The Four Models of Health Care

Last night PBS broadcast a very good program on the health care systems of other countries such as England, Germany, Switzerland, Taiwan and Japan. The program entitled "Sick Around the World" and produced by John Palfreman and T.R. Reid illustrates how sick the U.S. Health care system is.  The selected countries spend much less than the U.S., yet are able to cover all their citizens, while America has 47 million uninsured people.  Also, the quality of medical care is quite good and compares well with the best of U.S. care.

                            On-Camera Correspondent T.R. Reid

Americans are woefully uniformed about the health care system in our country, much less those of other countries.  I am a volunteer for AARP and at one of our events at the New Mexico State Fair I helped hand out material on the AARP's "Divided We Fail" campaign that urges U.S. politicians to stop fighting each other and instead work together to help our citizens regarding such issues as financial security (Social Security) and health care.  All the people walking by our booth were very concerned about both issues, especially health care.  Yet, I found some people who were of the opinion that the American health care system was the best in the world and that we did not need to establish "socialized medicine".   Yes, our health care system is very good for those who can afford it and it is not necessary to go to a full-fledged socialized medical system to cover everyone in a responsible manner.  In the best examples given in "Sick Around the World", the government allowed privatization, but did not rely on the market to determine all things about the health care system 

The following excerpt from the PBS.org website presents the four basic models of health care available around the world.  The center-right President of Switzerland Pascal Couchepin said on the program that it would be a national scandal if anyone went bankrupt because they were unable to pay their medical bills.  It is imperative that our politicians do something about our medical care scandal.  I urge all readers to visit the PBS website and inform yourselves about this vitally important issue.  Posted by Richard Griego

There are about 200 countries on our planet, and each country devises its own set of arrangements for meeting the three basic goals of a health care system: keeping people healthy, treating the sick, and protecting families against financial ruin from medical bills.

But we don't have to study 200 different systems to get a picture of how other countries manage health care. For all the local variations, health care systems tend to follow general patterns. There are four basic systems:

The Beveridge Model

Named after William Beveridge, the daring social reformer who designed Britain's National Health Service. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library.

Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge.

Countries using the Beveridge plan or variations on it include its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong still has its own Beveridge-style health care, because the populace simply refused to give it up when the Chinese took over that former British colony in 1997. Cuba represents the extreme application of the Beveridge approach; it is probably the world's purest example of total government control.

The Bismarck Model

Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Despite its European heritage, this system of providing health care would look fairly familiar to Americans. It uses an insurance system -- the insurers are called "sickness funds" -- usually financed jointly by employers and employees through payroll deduction.

Unlike the U.S. insurance industry, though, Bismarck-type health insurance plans have to cover everybody, and they don't make a profit. Doctors and hospitals tend to be private in Bismarck countries; Japan has more private hospitals than the U.S. Although this is a multi-payer model -- Germany has about 240 different funds -- tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides.

The Bismarck model is found in Germany, of course, and France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in Latin America.

The National Health Insurance Model

This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there's no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance.

The single payer tends to have considerable market power to negotiate for lower prices; Canada's system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated.

The classic NHI system is found in Canada, but some newly industrialized countries -- Taiwan and South Korea, for example -- have also adopted the NHI model.

The Out-of-Pocket Model

Only the developed, industrialized countries -- perhaps 40 of the world's 200 countries -- have established health care systems. Most of the nations on the planet are too poor and too disorganized to provide any kind of mass medical care. The basic rule in such countries is that the rich get medical care; the poor stay sick or die.

In rural regions of Africa, India, China and South America, hundreds of millions of people go their whole lives without ever seeing a doctor. They may have access, though, to a village healer using home-brewed remedies that may or not be effective against disease.

In the poor world, patients can sometimes scratch together enough money to pay a doctor bill; otherwise, they pay in potatoes or goat's milk or child care or whatever else they may have to give. If they have nothing, they don't get medical care.

These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus. When it comes to treating veterans, we're Britain or Cuba. For Americans over the age of 65 on Medicare, we're Canada. For working Americans who get insurance on the job, we're Germany.

For the 15 percent of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you're sick enough to be admitted to the emergency ward at the public hospital.

The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it's fairer and cheaper, too.