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In the UK we have the NHS, which is all most of us know, and free at point of use is pretty damn seductive.
At the opposite end of the scale of developed nations, we have the US system, which if you can afford it is superb, however if you cannot afford your are stuffed.
In May this year I experienced the Dutch healthcare system and I have to say I was impressed. But it was only a snapshot.
But it has got me wondering which of the developed countries does have the best system.
Judged by outcomes and equality of access to all citizens.
The Germans seem to know how to run a country and so do the Swiss, what about NZ or Australia.
Does anyone have personal experience of these systems? -
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This is well covered by the WHO and other organizations. Each research org will highlight a different 1st world country depending on their methodology. However, broadly the likes of France, Italy and Spain feature in the top five, the UK in the top 20 the US in the top 40. Most of these rankings look at the total spent on healthcare only, and the outcomes in terms of survival of certain illnesses, or lifespans. Some factor in equity and accessibility too. What most of these studies miss is what the supporting spend is like in services around healthcare, such as social services, mental health etc. I have no doubt the UK could do better, but it will cost more.
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The one you never have to use.
Which is why Cuba is a great place to be born for health, but not a good place to get sick.
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The European social insurance based systems (premium based on ability to pay) are generally pretty good, I’d be in favour of moving to that here.
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You mean like income tax?
Why do healthcare discussions always start with how a health care system is funded rather than how it is organised or by how much it is funded? After all if you wanted to improve the NHS the first thing you would look at is organisation, second funding level and third, method of funding.
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I guess many responses will be based on relatively fit young to middle aged adults and their experiences. I’d like to describe what I’ve seen happen with an elderly parent on a small fixed pension in an insurance based system (Germany).
1) Pre-existing conditions: insurance company had her over a barrel as it could raise prices indefinitely – she couldn’t move companies because pre-existing conditions either made it prohibitively expensive or wouldn’t be covered.
2) GP visits: she wouldn’t visit the GP as often as necessary because each aspect of health discussed incurred an additional charge.
3) Specialists: “freedom” to choose specialists resulted in complete bafflement. Which specialist, for a chronic cough: lungs, stomach (cough caused by reflux), throat? And once you’ve decided which type of specialist, then which specialist? Looking up lists of names with no knowledge of who might be actually good and who merely adequate. For mental health services, ringing round to see which specialists might even still be allowing people onto their waiting lists…
4) Billing: insurance has an excess, and some bills she had to pay, some she paid but could reclaim, some went directly to the insurance, some came to her and needed passing on to be paid. Which of these are which? Try sorting that out when you’ve just come out of hospital, still weak and confused i.e. just when you’re at your lowest ebb. We’re still trying to figure out what she should have claimed back. The paperwork fills a whole drawer of a filing cabinet. And on a small income even the excess charge made a worrying dent in her finances on top of the annual premiums.
5) Quality: just as any system made up of numbers of individuals, quality and competence vary. From the excellent to the abysmal, *just as in the NHS*. Insurance systems do not miraculously mean universally excellent treatment.
All of these things might seem trivial to someone relatively young, with limited requirements – a pregnancy or a traumatic injury, dental treatment, etc. But to the elderly chronically ill: maybe my mother was uniquely placed (I seriously doubt this) but the burden financially, administratively and logistically added significant misery to her last years.
If the UK ever switches to an insurance-based system, I suspect that when you’re elderly and chronically infirm you may finally realise what you’re missing.
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In Germany you can opt out of the public insurance system if above a certain income level, but it is deliberately made hard to rejoin the public insurance system later when your private premiums rise. E.g., I am voluntarily insured in the public system even though I earn above the threshold and would currently pay less in private insurance. Rates for the public insurance (delivered as standard packages by an entire zoo of public and private insurance companies, for some bizarre reason) are constant, and will not rise with age or conditions.
Your description indicates that the elderly person had private insurance despite a low income, which sounds odd.
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Hmm, well she must have been in some exceptional circumstances, if your earnings are less than €59,000 per year you will be in the state health insurance scheme anyway (AOK) which has nothing to do with “insurance companies” and if you are a pensioner you will be (must be) contributing to the KVdR anyway which is state organised (and subsidised).
