By Jeffrey Weiss
There are about 200 nation-states and each devises its own
set of arrangements for meeting the three basic goals of a health care system:
keeping society healthy, treating the sick, and protecting families against
financial ruin from medical bills.
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.
This is publicly delivered and publicly paid for health care
or the closest thing to "Socialized Medicine"
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.
Jeffrey J Weiss is an adjunct professor in the social
sciences at DMACC and Grand View. He can
be reached at jjwcpm@yahoo.com
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