Healthcare in the united states and around the world

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In the lecture this week on health care in the US, hopefully you gained a general overview into how our system works and the way we pay for it.  What is your opinion on our current system? Is it working well for Americans or do you see any areas that are in need of improvement?  If so what are they specifically and how can we solve those issues?  Be sure to address any potential issues with your “solution” since we know nothing this complicated is solved easily! If you think it’s working well, please point out specifically why you think so.

Discussion Rubric

Discussion Rubric

Criteria

Ratings

Pts

Timely post of original introduction

1.5 pts

On time

0.0 pts

Late or not present

1.5 pts

Timely post of peer reply view longer description

1.5 pts

On time

0.0 pts

Late or not present

1.5 pts

Proper attention to spelling, sentence structure, grammar, and punctuation

1.5 pts

Error free or 4 or fewer minor errors

0.0 pts

5 or more minor errors OR major mistakes

1.5 pts

Content of original post meets requirements

4.0 pts

Addresses all requested aspects

2.0 pts

Partially addresses all elements required

0.0 pts

No original post OR does not address required elements

4.0 pts

Reply to peer meets spirit of substance requirements


1.5 pts

Post to peer references peer’s post or engages in a meaningful way

0.0 pts

No peer reply OR reply to peer only is not very meaningful (e.g., no reference to peer’s post or posing of a question)

1.5 pts

Total Points: 10.0

The Best Healthcare System in the World which
would you Pick?

By AARON E. CARROLL and AUSTIN FRAKT SEPT. 18, 2017

Published in the New York Times

To better understand one of the most heated U.S. policy debates, we created a
tournament to judge which of these nations has the best health system: Canada, Britain,

Singapore, Germany, Switzerland, France, Australia and the U.S.

“Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats.

This is often accompanied by calls to match the health care coverage of “the rest of the
world.” But this overlooks a crucial fact: The “rest of the world” is not all alike.

The commonality is universal coverage, but wealthy nations have taken varying
approaches to it, some relying heavily on the government (as with single-payer); some
relying more on private insurers; others in between.

Experts don’t agree on which is best; a lot depends on perspective. But we thought it
would be fun to stage a small tournament.

We selected eight countries, representing a range of health care systems, and
established a bracket by randomly assigning seeds.

So that you can play along at home and make your own picks, we’ll describe each
system along with our choices (the experts’ selections will decide who advances). When
we cite hard data, they come from the Commonwealth Fund’s International Country
Comparison in 2017.

But enough talk. Let’s play.

To select the winner of each matchup, we gathered a small judging panel, which includes us:

Aaron Carroll, a health services researcher and professor of pediatrics at Indiana University
School of Medicine

Austin Frakt, director of the Partnered Evidence-Based Policy Resource Center at the V.A.
Boston Healthcare System; associate professor with Boston University’s School of Public Health;
and adjunct associate professor with the Harvard T.H. Chan School of Public Health

and three economists and physician experts in health care systems:

Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of
Management

Uwe Reinhardt, a health economist with Princeton University’s Woodrow Wilson School of
Public and International Affairs

Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of
the Harvard Global Health Institute

FIRST ROUND
Canada vs. Britain: Single-Payer Showdown

Both have single-payer systems, but vary in the government’s role and in what is
covered.

In Canada, the government finances health insurance, and the private sector delivers a
lot of the care. Insurance is run at the province level. Many Canadians have
supplemental private insurance through their jobs to help pay for prescription drugs,
dentists and optometry. The government ends up paying for about 70 percent of health
care spending in all.

Britain has truly socialized medicine: The government not only finances care, but also
provides it through the National Health Service. Coverage is broad, and most services
are free to citizens, with the system financed by taxes, though there is a private system
that runs alongside the public one. About 10 percent buy private insurance.
Government spending accounts for more than 80 percent of all health care spending.

U.S. analogues are Medicare (more like Canada) and the Veterans Health
Administration (more like Britain).

Canada and Britain are pretty similar in terms of spending — both spend just over 10
percent of G.D.P. on health care. They also have reasonably similar results on quality,
although neither ranks near the top in the usual international comparisons. In terms of
access, though, Britain excels, with shorter wait times and fewer access barriers due to
cost.