So for normal working people, pensioners unemployed etc in Germany you will be contributing to a state health fund, for higher earners you move to a private insurer. About 90% of Germans are in the state system.
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She did have complicated circumstances – as a housewife (non-earning) having spent some time abroad she wasn’t allowed in the national system despite her limited income, and then as you say it’s difficult to get back in. I think she may have been allowed to transfer in her last years. If it weren’t an insurance-based system, would she have had to deal with such complicated rules as to how her healthcare would be handled?
Furthermore, the paperwork burden, plus the question of premiums, excesses and simply the difficulty of finding the required help (she wanted to switch GPS but had no idea how to find a new one) remain constant and as I said, added a lot of misery to her life especially when she began to lose her sharpness of mind and to be hospitalised more often.
I’ve actually given more personal detail than I wanted to – my main aim is to show that the experience we as relatively healthy young(er) people have can be completely different once we start to lose our health and mental acuity. The insurance system does at the very least add a layer of administration onto patients at a time when they might be in no shape to deal with it.
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Part of the problem we are facing with the NHS is governments have restructured a relatively efficient NHS in the name of improving it but it would appear to head it towards stealth privatisation.
Funding is key, I think removing it from general taxation is part of this.
An NHS tax of some sort, whatever we do I think we should steer clear of any pseudo market bullshit, successive governments have shown with rail, PfI, disability benefits, back to work training, universities etc that we just can’t play at market place government.
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@chris This is indeed the problem in my opinion (having lived a long time under both the German system and the NHS).
Funding for the NHS is completely at the whim of whatever economic policy a particular government decides to follow it being part of the general budget. In Germany (and other countries) the funding is provided by mutual funds as part of a state-overseen system (state, not government) and the government can´t get their hands on the money, screw up the system for some short-term interest or use health care as a political pawn. The patients themselves can decide if the fund is doing a good job and move to another if they wish. Or move to the private sector and contribute nothing to the state system.
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I only have limited experience with the Dutch system, but a few points:
1. Cost/funding:
Until 2006 the Netherlands had a system similar to the NHS. Since 2006 everyone (apart from minors I think) has to pay for private health insurance. Insurers have to offer their basic insurance package to everyone, and cannot charge differentiated rates based on someone’s health, age, etc. The state mandates what the basic insurance package covers – which is most things people might need. Some things (dentist, contraception) are covered through taking out additional insurance, for which insurers are allowed to charge differentiated rates.
The basic health care package costs about €100/month. On top of this, there is a minimum excess of €385/year for some treatments and most (all?) medication. You can increase your excess in return for a lower premium.
There are tax credits for those on a low income to help with the cost of insurance. If you earn less than €28,000/year (as a single person) or €36,000/year as a couple you get part of your insurance costs refunded. This ranges from getting nearly the full cost covered if you earn less than €20,000/year to getting a rebate of only a few euros if you earn close to the income threshold above.
2. Quality of care
Waiting lists are shorter now than they were, so that is a definite improvement.
People have (in theory) the freedom to choose to go to different hospitals or choose their own specialist by whom they want to be treated. Nonetheless, in practice it is difficult to do this due to a lack of info (how do you even begin to choose a doctor to treat you?) and red tape.
Many hospitals have merged. There are now fewer, but larger hospitals, with people having to travel further for treatment. These large hospitals often have set agreements with insurers to treat their patients, which means they don’t have to compete on quality of care or cost. Smaller hospitals, which do not have all-encompassing contracts with health insurers have to be more competitive in this new system. Not all manage and last month two smaller hospitals were declared bankrupt: all patients had to be transferred and 2000 people lost their jobs. This is a relatively minor issue in a densely-populated country like the Netherlands, but in the UK there would need to be regulations in place to ensure that remote hospitals cannot be closed because they are not sufficiently cost-competitive.
Overall, quality appears to have improved, especially after further changes were made in 2012 to tackle some ongoing issues. However, the Netherlands spends a high proportion of its GDP on healthcare (about a percentage point more than the UK), and costs for individuals have increased quite significantly. People like my parents now pay €1200-€1500 (each) more than they did before 2006. I guess it’s impossible to know if a similar increase in healthcare spending through increased taxation rather than private insurance would have had similar results.
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