By Roosa Tikkanen and Robin Osborn
The Commonwealth Fund, July 11, 2019
As recent congressional hearings on Medicare for All proposals have illustrated, members of Congress and presidential candidates are looking outside the United States to find ways to achieve universal coverage. Some have suggested that other countries are able to provide universal coverage because they “ration” care — a term rife with negative connotations. This post examines the extent to which health care is rationed in Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom — as compared to the U.S.
Examples of health care rationing tend to focus on long wait times for procedures —such as hip replacements, or MRIs — or limited access to the newest drugs. This happens in some (but not all) countries and can be a challenge for policymakers. But there are other ways in which health systems engage in rationing, by restricting access to insurance, through insurance benefit design, or by imposing high patient cost-sharing. While other countries may ration because of national budget constraints and supply-side factors, the United States’ lack of access to comprehensive insurance and affordable care represent a de facto form of rationing that leads people to delay getting care or going without it entirely.
Getting in the Door
In the five European countries we examined, all residents are entitled to health care through the national system. These range from tax-funded systems in Sweden or the U.K. to private insurance-based systems in Germany, the Netherlands, and Switzerland. In the latter, governments regulate premiums to be affordable and provide income-related subsidies to low-income families, which include 27 percent of Swiss and 30 percent of Dutch residents. Governments also mandate generous benefit packages that typically guarantee a minimum set of services: primary, specialty, and hospital care; prescription drugs; mental health; maternity; and palliative care.
In comparison, there are 30.4 million uninsured people in the U.S. Not having affordable, comprehensive insurance coverage often means that sick Americans do not even get in the door to see a doctor. For those who do have coverage, new rules that allow states to circumvent the Affordable Care Act’s mandated essential health benefits may mean skimpy coverage for some.
Waiting to Be Seen
Patients in some countries face longer wait times for specialty care than in the U.S., where only 25 percent of Americans need to wait longer than one month for a specialist appointment. Patients in Germany and Switzerland get in just as fast (27% and 26%, respectively) as their U.S. counterparts, but those in Sweden and the U.K. do not (45% and 43%, respectively). Similarly, very few U.S., Dutch, and Swiss patients (4% to 7%) who need elective surgery face wait times longer than four months, while 12 percent of Swedish and British patients do. It should be noted that in Sweden and the U.K., where wait times for specialty care are longer, people can buy supplemental insurance to gain quicker access to private specialists.
While Americans overall enjoy shorter wait times for specialty care, wait times for same- or next-day appointments when sick are around average compared to other countries. U.S. adults are among the most frequent users of emergency departments. Nearly half who do report doing so because they couldn’t get an appointment with their regular doctor.
Weighing Health Against Your Wallet
In a recent Commonwealth Fund survey, fewer than one of 10 patients in the U.K., Germany, the Netherlands, or Sweden reported skipping needed care or treatments because of cost. This contrasts sharply with the U.S., where one of three Americans reported the same. This is partly because of the rise in high deductibles, unpredictable and opaque copayments, and higher health care prices in the U.S. than in other countries. An estimated 44 million Americans who have insurance are effectively underinsured because their out-of-pocket costs and deductibles are very high relative to their incomes.
Other countries are more protective. In the U.K., Germany, and the Netherlands, patients have no out-of-pocket costs when they visit a primary care doctor, and Brits never pay for hospital care. In Germany, out-of-pocket costs are capped at 2 percent of annual household income and 1 percent for chronically ill people. In Sweden, out-of-pocket costs for physician visits and drugs are capped at $370 annually. No one in these five countries declares bankruptcy because of medical debt.
Paying for Value
A commitment to providing universal coverage means that other countries have to make hard choices to ensure that each health care dollar is spent effectively.
Countries aim to give patients access to the most clinically meaningful and cost-effective drugs. In the U.K., only drugs that are deemed cost-effective are covered, while in Germany, manufacturers have to demonstrate that their new drug adds clinical benefit to negotiate a higher price than other existing drugs. This doesn’t mean that new technologies aren’t available; in fact, 79 percent of new cancer drugs are approved for routine use in the U.K.
These kind of controls, coupled with fixed copayments and annual caps on patient drug spending, translate into better access. While nearly one of five U.S. adults skip doses or do not fill a prescription because of costs, just 2 percent to 9 percent of patients do so in the other countries discussed here.
It would be a missed opportunity for America to ignore lessons about universal coverage from other countries out of a fear that they ration health care more than we do. In reality, more people in the U.S. forgo needed health care because access to care is rationed through lack of access to adequate insurance or unaffordable services and treatments.
By Don McCanne, M.D.
Opponents of single payer frequently claim that if we enact Medicare for All we will have rationing of health care like they have in Canada and the European nations. They then usually provide a selected statistic from a selected country (often Canada or the United Kingdom) that shows a delay (queue) for some service (such as cataract removal), or a product (often a drug) that may be in short supply. This Commonwealth Fund report provides a proper perspective by comparing the United States with five European nations – Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom.
Supply side controls sometime result in prolonged queues for services such as elective joint replacement. Some nations do better than others in providing stewardship of their system capacities and application of queue management. Excessive queues are not an inevitability though they can occur even in nations with very high spending, as we sometimes see in the United States. But the United States is unique in that millions of individuals are not allowed a place in the queue.
Drug prices? Most other nations use government oversight to demand that drugs be cost effective, but not the Unites States, not to mention that we allow exorbitant pharmaceutical firm profits plus middleman gouging such as through pharmacy benefit managers.
Access to acute and primary care services tends to be quite adequate in all nations, except the United States. So what is going on?
In this report, these authors state, “In reality, more people in the U.S. forgo needed health care because access to care is rationed through lack of access to adequate insurance or unaffordable services and treatments.” That is, as has been stated many times before, we ration based on the ability to pay. In spite of per capita spending at twice the average of other nations, this rationing based on our flawed health care financing system has resulted in relatively poor outcomes on average compared to other higher performance nations. Of course, those poor outcomes are much more prevalent amongst the uninsured and underinsured – health financing deficiencies that are almost nonexistent in other nations.
We are spending more than enough to eliminate rationing in the United States, except for legitimate scarcity such as organs for transplant. But to do that we need to change the way we collect and allocate our health care funds. That is precisely what the single payer model of Medicare for All is designed to do. Merely adding a Medicare public option will not fix our financing system.
So when are at a meeting and you hear that Medicare for All will bring rationing to the United States, use your bullhorn to let the speaker know that single payer will virtually eliminate our highly prevalent form of rationing – rationing by ability to pay. If they try to pull you out of the meeting, flip your bullhorn over to a colleague – and keep passing it to other colleagues until we are absolutely certain that they got the message.
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