Our pick: Britain, 4-1

AARON: Britain. It’s efficient. Given the rather low spending, it provides great access
with acceptable outcomes.

CRAIG: Britain. Patients in Britain have a greater ability to shop across providers (using
additional private insurance). This, combined with reforms within the N.H.S., helped
increase competition and quality.

AUSTIN: Britain. While the countries are close in spending and quality, Britain has
much lower cost-based barriers to access.

ASHISH: Britain. Access problems can be profound in Canada — nearly one in five
Canadians report waiting four months or more for elective surgery, which can be more
than just an inconvenience.

UWE: Canada. The Canadian system is simpler for citizens to understand and highly
equitable.

U.S. vs. Singapore: A Mix of Ideas

The United States has a mix of clashing ideas: private insurance through employment;
single-payer Medicare mainly for those 65 and older; state-managed Medicaid for many
low-income people; private insurance through exchanges set up by the Affordable Care
Act; as well as about 28 million people without any insurance at all. Hospitals are
private, except for those run by the Veterans Health Administration.

Singapore has a unique approach. Basic care in government-run hospital wards is
cheap, sometimes free, with more deluxe care in private rooms available for those
paying extra. Singapore’s workers contribute around 37 percent of their wages
to mandated savings accounts that may be spent on health care, housing, insurance,
investment or education, with part of that being an employer contribution. The
government, which helps control costs, is involved in decisions about investing in new
technology. It also uses bulk purchasing power to spend less on drugs, controls the
number of medical students and physicians in the country, and helps decide how much
they can earn.

Singapore’s system costs far less than America’s (4.9 percent of G.D.P. versus 17.2
percent). Singapore doesn’t release the same data as most other advanced nations,
although it’s widely thought that it provides pretty good care for a small amount of
spending. Others counter that access and quality vary, with wide disparities between
those at the top and bottom of the socioeconomic ladder.

Our pick: United States, 4-1

AARON: United States. Singapore is intriguing, because it’s so different from other
systems. But its huge mandatory savings requirement would be a nonstarter for many
in the United States.

CRAIG: United States. Singapore, a scrappy underdog, has become a fan favorite of
conservatives. But its reliance on health savings accounts is problematic: When people
are spending more of their own money on health care, they tend to forgo both effective
and ineffective care in equal measure.

AUSTIN: United States. It’s hard for me to overlook Singapore’s lack of openness with
data.

ASHISH: United States. The lack of data in Singapore is a problem, and it had higher
rates of unnecessary hospitalizations and far higher heart attack and stroke mortality
rates than the United States. Plus, the U.S. has a highly dynamic and innovative health
care system. It is the engine for new diagnostics and treatments from which Singapore
and other nations benefit.

UWE: Singapore. It’s hard to defend the messy American health system, with its
mixture of unbridled compassion and unbridled cruelty.

France vs. Australia: Everyone Covered

The list of services covered in France is more extensive than in Australia — perhaps
more than in any other health care system. Australia has the advantage in expense.

Australia provides free inpatient care in public hospitals, access to most medical
services and prescription drugs. There is also voluntary private health insurance, giving
access to private hospitals and to some services the public system does not cover.

The government pays for at least 85 percent of outpatient services, and for 75 percent of
the medical fee schedule for private patients who use public hospitals. Patients must
pay out of pocket for whatever isn’t covered. Most doctors are self-employed, work in
groups and are paid fee-for-service. More than half of hospitals are public.

Everyone in France must buy health insurance, sold by a small number of nonprofit
funds, which are largely financed through taxes. Public insurance covers between 70
percent and 80 percent of costs. Voluntary health insurance can cover the rest, leaving
out-of-pocket payments relatively low. About 95 percent of the population has
voluntary coverage, through jobs or with the help of means-tested vouchers. The
Ministry of Health sets funds and budgets; it also regulates the number of hospital beds,
what equipment is purchased and how many medical students are trained. The
ministry sets prices for procedures and drugs.

The French health system is relatively expensive at 11.8 percent of G.D.P., while
Australia’s is at 9 percent. Access and quality are excellent in both systems.

Our pick: France, 4-1

AARON: France. It provides almost everything you’d want, and it’s expensive only
compared with countries other than the United States. (Compared with the U.S., it’s a
bargain.)

