Healthcare Around the World

From American Academy of Emergency Medicine
Michael Ybarra, MD

AAEM and the Resident & Student Association continue to be involved in advocating for physicians' practice rights, emergency medicine's place in the "house of medicine," and national tort and reimbursement issues, as well as broader health care reform. As the national debate on the future of health care smolders on, here is a glimpse of health care around the world.

England
In the wake of World War II, The United Kingdom faced the challenge of rebuilding their country. It was in this tumultuous decade that Winston Churchill, a conservative icon, spoke to the Royal College of Physicians and Surgeons, stating:

"The discoveries of healing science must be in the inheritance of all... Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available."[1]

The official bill authorizing the National Health Service (NHS) in England and Wales was signed in to law in 1946. It provides free point of care health services to all citizens of England and is paid for by tax dollars. The budget was roughly $200 billion in 2008-2009 and has seen an approximately 3% annual rise in costs since it's founding in the late 1940s.[2] For comparison, the 2007 budget of Medicare in the United States was over $400 billion and rises annually anywhere from 5-15%.[3] 60% of the NHS budget pays salaries for the staff, 20% for drugs and supplies and 20% for buildings and equipment.

The NHS is the world's largest provider of health care and is also the world's fourth largest employer. There is a small market for private health care, paid for out-of-pocket or by insurance policy. Life expectancy at birth in the United Kingdom is 79 years, higher than in the U.S. Though outcomes are generally exceptional, there is less access to some novel therapies, contributing to a lower survival rate for certain cancers.

China
China currently has a disorganized health system. In the late 1970s, the government privatized the health care system and took away a chunk of government subsidies. Now, the nearly 700 million rural Chinese citizens have little to no access to care, and most of the 1.3 billion citizens must pay for any care they receive almost entirely out of pocket. According to The Lancet, the average cost of hospitalization exceeds the average person's wage.[4] The Chinese have one of the world's highest personal savings rates, and many believe this is because individuals shoulder the majority of the cost of illness.[5]

The government has introduced a plan called Healthy China 2020, which ambitiously intends to create universal health care for 1.3 billion people over the next ten years. The plan provides some form of health insurance and drug coverage to all citizens. China has invested $120 billion on hospital infrastructure and set price controls on 300 of the most commonly used drugs.[6]

France
Health care in France, like in England, is provided to all citizens, financed through a national health insurance system, paid for by the government through tax revenue. France spends approximately 11% of their GDP on health care, which is the highest of any country in Europe but less than the 16% spent in the United States.[7]

Physicians are "self-employed" but receive reimbursement from a single-payer government insurance fund on a fee-for-service basis. The government sets the reimbursement schedule. Individuals have the option of purchasing private supplemental insurance. Many employers offer supplemental insurance as part of their benefits package. The government programs pay the vast majority of hospitals' (public institutions) and doctors' fees, and private insurance can be purchased to pay for drugs, prostheses, dental care and health care at private for-profit hospitals.

In general, taxes in France are higher than in the United States, but because of the complexity of both nations' tax codes, it is difficult to compare apples to apples. Individuals in France pay 5.25% of their income to the health care plan.[8] The government then plays a role in managing the health insurance funds themselves and negotiates drug costs and physicians' reimbursements.

Japan
The Japanese have one of the longest life expectancies in the world. They have a two-pronged approach to health insurance: employer-based health premiums and taxes. Profits at health insurance companies are banned. The program costs 8% of the GDP.[9]

The Japanese see their physician on average 14 times per year (four times more frequently than U.S. citizens). Patients have access to preventive services and low cost prescription drugs, all leading to a lower prevalence of chronic diseases than in the United States, contributing to their longer lifespan.

Despite the inexpensive, easy access system, the limitations on doctors' fees and a number of novel therapies may be unacceptable to many well-insured Americans. And, while the Japanese have a much lower incidence of heart disease, the chances of surviving a heart attack are about two times higher in the U.S.

There are as many approaches to providing and funding health care as there are countries and localities in the world. The challenges we face in the United States today are not as unique as we may think. No one country has the perfect system, but there is always something to be learned by looking at others' successes and shortcomings along with our own.

References