Health care systems in the Organization for Economic Cooperation and Development (OECD) countries primarily reflect three types of programs:
1. In a single-payer national health insurance system, as demonstrated by Canada, Denmark, Norway, Australia, Taiwan and Sweden (1), health insurance is publicly administered and most physicians are in private practice. U.S. Medicare would be a single payer insurance system if it applied to everyone in the U.S.
2. Great Britain and Spain are among the OECD countries with national health services, in which salaried physicians predominate and hospitals are publicly owned and operated. The Veteran’s Administration would be a U.S. single payer national health service system if it applied to everyone in the U.S.
3. Highly regulated, universal, multi-payer health insurance systems are illustrated by countries like Germany and France, which have universal health insurance via non-profit “sickness funds” or “social insurance funds”. They also have a market for supplementary private insurance, or “gap” coverage, but this accounts for less than 5 percent of health expenditures in most nations.
Sickness or social insurance funds do not operate like insurance companies in the U.S.; they don’t market, cherry pick, set premiums or rates paid to providers, determine benefits, earn profits or have investors, etc. In most countries, sickness funds pay physicians and hospitals uniform rates that are negotiated annually (also known as an “all-payer” system). Princeton economist Uwe Reinhardt calls Switzerland’s “sickness funds” quasi-governmental agencies(2). In France, the overwhelming majority of the population is in a single non-profit fund, so many observers consider the French system “single payer.”
There is no model similar to sickness funds operating in the U.S. (3), although they are often confused with the Federal Employee Health Benefit Program (FEHBP), which is simply a group of for-profit private insurance plans with varying benefits, rules, regulations, providers, etc. The 1993 Clinton health plan was an attempt to regulate private insurance companies in the U.S. to behave more like sickness funds, but the insurance industry defeated it.
Notes:
(1) The three basic models are general outlines, and there are many examples of “mixed models” (e.g. although Sweden has national health insurance, the hospitals are owned by county government, a feature more common to countries with a national health service).
(2) Many countries are tinkering with how sickness funds operate (e.g. Germany). The most extreme change is in the Netherlands, which since 2006 has allowed the non-profit regional sickness funds to become for-profit insurance companies, and new insurance companies to form, in the hope that “competition” would control costs. After just one year of experience, the country has experienced 1) a wave of anti-competitive mergers of the insurers 2) emergence of health plans that “cherry pick” the young and healthy and 3) loss of universal coverage and the emergence of 250,000 residents who are uninsured and 4) another 250,000 residents who are behind on their insurance payments. All of the positive data from the Netherlands (on costs, infant mortality, quality, etc) is based on the system pre-2006 (personal communication, Hans Maarse).
(3) In the film “Sick around the World” five nation’s health systems are shown. The U.K. is an example of a single payer national health service. Taiwan is an example of a single payer national health insurance. Germany, Japan, and Switzerland use multiple”sickness funds” that are non-profit and pay uniform rates to providers (“all-payer”)
The OECD regularly publishes a CD-ROM with 10+ years of comparative data for those interested in pursuing further research. It is available on the OECD website at www.oecd.org.
Comparative studies of several nations’ systems by Gerard Anderson at John Hopkins are on the Commonwealth www.commonwealthfund.org
by Ida Hellander, MD
Physicians for a National Health Program
QUENTIN YOUNG, MD, Chicago, Dr. Young is a practicing internist in Hyde Park. He chaired the Department of Internal Medicine at Cook County Hospital for a decade. He is the former President of the American Public Health Association. Contact: 312.782.6006
OLVEEN CARRASQUILLO, MD, MPH, New York City is Assistant Professor of Medicine and Public Health at Columbia University’s College of Physicians and Surgeons. Dr. Carrasquillo is a member of the Advisory Committee of the National Hispanic Medical Association, and is a practicing internist with patients in the predominantly Latino community of Washington Heights.
CLAUDIA FEGAN, MD, Chicago, Associate Chief Medical Officer of the Ambulatory and Community Health Network, of the Cook County Bureau of Health Services. She is a co-author of “Universal Healthcare: What the United States Can Learn from Canada” (The New Press, 1999)
OLIVER FEIN, MD, New York, is Professor of Clinical Medicine and Clinical Public Health at Weill Medical College of Cornell University. He was Robert Wood Johnson Health Policy Fellow during 1993-1994, when he worked as a legislative assistant for Senate Democratic Majority Leader, George Mitchell.
JERRY FRANKEL, MD, Dallas, is a urologist who is recently retired from private practice in McKinney, Texas. He is a leader in the development of less-invasive surgical techniques in his field. He ran for Congress in 1996 against House Republican Dick Armey. Dr. Frankel has published numerous articles and letters on single-payer national health care and appeared on the local affiliates of ABC, NBC, PBS, and NPR.
DAVID HIMMELSTEIN, MD, Boston, is an Associate Professor of Medicine at Harvard. He is a co-founder of PNHP and his research focuses on problems in access to care, administrative waste, and the advantages of a national health program.
DON McCANNE, MD, California, (Senior Health Policy Fellow) Dr. McCanne is a retired family physician in San Clemente, California. For three decades, Dr. McCanne has allotted one-half of his practice hours to indigent patients.
DEB RICHTER, MD, Vermont, practices family medicine in Montpelier, Vermont, and is a frequent spokesperson in the print, TV, and radio media.
GORDON SCHIFF, MD, Massachusetts, Dr. Schiff is an internist at the Brigham and Women’s Hospital in Boston. He is an expert in patient safety and Medical Informatics and teaches at the Harvard School of Public Health.
WALTER TSOU, MD, MPH, Philadelphia, Dr. Tsou is an internist and former Health Commissioner of Philadelphia. He currently serves on the Executive Board of the American Public Health Association.
STEFFIE WOOLHANDLER, MD, MPH, Boston, Dr. Steffie Woolhandler is an Associate Professor of Medicine at Harvard and co-director of the Harvard Medical School General Internal Medicine Fellowship program. She worked in 1990-91 as a Robert Wood Johnson Foundation health policy fellow at the Institute of Medicine and the U.S. Congress. Dr. Woolhandler is a frequent speaker and has written extensively on health policy.