CRAIG: France. It has seemingly done a better job of using markets to create
competition across public and private hospitals — which provides incentives for quality
provision and innovation.

AUSTIN: Australia. It was a close call. Australia achieves good outcomes (by some but
not all measures better than France) with a lot less spending, making it a better value.

ASHISH: France. Both countries cover everyone, but people in France report somewhat
fewer problems getting access to care, as well as shorter waiting times.

UWE: France. The Australian system is basically two-tiered: a public insurance-and-
delivery system, and another based on private health insurance, each of which cover
roughly half the population. This seems to work well in Australia, but in the U.S. the
public system most likely would be badly underfunded. Therefore, France would be
superior.

Switzerland vs. Germany: Neighborly Rivalry

Germany’s system and Switzerland’s have a lot in common. Germany has slightly
better access, especially with respect to costs. Switzerland has higher levels of cost-
sharing, but its outcomes are hard to beat — arguably the best in the world.

Like every country here except the U.S., Switzerland has a universal health care system,
requiring all to buy insurance. The plans resemble those in the United States under the
Affordable Care Act: offered by private insurance companies, community
rated and guaranteed-issue, with prices varying by things like breadth of network, size
of deductible and ease of seeing a specialist. Almost 30 percent of people get subsidies
offsetting the cost of premiums, on a sliding scale pegged to income. Although these
plans are offered on a nonprofit basis, insurers can also offer coverage on a for-profit
basis, providing additional services and more choice in hospitals. For these voluntary
plans, insurance companies may vary benefits and premiums; they also can deny
coverage to people with chronic conditions. Most doctors work on a national fee-for-
service scale, and patients have considerable choice of doctors, unless they’ve selected a
managed-care plan.

A majority of Germans (86 percent) get their coverage primarily though the national
public system, with others choosing voluntary private health insurance. Most
premiums for the public system are based on income and paid for by employers and
employees, with subsidies available but capped at earnings of about $65,000. Patients
have a lot of choice among doctors and hospitals, and cost sharing is quite low. It’s
capped for low-income people, reduced for care of those with chronic illnesses, and
nonexistent for services to children. There are no subsidies for private health insurance,

but the government regulates premiums, which can be higher for people with pre-
existing conditions. Private insurers charge premiums on an actuarial basiswhen they
first enroll a customer, and subsequently raise premiums only as a function of age —
not health status. Most physicians work in a fee-for-service setting based on negotiated
rates, and there are limits on what they can be paid annually.

Both systems cost their countries about 11 percent of G.D.P.

Our pick: Switzerland, 3-2

AARON: Switzerland. It has superior outcomes. It’s worth noting that its system is
very similar to the Obamacare exchanges.

CRAIG: Switzerland. The Swiss system looks a lot like a better-functioning version of
the Affordable Care Act. There’s heavy, but quite regulated, competition among
insurers and an individual mandate.

AUSTIN: Germany. Germany has a low level of cost-based access barriers — tied with
Britain for the lowest among our competitors.

ASHISH: Switzerland. Switzerland outperformed Germany on a number of important
quality measures, including fewer unnecessary hospitalizations and lower heart attack
mortality rates.

UWE: Germany. The Swiss social insurance system — a late comer, enacted only in the
1990s, and financed by per-capita premiums — is less equitable than many other
European systems, including Germany’s.

SEMIFINALS
Switzerland vs. Britain: Meaning of a Market

How does the cost-effectiveness of Britain’s “socialized medicine” stack up against the
competitive but heavily regulated private system of Switzerland?

Our pick: Switzerland, 3-2

AARON: Switzerland. It has better quality, and perhaps access, but those come at a
higher cost. I’m willing to make that trade-off.

CRAIG: Britain. Switzerland’s system — privately funded with private insurers — is
often held up as a bastion of competition. But it is not necessarily more of a market than

Britain; it just hides the heavy hand of government a bit more. In reality, the insurance
and provider market is heavily regulated.

The U.K. system is almost entirely publicly funded, but it has done a lot to try to
increase the competition between facilities, which has increased the quality of service.

