No Politics Allowed: Health Care

Two things in life are inevitable—birth and death—and they both fall in the domain of the health care system. Although health care is one of the most basic services a government can provide, it's also one of the most ominous and convoluted. Every industrialized nation offers its citizens some form of free health care, but the balance between public and private funding differs from country to country and from administration to administration.Â

At one extreme is the United Kingdom, in which universal health care is funded directly from taxes and there are no insurance companies. At the other extreme is the United States, with its dazzling array of public and private services designed to both protect the poorest Americans and let the free market determine the best possible care. But at both ends—and everywhere in between—the systems are messy. To better understand our system and our options, we're fielding your questions about health care around the world.

Are there really no health insurance companies in the United Kingdom?

Pretty much. A few of the wealthiest citizens have private insurance for private hospitals, but for the most part, the Brits use the National Health Service (NHS)—the largest employer in Britain, with more than 1 million workers. The brainchild of the Labour government after World War II, the NHS was created to provide "cradle to grave" service for all members of the realm. Because it was funded entirely by taxes, there were no hospital fees, no hassles with insurance companies, minimal administrative costs, and little paperwork. Patients simply paid taxes, went to a doctor, and received free health care. Sounds simple, doesn't it?

Not entirely.

Soon after the establishment of the NHS, citizens began complaining that customer service was shoddy. The system required specialists to spend half their days working for the NHS, and the rest for private practice. But no matter how hard physicians worked for the government, their salaries stayed the same. Why would an orthopedic surgeon perform 20 hip replacements a week, when he could perform three for the same money? Specialists dragged their feet, which created long waiting lists for treatment. If a patient couldn't wait for a procedure from an NHS surgeon, he could go down the street to the same doctor's private practice and receive treatment right away—for a price. In that way, health care costs for some citizens actually increased.

Things began to change in 1990, when Margaret Thatcher's administration experimented with letting hospitals compete with one another for government funding. In theory, this should have cut costs and promoted self-regulation, but in practice, each hospital had a fairly strong monopoly in its local area. These days, the NHS relies on general practitioners to act as gatekeepers for the whole system. They're the first doctors patients see, and their services are free. They perform routine checkups and recommend specialists. If a patient needs to go to a hospital, the general practitioner helps decide whether it should be a free NHS hospital or a private one. Ultimately, general practitioners help control costs by guiding money towards NHS specialists, hospitals, diagnostic tests, and medications. However, long waits and poor care are still concerns. It's not a perfect system, but everyone gets to use it.

Is the United Kingdom the only nation with universal health care?

Not at all. Most industrialized nations, such as Japan, France, Sweden, and Australia, have universal health care. And in Canada, the government has been doling out free medical services to its citizens since 1962. Its system, called Medicare (not to be confused with America's Medicare, which is totally different), is based on the five principals of the Canada Health Act: It's universal, comprehensive, accessible to all citizens regardless of income, portable inside and outside of the country, and publicly administered. Also, to make the distribution of goods more efficient, the system is managed individually by province.

Unlike the United Kingdom's National Health Service, the Canada Health Act doesn't permit citizens to seek out private doctors to cover services provided by the government. If you want a hip replacement in Canada, there's no running down the street to a private surgeon—you've got to get in line. This prevents physicians from concentrating more on private practice than on public medicine, which has helped keep the system cost-effective and egalitarian.

Of course, this system has its problems, too. To fund Medicare solely with taxes, the federal government matches whatever each province spends on its own system. Unfortunately, that has resulted in wealthier provinces receiving more money from the federal government, because they spent more on health care. Despite efforts to even out funding, large disparities in the quality of services have emerged throughout the country. As a result, many poor, rural communities are still in bad shape.

It sounds like both the United Kingdom and Canada rely solely on taxes to fund health care. Are there other ways to finance the system?

Yes. Some countries, such as Germany and Japan, insist that all citizens own health insurance, the same way that most U.S. states require all drivers to purchase auto insurance.

Germany's health care system began in 1883, when Chancellor Otto von Bismarck set up insurance structures for workers called "sickness funds." Today, German law mandates that all citizens belong to them, unless their income is above a certain level. (Currently, that's about $5,500 US per month.) Sickness funds work like private insurance in the United States, with employers and employees splitting the cost of membership. Germans can choose from more than 1,000 different funds, which offer medical, dental, and drug coverage. Retirees pay with their pensions, while the government supports the poor and unemployed.

While 90 percent of Germans belong to sickness funds, the remaining 10 percent opt for private insurance, which tends to have higher fees. Although people with private insurance go to the same doctors and hospitals as people with sickness funds, private insurance usually means better care. To some, the German system has two tiers—one for the rich and one for the poor. The differences aren't huge, but people with private insurance have beds reserved for them in hospitals and don't have to wait as long to see a doctor. But unlike Canada and the United Kingdom, the waiting lists for treatment in Germany are short. On the downside, the quality of diagnostic testing and palliative care (treating the symptoms associated with serious illness) lag behind the rest of Europe, even though Germany spends more on health care than any other country on the continent. According to a 2000 study by the World Health Organization (WHO), in terms of distribution of goods and services across the population, Germany has one of the most fair and equitable systems of any industrialized nation.

