Universal health care systems around the world

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September 22, 2019

By Gerhard Ottehenning

Washington, D.C. — Despite the constant hum of palace intrigue coming from 1600 Pennsylvania Ave., kitchen table issues like health care remain at the forefront of voters’ minds. Riding off the success of the 2018 congressional midterms, Democrats have rallied behind the idea of “Medicare for all” or “single-payer” health care to bring the United States’ system up to par with the rest of the industrialized world. But what kind of health care system does the “rest of the industrialized world” have?

The common rhetoric in health care debates in the U.S. today can sometimes deliver the impression that there are only two options: whatever it is that we currently have, and “socialized medicine,” with voters attaching various meanings to the word “socialized.” Examination of other countries’ health care systems yields a fuller picture of the various avenues to universal health care. Here at SAIS, international students can provide a unique perspective into the strengths and weaknesses of three such health care systems in the United Kingdom, Germany, and Switzerland.

The United Kingdom’s nationalized, single-payer system provides healthcare for all, but at a cost

The United Kingdom administers health care through the National Health Service (NHS). The NHS is a national, government-run, or single-payer, system. The government provides health insurance, employs health care workers and runs the country’s hospitals. Health care in the UK provides preventative services, mental health services and medical drugs for free, once citizens have paid taxes. Private insurers and private doctors exist for those willing to pay more for supplemental plans.

Downsides of the NHS include the unavailability of certain drugs, increasing health disparities between the rich and poor, and longer wait times than those experienced by most Americans. Miranda Bain, a second year SAIS student and UK national described some of the challenges she faced under the NHS: “The issue I had was that, because it’s very under-resourced—you only get 10 minutes with a doctor—it can be quite rushed if you’re trying to talk through something complicated and they’re seeing so many people at one time. It was a bit chaotic trying to get to the bottom of what was making me sick.”

Despite these downsides, Bain said that “people feel very strongly about the NHS and are quite proud of it. Although the current government has made moves to privatize it, if there was a big attempt to do that there would be a lot of protests and grievances from the public.” A comparison of health care systems by the Commonwealth Fund’s International Country Comparison (CFICC) gives the NHS high marks in terms of access to care, administrative efficiency and equity.

Germany’s health care model: A mixture of public and private insurance systems

In Germany, health insurance is mandatory for all citizens and is provided primarily through a national public system, with those above a certain income threshold buying private insurance. Public non-profits run half of hospitals, private non-profits run a third, and private for-profits run the rest. Income determines health care premiums, and a tax on employees and employers pays the premiums. The government subsidizes children and those below a certain income threshold.

The German system receives criticism for its fee-for-service system, which penalizes doctors if they provide too much care. Additionally, second-year SAIS student and German national Paulina Koch said that there is public criticism of the two-class system. “If you have private health insurance…it’s easier to get an appointment because those doctors can get more money from a private patient than from a public patient. And that is obviously unfair.” While Germany scores highly on the CFICC’s measures of access to health care, it scores lower on health care outcomes and care process.

Switzerland’s privatized health care system relies on “individual mandate”

Of these three foreign health care systems, Switzerland’s is the only one that can boast to be younger than the average SAIS student—Switzerland established its current health care system in 1996. The Swiss government obligates every citizen to buy health insurance from a private insurer, ensuring that healthy people stay in the system—which helps keep costs low. The majority of doctors and hospitals are run privately. The government provides financial assistance to low-income residents and regulates insurance companies to ensure access for patients with poor health. In the U.S., the Affordable Care Act (ACA) aimed to expand health coverage through the use of subsidies and regulation, similar to the Swiss system; Paul Krugman called the ACA an attempt to “swissify” the American health care system.

Sarah Aver, a Tsinghua-SAIS dual-degree student and French national who attended college in Geneva, Switzerland, described the Swiss system as “really efficient. Every time you go to see the doctor, you get a receipt, you pay and then you send it to your insurance. You can do it online and it’s always very efficient.”

The Swiss often cite high costs as a major drawback of their system, a point reiterated by Aver. “There’s always a debate about the price. People think it’s too expensive.” While the Swiss system is more costly than either Germany’s or the UK’s, it is still less of a budget-buster than the United States’ current system.

As in the U.S., politicians in Switzerland continue to debate the role of government in providing health care. Aver said, “because it’s private companies, some people think that it’s the state’s job to provide health care. It’s a debate but for most people it’s not an issue that it’s privatized.” The CFICC gives Switzerland high marks for health outcomes and equity, though its system is judged to fall short in terms of access and administrative efficiency.

The leading Democratic presidential candidates all mention universal health care as a top policy priority. Bernie Sanders and Elizabeth Warren support implementing a single-payer system dubbed “Medicare for All” that in part resembles the UK’s NHS, with the government acting as the sole health care insurer. Joe Biden and Pete Buttigieg’s campaign platforms focus on shoring up the existing ACA by adding a public option and creating a more competitive insurance market—most closely aligning with the German system. As the Democratic field narrows, expect the candidates to flesh out their plans as they strive to differentiate themselves from their competition.