One of the most frustrating aspects of the health care
reform debate is how often everyone pretends that we have no good options. We let people tell us that really, our only
choice is what we have or “European-style socialism”. A free market capitalist system, or a
“government run system”. That’s just not
true.
You see, this argument assumes that every other system
around the world is the same. And so,
each time someone “discovers” another country’s system, as the New York
Times did last week with Switzerland, we all get to pretend to be shocked
that there might be another option. Or,
we are treated to Senator Conrad’s apparent recent discovery (and perhaps still
incomplete
understanding) of the French health care system from TR Reid’s The
Healing of America, as if the intricacies of that system were previously a
secret. Of course, these revelations always seem to come apparently far too
late to actually do anything about reform here in the United States.
Let me set the record straight for the rest of you. Contrary to what you’ve heard, Europe isn’t
one big country. It’s not one big health
care system either. It’s home to a
wealth of different insurance schemes and varying government involvement. They are all, however, cheaper than ours and
cover all their citizens. Many also have better outcomes.
At one extreme, you’ve got the United Kingdom. Its National Health
System is entirely government run, with the hospitals and the doctors
employed by the government. And, boy, is
it cheap. Their outcomes are pretty
good, they cover everyone, and still manage to spend over $4000 less per person than we do. It might surprise you to learn, however, that
private options also exists there and are growing every day.
France, on
the other hand, has a mostly private physician run system with comprehensive,
basic government-run health insurance for all their citizens. Private supplemental insurance also can be
bought, and most people get it from their employers. Their health system is often ranked best in
the world. And it’s way cheaper than
ours and everyone in France gets it.
Switzerland,
as you may have heard, has an entirely private-run insurance system. They require significant cost-sharing
designed to avoid shielding patients from the costs of health care. Although premiums on average are similar to what we pay here, their
out-of-pocket
costs are much higher. All insurance carriers must provide basic
insurance plans on a not-for-profit basis.
They can make a profit on more expensive plans. There is enormous government regulation to
limit the cost of drugs, devices, and lab tests, and insurers watch
physicians very closely to make sure they don’t spend too much. Their system is still better than ours, and
still cheaper overall.
The Dutch
(and why aren’t they talked about more often?) have a very regulated, entirely
private, often for-profit insurance system.
They also have private hospitals and private doctors. They have mandatory insurance that is the
same price regardless of your health and regardless of your age. The system is regulated
in such a way as to actually make it no more expensive to ensure high-risk
patients. They have good outcomes
(although they could be better), universal coverage, and pay less than we
do.
If you’re willing to break outside of Europe, Singapore might blow
your mind. They have a complex scheme of
mandatory medical savings accounts with compulsory savings based on
income. Sounds like a conservative’s
dream! They also have catastrophic
insurance, provided by the government on a single-payer basis, funded through
taxes. Their health care system cost
only 3.8% of GDP in 2005. That’s
insane. Back when the WHO compared health care systems,
Singapore ranked 6 out of 191 countries. The US was 37.
And, yes, there is the Canada. Single-payer health insurance without a parallel
private system. There is private
insurance to cover what the public system does not. Much cheaper than ours. Universal coverage. And outcomes so similar that we’re still
arguing about which of our two systems is better after decades of comparisons.
Know what all these systems have in common, though? Serious, huge government regulation. Know what else they all have in common? They are all cheaper than our system. They all have comparable or better outcomes
than our system. And they all manage to
achieve universal coverage. All of them.
Other than that, though, they are all over the map, both
literally and figuratively. Can we pull
our heads out of the sand long enough to admit that maybe – just maybe – we
might be able to learn something from one of them?
If I had my first choice, I favor a single payer
system. Not because of any governing
ideology, but because I believe it achieves universal coverage along with the
most efficient means of cost containment/quality enhancement through incentivizing
innovation and improvement at the provider and system level. I think it’s better done there than at the
consumer level, and I think that’s been shown empirically as well as
theoretically. But I’m not ideological purist. Singapore’s system is, frankly, unbelievable. It’s enough to make me believe that consumer
competition, done in a progressive way with a single-payer backup, may have
something to offer as well.
And, look, I would take almost any of these other systems over our own. I’d happily choose the highly regulated
non-profit system, the mandatory MSA/single-payer catastrophic system, a
government run single-payer system with optional private supplemental coverage,
or even the highly regulated profit-minimizing system. They are all better than what we’ve got.
But, no. We’ll continue to shout at each other that there’s
only the American system and “them”. That’s
true, of course, if you mean to say that there’s only the worst system and
“better ones”. Otherwise, you’re just
ignoring the facts.
Read more about health care policy and get your questions answered at Rational Arguments.