International Health System Design

Each nation has a uniquely tailored health care system. The Commonwealth Fund’s annual health policy survey provides insights about how the United States compares to the rest of the world’s industrialized democracies.

This 2010 Commonwealth Fund health policy survey was designed to observe the insurance-related experiences of adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United States, and the United Kingdom.  Each of these countries has implemented unique systems of coverage from public to hybrid public/private insurance with varying levels of basic coverage and cost sharing.  The majority of systems do not require patients to pay deductibles with the exception of the Netherlands, Switzerland, and the United States.

All health systems contain some sort of pharmaceutical core benefit with the exception of Canada.  Cost sharing for primary care visits is common across all systems with the exception of Canada, the Netherlands, and the United Kingdom.  The role of private insurance varies widely across systems, ranging from fewer than 5 percent who purchase private coverage in Norway and Sweden to ninety percent of the population in France. Most countries, with the exception of Norway and Sweden, offer some provision for lower income patients.

US respondents reported the lowest confidence in their ability of afford care. US citizens were significantly more likely to have gone without care because of cost, to have paid more than $1,000 out of pocket on medical care, and to have had serious problems paying medical bills in the previous year.  In fact, adults who had been insured the entire previous year were about as likely to pay $1,000 or more out of pocket as those who were uninsured in the US.   While cost proved to be a concern, a lower proportion of US adults reported confidence that they would receive the most effective treatment when needed.  Only Sweden and Norway reported lower confidence in treatment.  Nations that reported some of the highest confidence were the UK, Swiss, and Dutch.

Countries varied in their ability to provide 24-7 care.  Ninety-three percent of Swiss adults reported receiving same- or next-day appointments the last time they were sick.  Roughly two thirds of adults in Canada, France, Sweden, and the US reported difficulty in getting after hours care without going to the emergency department.  More than one-third of adults in Australian, Canada, Sweden, and the US said they had gone to the emergency department in the last two years.

Swiss adults, along with German and US adults were more likely to report quick access to specialists.  Adults in Canada, Sweden, and Norway were most likely to report having to wait two months or more for specialty care, and along with UK adults, to wait up to four months for elective surgery.

Responses varied widely with respect to time spent on insurance paperwork and disputes about what insurance would cover.  US respondents were most likely to report spending a lot of time on paperwork or disputes (17 percent) with a close second being Germany (16 percent).  US adults were more likely to report being denied insurance reimbursement or being reimbursed less than expected (25 percent) followed by adults in France (18 percent).  Thirty-one percent of US adults reported encountering some type of insurance concern in the last year, the highest rate among nations in the survey.  Reports of excessive paperwork or disputes about insurance were rare in New Zealand, Norway, Sweden, and the United Kingdom (less than 10 percent).

In all countries, adults with below-average incomes were more likely to need health care, and less likely to have the means to afford it.  Cost related access barriers were significant with all systems except the United Kingdom.  Rapid access to care when sick varied the most widely by income in Canada, the Netherlands, and the United States.  After hours ED use was higher among below average income individuals in Canada and  the United States.  Overall the study reports that the United Kingdom had the fewest significant differences in access and affordability by income; the United States had the most.

Commentary

This study provides an interesting cross country comparison of insurance experiences in these 11 countries and highlights the strengths and limitations of each country including the United States.  What has to be taken into consideration in such a piece, is that these insurance systems do not operate in a bubble, uninfluenced by outside factors which are unique to each nation’s healthcare environment.  While the study makes adjustments for health status, age, and in the United States insurance status, there is more to the story.  Many factors may have influenced the results of this article: the actual amount consumers spend per capita on healthcare both out of pocket and through tax-based revenues or employer contributions; geographic location (i.e rural versus urban); and actual cost of health care in each country.

It is important to remember that health insurance is only one piece to a very complex puzzle, and without comprehensive system reform involving pharmaceutical companies, medical device companies, hospitals, and providers, quality health coverage both public and private will continue to decline.

Schoen C, et al. “How health insurance design affects access to care and costs, by income, in eleven countries.” Health Aff (Millwood). 2010 Dec; 29(12):2323-34.