How does the U.S. health care system hold up in comparison to other countries?

In terms of fair and equitable distribution of goods and services, the same 2000 WHO study ranked the United States close to the bottom of the list. But that's because America not only has some of the worst health care on the planet, but also some of the best. The problem is that we don't have a system of health care so much as a mix of independent, overlapping, bureaucratic monstrosities. The United States is the only industrialized nation, except for South Africa, that doesn't guarantee health care to all its citizens. Currently, about 47 million Americans (15 percent of the population) have no health insurance, and about 20 million Americans can't afford the health services they need, even with insurance.

Most people in the United States have private health insurance, which simply means they pay an insurance company a monthly premium in exchange for health services. However, U.S. insurance companies aren't obligated to cover everyone who's willing to pay. They can deny coverage if they feel the patient would be too costly. From the insurer's perspective, covering someone who costs $100,000 per year in medical expenses isn't worth the $10,000 premium. In other words, some of the country's sickest people are often also the ones getting pushed out of the system.

Most Americans can't afford private health insurance unless they go through their employers, who shop around for the best insurance deal they can find. The bigger the company and the more employees, the more clout they have when haggling with insurance companies. While employers pay most of the premiums and employees pay the rest, the major benefit of this arrangement is that the entire premium is tax-deductible. The major drawback is that small businesses and the self-employed don't have much pull with insurance companies, which can force them to forego health care altogether.

To rein in expenses, many businesses require their employees to join health maintenance organizations, or HMOs. Like traditional insurance companies, HMOs limit the patient's choice of doctors and hospitals to a restricted "network," but they also review doctors' decisions and can refuse payment for services they deem unnecessary. In addition, HMOs tend to insist that doctors prescribe generic medications instead of name-brand ones. These measures save money, but many doctors feel second-guessed by HMOs, believing they promote the cheapest medicine rather than the best.

Is there public insurance in the United States?

Yes. Federal and state governments fund health insurance for the elderly, the military, the poor, the disabled, veterans, and some children. Many different agencies play a role in this, but the two biggest are Medicare, which covers adults 65 and older, and Medicaid, which covers the 55 million poorest Americans. Unfortunately, the bulk of uninsured Americans are people who either aren't old enough for Medicare or aren't poor enough for Medicaid.

Medicaid is designed to help the poor, but it's run at the state level, so regulations and services change from state to state. And that's part of the problem; you may qualify for Medicaid in one state but not another. The rules keep changing. Most states have a difficult time balancing Medicaid into their budgets, so they tend to cut benefits or add copayments, depending on the fiscal year. This doesn't make life simpler for our nation's poorest Americans.

What are the plans being considered for cleaning up the health care system?

They basically come in three varieties: expanding existing programs to fill in the cracks, using competition to improve efficiency, or creating a new comprehensive plan. The beauty behind expanding the current program is that it won't scrap a system that works well for at least two-thirds of Americans. Most of us already have access to the best medicine in the world, so why not just try to reach out to the rest? Advocates propose raising the salary caps on Medicaid to cover the working poor and lowering the age requirement for Medicare to 55. This would plug up most of the holes, but unfortunately, it would do nothing to increase efficiency. Some studies estimate that 20 percent of our health care costs go to administrative fees.

To make the American health care system more efficient, some people have proposed ways to encourage competition. One alternative is to create tax-free savings accounts to be used specifically for health reasons, which will help lower- and middle-class Americans finance their medical needs. Once people have the means to make choices, health care providers will compete with each other for their business, which will lead to lower prices. Others advocate letting people buy prescription drugs from Europe and Canada. If American drug manufacturers have to compete with foreign companies, it might stop the escalating cost of prescription drugs. On the other hand, it might also lower the incentive for investing money into research for developing new, better drugs.

The biggest problem with trying to create a free market for health care is that it doesn't guarantee medical coverage for everyone, which some people view as a fundamental human

right, like freedom of speech. These people believe that we need a comprehensive new plan, akin to the health care system of Canada or Germany. In the long term, administrative costs would drop because our system would be simpler, and the government could allocate resources to the people who need them the most. It would be costly, but, then again, so is our current system. In the short term, however, overhauling the system and replacing it with a new one would be massively expensive. And, as we know from other countries, universal health care programs have problems of their own.

Editor's Note: This article came from the "No Politics Allowed" series that appears in mental_floss magazine, in which we attempt to answer your questions about some of the most complex issues facing Americans today. Learn more about the magazine here.