Yeah, OK, that’s an ambitious title for what’s mostly an unresearched “what I know” type of post.
The key point is this: there is a lot of variation, and it’s a mistake to think that the rest of the world has single-payer healthcare and the U.S. is the outlier. Heck, even countries we think of as having single-payer healthcare, don’t, really. Now, the U.S. is an outlier in the amount of private spending on healthcare, to be sure, but the story is more complicated than Single Payer vs. the U.S.
Let’s start with the data:
Take a kuken* at this table from the OECD:
|Dollars, PPP (2012)||%s|
Yeah, sorry, that’s a long table. That’s from OECD Healthcare at a Glance — the full PDF is here, or a link to key tables is here. The PDF also has a number of graphs, but sometimes I like to have the actual numbers — namely, that even prior to the Obamacare subsidies/expanded Medicaid eligibility, nearly half of U.S. healthcare spending was public, not private, spending. (More recent figures don’t seem to be available to see how much more spending has shifted to public spending since then.)
Anyway, here are a few comments on specific countries, mostly off the top of my head (I figure that way I’m not sharing information that’s proprietary to my employer):
Yeah, 16% public spending isn’t huge, but it’s not nothing: middle-management and higher-level employees are provided private health insurance by their employers. Not for them the NHS horror stories! They have access to private clinics and treatments, and “upgraded” spots at public hospitals, whenever NHS is insufficient, has too long a wait list, doesn’t cover a treatment, or is just generally icky.
They’re actually the most Obamacare-ish country: a standardized basic level of private insurance is mandatory, with subsidies for the poor. No practice of employer provision — you just buy it on your own. The catch? They’re the second-highest-spending country, and are struggling with growing costs.
Health insurance is managed through regional quasi-public entities, which set (very low) reimbursement rates. How low? When we lived there, there was a protest march by doctors upset at their low pay. But hey — medical school was free. It’s paid for by a payroll tax. But if you make over a given income level (I think about 50K-ish), you have the option to opt out of the payroll tax and buy your own insurance, with the stipulation that you’re then obliged to continue buying private insurance, rather than switching back and forth. In addition to potentially cheaper coverage, private insurance gives you such benefits as top-tier doctors and the ability to select a private, rather than three-bed room at the hospital.
Employer-provided health insurance is customary (and I think not just for management but in general); it picks up the not-trivial copays. In addition, the reimbursement levels provided by the national health insurance are low enough that providers often have a surcharge which the private insurance covers. This system of surcharges at the “good doctors” and private clinics, paid for by private health insurance, is, it seems to me, fairly common, say, in Italy, as well.
Historically, insurance was not permitted to pay for any service that the national healthcare system covered, so that you couldn’t use it to get coverage at a private provider to skip waiting lists. It seems to me that I read recently that this has changed. In any case, what private health insurance does do is cover everything that the national healthcare system doesn’t: prescription drugs primarily, and upgrades from ward to semi-private or private rooms, and various sorts of therapists and other providers that aren’t covered otherwise. In addition, private insurance covers out-of-country treatment, and policies specify either all out-of-country treatment or only in cases of emergencies.
Again, single payer, but with a policy of encouraging upper-income folk to buy private insurance — it doesn’t allow you to opt out of payroll tax contributions, but does give you a modest rebate.
Yeah, they’ve got a large percentage of private spending; it seems to me that this is because the State healthcare provision has a lot of holes, copays, etc., which private insurance, routinely a part of employee benefits, covers.
Strictly speaking, there’s comprehensive medical coverage. But in practice, well, it’s like being obliged to use Cook County hospital for everything. Again, salaried employees expect to have insurance provided by their employer, to get them access to private, first-world hospitals. Same with Brazil, which is a huge health insurance market for white collar employees, and I think even blue collar employees at large employers, in order to escape the poor quality and wait times of the “free” national healthcare system.
One more, also not on the table — Singapore
Singapore’s system gets frequent mention by supporters of “market-based” systems, because one component is a “savings account” similar to the HSA savings accounts that accompany high-deductible plans in the U.S. See this older post, for instance. The reality is that “universal” coverage has a lot of copays and employer-provided insurance fills these gaps.
So there you have it: a world tour of health insurance.
(* “take a kuken” = a Dad-ism for “take a look.” Typical use: “take a kuken in the refrigerator to see what’s there.” An expression he picked up in Germany, where kuken is a regionalism for “look.”)
(By the way: the chart that appears as an image? I had a hard time getting a table to look right — that was one of the tries.)