Comparative Health Systems

This article compares the health systems of four nations: the United States, Canada, France, and the United Kingdom. The dimensions of comparison include organization and structure, access and coverage, and financing mechanism. The political influences on the development of health systems are also briefly considered.

Keywords Health Care Access; Health Care Finance; Health Care Systems; Health Insurance; Medicare; National Health Insurance; National Health Service; Universal Coverage

Health Care Management > Comparative Health Systems

Overview

The financing and delivery of health services in the context of a national health care system is a vast and complicated enterprise. Despite its political and fiscal importance, no one nation has to yet to design and implement a health care system that meets everyone's needs — everyone being consumers, providers, insurers, and governments. No matter the system and no matter the relative satisfaction with the system by any one constituent's criteria, policymakers in all nations are always tweaking and tinkering with their systems to improve fiscal stability and health outcomes for their citizens (Klein, 2003).

Because the issue of health care is a complex one, comparing health systems requires selecting specific dimensions on which to provide comparison. For the purposes of this essay, health systems are compared on three dimensions:

• Structure and organization.
• Access and coverage.
• Financing mechanisms.

The countries for comparison are the United States, the United Kingdom, Canada, and France. These countries were selected because they are all economically developed nations and represent both similarities and differences on each of the three comparative dimensions. Less developed nations pose their own unique differences from nations with advanced economies and therefore would be less instructive for the purposes of this essay.

Structure & Organization

The structure and organization of a nation's health care system is composed of health care providers (physicians, nurses, dentists, pharmacists, and others) and health care facilities (hospitals, clinics, and long term care facilities). Providers and facilities can be either public (i.e. government owned and operated) or private (independently owned and operated). The United States has a primarily private system of providers and facilities, with the exception of Veteran's Administration hospitals and clinics and state-run hospitals for mental health care and in some cases long-term care. Doctors are free to operate solo practices as small businesses or form group practices of similar or diverse specialties. Hospitals are largely not-for-profit organizations governed by community boards of directors or trustees. There are a limited number of for-profit hospital networks.

United Kingdom

In marked contrast to the essentially private business approach that characterizes the U.S. system, the National Health Service (NHS) of the United Kingdom is centrally controlled by the national government. The NHS evolved following World War II. During the war, a system of national Emergency Medical Services was established to control and organize medical services. Following the war, there was considerable public and government support for this system of medical services to continue and expand to provide universal coverage for all citizens. Establishing relationships among general practitioners, specialists, hospitals, and other providers to enact a national health system proved contentious. Aneurin Bevan, minister of health in 1944, was able to pull the factions together in a series of compromises that launched the NHS. The initial system used a three part organization (Light 2003):

• Hospitals and specialists were organized under fourteen regional boards.
• General practitioners worked under a contractual arrangement with the national government.
• Community health services such as home health care, long-term care, and midwives and maternal and child health were organized at the local level.

Since its inception following World War II, the NHS has undergone a series of incremental changes in its organization. A series of reforms in the late 1990s under Prime Minister Tony Blair emphasized creation of partnerships, with some devolving of responsibility from the national to the regional and local levels, and an integration of services. For example, community health services were combined with general practitioners to form primary care trusts, which were in turn replaced with clinical commissioning groups in mid-2013. The strength of the NHS is its emphasis on primary care. Physicians are offered incentives to establish primary care practices in underserved areas and to treat patients who have ongoing and complex medical management issues (Light 2003).

France

France has universal coverage in a system of compulsory national health insurance (NHI). Physicians establish their own private practices and are reimbursed under a fee-for-services arrangement. Hospitals can be either public or proprietary, and patients are free to choose among them. Proprietary hospitals have somewhat more limited services. Complex cases are generally treated in public hospitals (Rodwin, 2003).

Patients have extensive freedom of choice among physicians and hospitals, including proprietary hospitals. Prescription drug coverage is generous. French citizens also have the option of purchasing private supplemental insurance. Patients pay their doctors directly and are reimbursed through local health insurance funds (Rodwin, 2003).

Canada

The Canadian health system, sometimes known as Medicare, is a government-funded system organized by the individual Canadian provinces. Doctors operate in solo or group practices under a fee-for-service arrangement and are typically reimbursed by the provincial government. Physicians must comply with rates set by the government, based on a negotiated schedule of benefits. Hospitals are generally private non-profit organizations that receive reimbursement for operations through the provinces (Irving, Ferguson, & Cakett, 2005).