AUSTIN: Britain. It systematically incorporates cost effectiveness into coverage
decisions.

ASHISH: Switzerland. These are two countries with high-performing health systems,
but Switzerland has better access and quality, albeit at somewhat higher costs.

UWE: Switzerland. Switzerland has better facilities and speed of access to care.

SEMIFINALS
France vs. U.S.: Access vs. Innovation

France has extensive coverage, with costs that are high relative to many other nations.
The U.S. system, praised as dynamic and innovative, is even more expensive, falls short
of universal coverage and can be bewilderingly complex. Which do our experts prefer?

Our pick: France, 3-2

AARON: France. France provides an amazing level of access and quality for the cost.
The U.S. is considered the driver of health care innovation, which comes at a high price.
But there are other ways to incentivize innovation in the private sector besides how we
pay for and deliver care.

CRAIG: United States. The U.S. system is a bit of a mess in that it is quite expensive and
doesn’t offer complete coverage to its populace. But the system really does have the
strongest incentives for innovation on medical technology — which provides an
amazing amount of welfare for citizens around the globe.

AUSTIN: France. It’s hard to justify the very high level of U.S. spending based on
innovation alone, particularly without mechanisms to steer innovation toward
technologies that are cost-effective.

ASHISH: United States. France has a far more equitable system, with few delays and
reasonably good outcomes. However, the U.S. delivers a superior quality of care on the
measures that matter most to patients, and the system is far more dynamic and
innovative. It was close, but I picked the United States.

UWE: France. The U.S. is just too expensive for what it delivers, and includes too much
financial insecurity to boot. At international health care conferences, arguing that a

certain proposed policy would drive some country’s system closer to the U.S. model
usually is the kiss of death.

France vs. Switzerland: Top of the Mountain (Alps Edition)

France’s system is impressively comprehensive and in some respects simpler.
Switzerland relies on a competitive yet much-regulated system of private insurers.
Which has the edge and why?

Our pick: Switzerland, 3-2

AARON: Switzerland. This is a tough call. Switzerland does a good job of combining
conservative and progressive beliefs about health care systems into a workable model
providing top-notch access and quality at a reasonable cost. It doesn’t hurt that it does
so through private (although heavily regulated) insurance.

CRAIG: France. Its system has more competition among providers than Switzerland’s
does.

AUSTIN: Switzerland. The Swiss system is so close to the A.C.A.’s structure (which, to
date, has survived all manner of political attacks) that something like it could work in
the U.S.

ASHISH: Switzerland Both of these countries spend a lot on health care, outpacing the
average among high-income countries, and both perform comparably on measures of
access to care. However, in general, the Swiss health care system delivers a higher
quality of care across a range of measures and invests more in innovation that fuels new
knowledge and, ultimately, better treatments that we all benefit from.

UWE: France. It is cheaper, its financing is more equitable, and its system is simpler.

Conclusion

Germany would have tied Switzerland had we averaged our rankings of the nations
instead of using head-to-head matchups in a bracket system (Switzerland eliminated
Germany in the first round). It’s an example of how close the voting was. Not one vote
was unanimous among the judges, and all the semifinal and final votes were 3-2.
Clearly, there is room for disagreement about the relative merits of health systems, and
different experts would surely reach different conclusions.

Some judges took a global view, giving the edge to countries, like the United States, that
promoted innovation that benefited the rest of the world. In other cases, how health
systems treated the poorest of society was paramount.

To nobody’s surprise, the United States could do better at balancing health care costs
with access, quality and outcomes. But there are many ways to reach that goal, and
there will always be trade-offs. Learning about them from other systems and debating
them honestly would probably do us a lot of good.

We hope that readers will consider this to be merely the beginning of a discussion, not
the end. We welcome your questions or comments. In fact, we look forward to writing
articles in which we answer those questions and ask other experts with different views
to weigh in.

Have you experienced a health system outside the United States? Tell us its best or
worst feature. And what advice would you give Americans?

A Little Bit of History

As we begin our discussion about healthcare in the United States, let’s recall the early health history of our country and take a look at how far we’ve come. In the mid-1800’s/ early1900’s we had a lot of very contagious diseases and infections that we didn’t know how to control or treat. So, they would get out of control and reach epidemic proportions, and that’s what we were concerned with treating. We were basically just taking care of those who were ill.

