During June’s Democratic
debate, moderator Lester Holt asked Bernie Sanders a question about
Medicare for All. Sanders replied:
Lester, I find it hard to believe that every other major
country on Earth, including my neighbor 50 miles north of me, Canada, somehow
has figured out a way to provide health care to every man, woman, and child,
and in most cases, they’re spending 50 percent per capita what we are spending.
Taken at face value, the statement is close enough to pass
for true by the standards of contemporary political discourse. But as a defense
of Medicare for All, it is a non sequitur.
The reason: No other major country offers a plan that is
anything like Medicare for All.
Here is a chart, based on data from the Commonwealth
Fund, that compares the United States with 10 other major countries in
terms of heath care spending and health care performance.
Yes, all countries shown have better health care outcomes
than the United States, and all spend less (although more than half as much).
But how closely do their health care systems resemble Medicare for All? How
broad is their coverage? How centralized are they? What role do they assign to
private insurance? What do they require by way of premiums and cost-sharing?
Here are some answers, starting with the three top performers. (See
here for the full health system profiles of each country.)
United Kingdom. The British National Health Service
comes closer to being a “single payer” system than those of other countries,
even though it is decentralized to a degree, with separate services for
England, Scotland, Wales and Northern Ireland. Care is provided free at the
point of service. The NHS covers all regular UK residents. But visitors and
undocumented immigrants are eligible only for emergency services.
Government pays 79 percent of health care costs in the UK,
more than the 49 percent in the United States but less than everything.
Copayments are required for outpatient drugs, dental, and vision services,
although these are waived for children, students, and people with low incomes.
There is a small but thriving private health care system that caters to
patients who prefer to seek care outside of the NHS. About 10 percent of the
population carries private health insurance.
Australia. Health care in Australia is a
three-way effort, with the national government providing most of the funding
while state and local governments administer services. The three levels of
government combined account for 68 percent of all health care spending. All
citizens and permanent residents are covered, as well as citizens of a few
other countries, by special agreement. Other than that, visitors and
undocumented immigrants are not covered.
Hospital treatment is covered in full, but cost-sharing is
required for prescription drugs, dental services, specialist visits, and some
other services. Out-of-pocket spending for drugs is capped. Cost-sharing is
waived for people with low incomes. About half of all Australians carry
supplemental private health insurance to fill the gaps in the national system.
The Netherlands. Citizens and permanent
residents of the Netherlands are covered through the compulsory purchase of
private health insurance, which is heavily subsidized by the government. The
government share of health spending is 77 percent. Visitors and undocumented
immigrants, in most cases, are eligible only for emergency services.
The insurance industry is dominated by four closely
regulated private companies. They must charge the same premiums to everyone regardless
of health status, and are prevented from distributing profits to shareholders.
Most people also purchase private supplemental insurance to cover additional
benefits such as dental care, alternative medicine, physiotherapy, eyeglasses
and lenses, contraceptives, and copayments for nongeneric drugs.
Other countries. The other countries shown in
the chart use various combinations of the policies found in the UK, Australia,
and the Netherlands. The government share of health spending varies from 64 percent
in Switzerland to 85 percent in Germany.
Switzerland, like the Netherlands, follows the model of
compulsory purchase of private insurance. Germany uses a unique system of
independent, not-for-profit “sickness funds.” Public insurance is the
predominant form of coverage elsewhere, with private supplemental insurance
available for those who choose to use it.
Countries vary in the degree of cost sharing that they
require. For example, Norway requires copayments for hospital services and
doctor visits but Sweden does not. Canada has more limited coverage of
prescription drugs than other countries. Vision and dental coverage, except for
children, is limited everywhere. All countries have special provisions to cover
health care costs of people with low incomes. None of the countries covered in
the Commonwealth study offers full services for visitors and undocumented
immigrants.
Comparison with Medicare for All. The other 10
countries in the Commonwealth study offer universal or near-universal health
care, with full coverage for children and people with low incomes. However,
they all differ from Sanders’ Medicare for All in important ways:
- They
do not cover vision and dental services in full for everyone.
- They
do not offer full coverage for undocumented immigrants.
- They
do require premiums, deductibles, or copayments for many kinds of
services.
- Most
of them are less centralized than Medicare for All would be.
In short, although other countries do provide health care
that is better in some ways than ours, and at lower costs, it does not
logically follow that we should implement Medicare for All. Instead, the proper
conclusion to draw from what other countries do is that we should learn
from their experience:
- We
should provide full coverage for children for children and for people with
low incomes.
- We
should ensure that no one faces financially ruinous medical expenses.
- We
should require those who can afford it to pay a fair share of their own
health care costs.
- We
should use a flexible mix of public and private practitioners and insurers
based on the realities of our own history and public expectations.
To insist on Medicare for All is not to learn those lessons,
but to willfully ignore them.
Posted earlier at Medium.com. Follow
this link for more on my thinking about health care reform.
Photo credit: Cropped image courtesy of Infrogmation of New Orleans, via Wikimedia
Commons.
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