Health Care Elsewhere

“Well Julie, the move into an apartment from the house that was our home for 40 years has been accomplished.  It required a lot of physical labor and, as you mighty expect, was accompanied by a bit of emotional trauma.  It’s almost refreshing to return to thinking about health care.”      

“I welcome your weary mind and fatigued body back to the blog, Curmudge.  You know, I seem to recall that as you got older you became less adventuresome in selecting foreign countries to visit.  Was that because of concerns about their health care?”

“Sanitation, Julie, as well as health care.  Even in countries where the water was good, Mrs. Curmudgeon drank bottled water and I drank beer.”

“At the end of our last discussion you promised to tell me about health care in other countries.  From these countries’ experience, we will attempt to learn how a complex system like health care can be centrally managed.  Although one can’t go into much detail in a blog, perhaps you can mention some of their key features.  More complete data are available on the Web.”

“Let’s start with Switzerland, where the health care delivery system seems to work well.  In Switzerland 99% of the citizens are covered by nonprofit compulsory universal health insurance called LAMal.  LAMal is a multi-payer, private, nonprofit insurance system with over 70 different plans, and it is financed by premiums and by government subsidies paid for low-income individuals.  Overall, the Swiss system might be considered a public-private combination.  Coverage cannot be denied on the basis of poor health.  In 2007, government health expenditures were 19.8% of total government expenditures.”

“With 26 cantons (states) and four official languages (the fourth is Romansh), one would think that Switzerland would be considered a complex system, as we discussed last time.”

“Perhaps, Julie, but with only 7.6 million people and a propensity for doing things right, I would think otherwise.  Their most obvious unifying characteristic is their ability to efficiently extract money from tourists.  I know; I’ve been there.”

“I believe, Curmudge, that the United Kingdom is next on your list.  Their publicly-funded single health care system, the National Health Service (NHS), provides care free at the point of service to all legal residents of the UK.  Physicians are technically self-employed and provide services under contract with the NHS.  Many ‘moonlight’ and see patients outside the system.  The general practitioners serve as gatekeepers for access to specialists.”

“Traditional problems with the NHS have been access and waiting times for specialty care.  One feature most familiar to Americans is their National Institute for Clinical Effectiveness (NICE) for assessing the evidence for the clinical and cost-effectiveness of drugs and medical procedures.  Recently the government has increased taxes and health care spending to cover the cost of the aging population.”

“I’ll summarize the UK, Curmudge.  Their system appears to work fairly well, especially if one is not very sick.  Americans would dislike long waiting times and would have reservations about the NICE committee.”

“Let’s take the Chunnel to France, Julie.  Get ready for better food, a different language, and a different health care system.  There almost everyone is covered by public universal insurance (Securité Sociale) paid for by the government.  Ninety-two percent of the people purchase additional private insurance to pay co-pays.  The government pays for the supplemental insurance of low-income people, and the supply of hospitals and clinicians has helped France avoid the problem of long waiting times.”

“Apparently, the lack of gatekeeper protocols has driven the system into economic deficit.  So what is the value of a good system that is not sustainable?”

“One intriguing feature of the French Securité Sociale card is that it contains microchips storing a person’s medical record.  It also provides for immediate reimbursement of a patient’s out-of-pocket co-pay.”      

“For our final health care thumbnail, let’s go to the other side of the world to Singapore. Wow, Curmudge!  That was sure a long plane flight.”

“The health care system in Singapore is based on compulsory medical savings accounts (Medisave) and voluntary catastrophic insurance (Medishield).  Payment for this insurance comes from an individual’s Central Provident Fund (CPF) that is funded by 40% (half from employee and half from employer) of his wages.  There is also a government-sponsored safety net program (Medifund) for those with insufficient resources in their Medisave account.  But despite the apparent success of its National Health Plan, Singapore will be facing rising costs due to growth and the aging of its currently young population.”

“Okay, Curmudge, it’s crunch time.  We know that health care delivery is inherently complex, and we have just learned how several countries—large and small and more or less complex—are dealing with it.  We also know that expenditures for health care are getting out of hand most everywhere.  If you have a solution, tell us about it.  Jump on your horse and spread the alarm; ride through every village and farm.”

“Actually, Julie, I believe it’s nap time.  We’ll talk more about this in our next conversation.  Don’t go away.”

Kaizen Curmudgeon