As we learned more about the science behind the cause of these illnesses, we were able to find ways to control them. As we progressed through the 1900’s there were many developments that helped improve healthcare and decrease the high death rate due to epidemics and outbreaks. One of the areas that you might be interested in going into and that has really made a difference in controlling the spread of diseases is epidemiology. Epidemiology is the study of tracking and studying how a disease is being spread, where it’s being spread, and where it originated. With that kind of data, we can try to figure out how to limit the impact and spread of the disease. We saw this in action with the Ebola outbreak. There were teams of epidemiologists tracking the victims, the carriers, trying to identify sources and contain the exposure. They worked alongside other healthcare providers to contain the outbreak. There were teams of epidemiologists tracking the victims, the carriers, trying to identify sources and contain the exposure. They worked alongside other healthcare providers to contain the outbreak and were able to prevent a more widespread epidemic.

Progress in Healthcare

When we look at science and technological improvements over the last century, there’s so much we know and can do now that we didn’t know and couldn’t do before. For example, it wasn’t until the 1990’s that ultrasounds started to become common for pregnant women to check on the health of a fetus. This is a 4-D ultrasound of a baby about thirty weeks in utero. Technology now allows us to take an in-depth look at the heart structure, the formation of the brain, and spinal cord. We have genetic tests we can do on babies ten weeks after conception to look for specific chromosomal abnormalities. This concept is amazing and the ability to have that kind of information has improved the way we can deliver healthcare and practice medicine. We’ve also had the establishment of health departments whose services promote the health of the public, and many public health initiatives whose aim is disease prevention. There are a lot of jobs in this area (I’ll give you a hint as to why, it has a lot to do with the current healthcare reform act). The Hill-Burton act, in the 1960s, led to the establishment of regulated hospital systems across the country, which are now flushed with technology and specialized staff that are able to provide much higher levels of care for individuals, with better outcomes compared to a century ago. We now know the importance of hygiene. It’s taught on many levels from school to the home. This advancement has led to improvements of the public’s health and healthcare. In addition, there’s been a lot of public education surrounding nutrition. So, now we know what to do to keep ourselves healthy and there is a lot of disease prevention associated with nutrition. We have gone from using basic apprenticeships to train doctors to establishing medical schools that have advanced training for physicians. This knowledge base that physicians have today compared to what they had even twenty-five years ago is huge in comparison and we have ways to deliver that care and knowledge to individuals. All of these improvements that we’ve talked about have really changed the focus of the way we provide healthcare.

Chronic Diseases

Chronic diseases are diseases that occur over a long period of time. Heart disease, for example, can be due to a genetic issue or a defect, but in many cases, it has to do with diet. High cholesterol can lead to the establishment of plaques within your arteries that make it difficult for you to efficiently transport blood and oxygen throughout the body. Someone with heart disease ends up having problems with different tissues in addition to the heart or circulatory issue. This is not like an infectious disease that’s relatively brief because people get it, get really sick and die because we don’t have a cure. Chronic diseases, like heart disease, build up over time. The individual will have side effects, and treat those effects for years and years in some cases and then ultimately may end up with surgery, transplants or potentially a debilitating effect like a stroke or heart attack. These may cause further tissue damage and leads to additional care needs. Other chronic (and unfortunately these days common) illnesses that you will recognize include diabetes, cancer, hypertension and dementia. It’s important to recognize that these are much more expensive, lengthy treatments and will have a different focus when we talk about insurance, healthcare and factors influencing healthcare reform.

Emerging Diseases

We also see more emerging diseases. By emerging diseases, we mean those new illnesses that pop up, for example the Zika virus that’s being spread by mosquitoes. It’s too early to tell with today’s technology if we may be able to control it and eradicate it, although it could turn into something more (it certainly would have 100 years ago!). Another example is MRSA (Methicillin-Resistant Staphylococcus Aureus), which is a bacterium that we used to be able to treat, but it has evolved to become resistant to previous drugs. It’s an emerging disease because we have a novel mechanism that it’s using to escape the drugs that we have. There are a few other drugs that were backups to methicillin that aren’t working either on some strains of staph aureus. HIV had been a focus for quite a while. Due to science and research, there are lot of improvement in the care and longevity of HIV patients. SARS, H1N1, and the Ebola virus have arisen in your lifetime, and in the past ten years have become diseases that needed research and resources put towards them.

