the well-known problems of the US health care system (high costs, lack of health insurance, unequal access to care, lower health outcomes than other high-income countries) with a vague alternative often called “national health insurance, like all other countries in the world” or sometimes “Medicare for all.” I call the alternative as “nebulous” because the suggestion seems that these alternative plans offer all the health care demanded, with all or most of the costs covered by others.
But more than half of Medicare recipients, for example, now get benefits managed by “Medicare Advantage” or Part C plans, in which the government makes risk-adjusted payments to private health insurance companies to provide care. Traditional Medicare plans, in which the federal government makes direct payments to providers, also include insurance premiums, co-pays and deductibles, so many traditional Medicare users also purchase “Medigap” health insurance plans to cover the risk of high out-of-pocket payments and missed services. Most people who examine “Medicare for all” don’t seem to envision health insurance partially paid for by the government, along with out-of-pocket payments, and a major role for private health insurance companies. Additionally, long-term projections under existing law for future Medicare payments over the next 75 years are $60 trillion or greater than long-term projections for Medicare revenues. It may be wise to deal with Medicare’s long-term solvency as it exists before it is called a solution.
When explaining the statement about national health insurance, it is also important to specify what national model you have in mind—because national health insurance systems differ among high-income countries. The Commonwealth Fund recently published a web page offering “Profiles of International Health Care Systems” for 31 countries. Many high-income countries: USA, Canada, ten countries in Europe, Japan, Australia, Taiwan, Israel. But there is also a selection of other large economies around the world: China, India, Brazil, Nigeria, Ethiopia, Indonesia, the Philippines, and others. Each country’s health profile runs about 20 pages: that is, the Commonwealth Fund tries to ride the thin line between a sufficiently in-depth summary and too much information.
When comparing health care systems in other countries to the US health care system, the most common comparisons I hear are other English-speaking countries, and especially Canada and the United Kingdom. Both countries have 100% population coverage for national health insurance, and both spend about 11% of GDP on health care, compared to 18% of GDP on health spending in the US. On the one hand, the country’s lower health care costs seem good, allowing for additional consumption of other goods and services; on the other hand, I suspect that the concrete and specific American proposal to cut total health spending by one-third-to the level of the UK and Canada-will go down in flaming low.
In addition, the Canadian and British systems differ from each other. In Canada, 69% of people have private health insurance to complement public programs; in the UK, only about 12% have private health insurance. In Canada, the national health care system is organized at the provincial level – giving all 50 US states the ultimate authority to regulate health insurance – while the UK system is organized nationally. As a result, wage determination for health care providers appears to be different: most British doctors are salaried, most specialists are paid directly by the National Health Service, while some Canadian doctors still work on a fee-for-service basis.
In short, it is not enough to worry about the US health care and health insurance system. Other national models differ among themselves. Indeed, Germany, the Netherlands, and Switzerland have organized their national health insurance systems in terms of individual-level health insurance, combined with organized competition between insurance companies. A serious discussion of US health care reform has many lessons to learn from other countries, but other countries’ health care systems are different, and a serious discussion should be explored in detail. The Commonwealth Fund’s national-level profile is a useful starting point for the journey towards literacy in health care policy choices.