The United States health system gets a lot of flak, right? Every year there are new suggestions, especially during election cycles, on how to improve it but is any other nation really doing any better? Personally, I've always head small antidotes about how there are certain issues we have in the U.S. that are not a problem elsewhere, but I honestly have never really did any research to make this determination for myself. For those who may be in a similar boat, Ezekiel Emanuel's book, "Which Country has the World's Best Health Care," has compiled the research and information you need to be able to really tell someone your thoughts next time you get asked, "Do you think the Canadian healthcare system would really be a bitter fit for the U.S.?"

A disclaimer for those who may be interested in reading the book - Emanual readily admits up front that the book's title and assumption that one nation may be given the gold medal for best healthcare system, is not going to happen. That being said, I found the book to be incredibly succinct way to learn about how differently things like coverage and healthcare financing work in other countries (a lot) and what struggles we face in the U.S. that all countries seem to be dealing with as well (more than you might think). While I encourage all to read the book, here is what stood out to me when comparing different countries: 

United States (U.S.)

The U.S. system admittedly does not look good on several criteria in comparison to other countries, but one area where we have made significant progress is in hospitalization rates and average length of stay. Since 1980, we have reduced our admissions per 1,000 population by 35% and the average length of stay per hospitalization has decreased by 29%


Canada's healthcare system is incredibly variable in its payment and delivery models by providence. Notably, within the Ontario province (the largest, by far), 30% of hospital payments are tied to quality metrics via their Quality Based Procedure Program.

United Kingdom (U.K.)

Healthcare in the U.K. is highly centralized through governmental coverage and delivery. What exactly does it cost a U.K. resident in taxes for this government service? Using their progressive income tax system, someone making $50,000/year would pay about $420/month while someone earning double that would pay about $625/month


France has a centralized public system that covers all individuals, but is fairly bare bones compared to other European nations, leaving a large financial responsibility for patients at the site of care (ex. 20% coinsurance on hospital bills, 40% on lab tests). Because of this, 95% of the population has additional supplemental voluntary health insurance which has an incredibly catchy abbreviation - VHI. 


Healthcare in Germany is very hospital driven when compared to other countries and thus has a 2.5x the number of beds per resident in the United States. The average length of stay is also significantly longer at 7.6 days, or roughly equivalent o the rate in the U.S. in 1980. 


The Netherlands' system does an incredible job managing pharmaceutical costs, accounting for just 7.6% of total healthcare spend compared to 17% of the United States. This is accomplished in large part by their national pharmaceutical maximum price setting system, which I noticed was actually a fairly common practice outside of the U.S. 


Switzerland mandates health insurance coverage for all of its residents, but it is entirely outsourced to about 90 private companies. Switzerland has achieved universal coverage through harsh "stick" incentives - the government retains the rights to withhold resident wages to pay their private insurance premium and will charge up to a 50% premium penalty for noncompliance. These premiums are not cheap either - the average premium for a family of four in is $1,840/month. 


Australia centralized public health insurance is very similar to French in that it heavily relies on private voluntary insurance to make patient copays and coinsurance more affordable. They also have an interesting way of promoting private insurance through the Lifetime Health Cover (LHC) program. Essentially, every year after turning age 30 that an Australian waits to buy private supplemental insurance results in a 10 year premium penalty which can be as high as 70%.


The Taiwanese government has implemented some fairly creative ways to keep their national healthcare costs down, none being more effective than global budgeting. Global budgeting is where the total expenditures for the entire country cannot exceed a present amount. How in the world do they control something as cost variable as healthcare? Once healthcare utilization volume exceed national projections, the rate paid per service decreases by an equivalent amount. So, if utilization comes in at 10% higher than expected, all providers get paid roughly 90% of the baseline unit price established at the onset of the projection. 


In China, public insurance works a lot differently than other countries. 70% of the funds that the government collects through taxes go into a traditional insurance product called a social pooling account (SPA). While the SPA pays a certain percentage of service costs after a deductible is met, all payments are capped at six time an employee's annual wage, after which the patient is responsible for any overages. 

Emanual's book does a great job giving the reader a better understanding on how people around the world receive and pay for care. I highly recommend this book to anyone curious on how other countries facilitate healthcare. 


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