Acute Diseases

Historically, the emphasis by insurance companies in the US has been on the short-term treatments. In other words, taking care of individuals who get very sick, acutely sick. This has been one of the problems in the US healthcare system. There are socio-economic disparities in terms of who’s getting the treatment that they need, who’s getting preventative treatment and who’s ending up sicker because they didn’t have access to preventative treatment. You might imagine if you were wealthy then you might go to the doctor if you had a cough or felt a little funny. If you didn’t have the money to go the doctor and your insurance wasn’t going to help you much, then you just wouldn’t go. An untreated cough and cold could progress into a more severe illness and eventually may end up as bronchitis or worse, pneumonia where the person ends up in the hospital. Whereas, if the person had had early preventative care maybe there would have been earlier treatment for that minor cough or cold and it would not have gotten worse. With regard to insurance and coverage it has been recognized that if we focus on prevention and care of chronic illnesses over a longer period of time where you’re maintaining that patient’s health then its more efficient in the long run. It’s much cheaper to provide for someone in smaller amounts over a period of time versus ending up in the hospital with huge medical bills and much worse prognoses in some cases. This is a big change in focus for insurance companies and as we will discuss a big difference between the US and other countries in terms of care.

Technology

The technology that we’ve talked about – the MRIs, Cat Scans, screenings, ultrasounds – is all expensive. It’s expensive to develop, it’s expensive to upkeep, it’s expensive to stay on top of the technology and make sure that you have the latest and greatest. The US is a world leader in this area.

Baby Boomers

Then there is the baby boomer population that is aging into the system, remember them? They have specific foci on their health, specifically those that go along with getting older. Disorders like Alzheimer’s, orthopedic issues, if there’s a weight issue, there may be diabetes or heart disease. Also, generally as you get older you tend to get sicker, that goes for pretty much everybody, therefore, we are starting to see a much larger group of people in this country with greater healthcare needs. That baby boomer population is going to cost money.

Reimbursement

Another factor in the cost of healthcare is the method of reimbursement for providers. I have to say here that although healthcare providers are the easiest targets to blame for costs, they are not the largest factor! However, there are ways to minimize costs and maximize quality related to provider care. Let’s remember that historically when some providers were paid for services under some methods of reimbursement, they may have been paid per procedure. They wouldn’t be paid by whether or not those procedures are helping you to get better or maintaining your health. Hopefully you see that basing reimbursement on procedures ethically has issues and may drive costs in ways that may incentivize unnecessary testing. Stated simply, in this type of model the more tests a provider does, the more money they may make. We like to think our providers are ethical. I’m sure everyone listening who’s going into healthcare will be, however, it’s tempting. There are systems setup that play on that kind of reimbursement scenario. This system does not minimize healthcare related costs and is addressed by the latest healthcare reform bill.

Prescription Development

Prescription drug development and marketing is also expensive. One prescription drug cost million upon millions of dollars to research and develop and years of clinical trials to gain FDA approval. Sometimes at the end of all that they end up with a drug that doesn’t actually get approved or ends up in clinical trials that aren’t successful so it, which adds to the overall cost. While we know the drugs themselves are costly there is a lot that goes into that price.

Administration

As I mentioned, we see more chronic diseases now than ever before and more hospitalizations as a result. A large proportion of healthcare costs goes to administration. That’s another area that healthcare reform is really trying to focus on – decreasing administrative cost and putting more money into care versus inflationary administrative costs. Along those same lines historically we’ve had a system that wasn’t streamlined. For example, let’s say you went to your primary care provider; afterward you might also follow up with a specialist. Your primary care provider might not get all of your information to the specialist that they need to go forward with treatment, so tests can be rerun and services billed again. A lack of communication between different healthcare providers can increase costs due to duplication of services or miscommunication of information. The idea is that streamlining of technology and communication in healthcare will lead to less repetitive testing and visits to doctors or specialists, and a decrease in the number of procedures that individuals really don’t need.

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