Access & Coverage

France

In France, universal coverage evolved as incremental changes were made to the program of National Health Insurance (NHI). Coverage was first extended to workers in industry and commerce whose income did not exceed a defined wage ceiling. In 1945, NHI was extended to all workers in commerce and industry regardless of salaries and wages. Expansion of NHI coverage progressed over the ensuing decades, with farmers and agricultural workers added in 1961 and independent professionals in 1966. In 1974, NHI was made universal. Despite the compulsory requirement for insurance coverage, there remains in France significant disparities in service access and delivery related to geography and social class (Rodwin, 2003).

Canada

Universal coverage and accessibility are two of the guiding principles of the Canadian health system. Canadian health care is organized at the provincial level, and health plans developed by the provinces must adhere to these principles. While access to providers and services is one component of a health system, availability, especially for new technologies, is another issue altogether. Critics of the Canadian system point to waiting lists for procedures such as MRI, CT scans, and certain surgeries that amount to weeks or months. The Canadian Medical Association has deemed these delays to be "unconscionable" (Grater in Irvine, Ferguson, & Cakett, 2005).

United Kingdom

Delayed treatment and waiting lists are also a major issue with the United Kingdom’s National Health Service. Light (2003) observes that shortages in providers and facilities are due to "chronic under funding and undersupply." He further observes that the NHS is a well-designed system but is consistently underfunded.

United States

The United States is the only one of these four industrialized countries without universal coverage. At the same time, it spends the most dollars on health care (as measured by percent of Gross National Product) as compared to other industrialized nations. There are certain population groups in the United States that receive government funded medical services. People age 65 and over, as well as individuals with certain disabilities and conditions, are entitled to receive medical benefits from Medicare, a national health care program. Medicaid is a national, means tested program for individuals and families that meet strict income guidelines. SCHIP (State Children's Health Insurance Program) is a federal-state means tested program that provides health insurance to low-income children and pregnant women. The reforms introduced through the 2010 Patient Protection and Affordable Care Act further expanded the availability of affordable health care to millions of Americans.

The majority of Americans receive health insurance coverage through their employers. The range of benefits varies widely, and many employers offer no health insurance benefits. Many workers earn too much to qualify for Medicaid but cannot afford to pay the high cost of private health insurance; as such, many go uninsured. The Patient Protection and Affordable Care Act sought to combat this trend through the creation of health insurance exchanges through which individuals could purchase subsidized insurance plans.

Financing Health Care Systems

Health care is paid for by patients themselves, the government, employers, third-party payers such as insurance companies, or some combination of the above. The funding comes from salaries and wages, employee and/or employer taxes, or other designated funding sources.

Canada

The Canadian health system is funded primarily by federal and provincial taxes. Some provinces charge a health insurance premium, although core services cannot be denied if a citizen cannot afford the premium. Private spending makes up the balance, being paid either out-of-pocket or by supplementary insurance.

France

In France, the National Health Insurance system is funded by a combination of taxes: employer taxes, General Social Contribution, employee payroll tax, and special taxes on items such as automobiles, tobacco, and alcohol. A distinguishing feature of the French system is that in cases of severe illness, the insurance coverage expands to meet the increased need (Rodwin, 2003).

United Kingdom

The United Kingdom’s NHS is financed through a dedicated national health insurance tax.

United States

In the United States, financing is achieved through a combination of employer/employee funding and private dollars. Medicare is financed through employee payroll deductions. Medicaid and SCHIP are paid through a federal/state partnership from general funds.

Politics

Health systems are not logically designed by a lone bureaucrat sitting in a corner office. Rather, health systems evolve over time and are shaped by political forces (e.g. political ideologies, interest groups, and transforming events).

United States

The U.S. health system has evolved in large part by the power of physicians working through the American Medical Association. Their power has been effective as much by keeping health care off the government decision agenda as by resisting specific proposed programs. Despite the attempts of presidents such as Franklin D. Roosevelt and Harry S. Truman to add health care to the programs of Social Security, it was not until 1965, under President Lyndon Johnson, that Medicare was passed. The successful passage of Medicare was accomplished in large part because the elderly were perceived to be a 'deserving' population. The American ideals of rugged individualism and free market enterprise appear to supersede the ideal of health care as a fundamental human right. Despite resistance from insurance companies conservative lawmakers, however, President Barack Obama made health care reform one of the key issues of his presidency and in 2010 signed the Patient Protection and Affordable Care Act into law. Various reforms went into effect over the course of the next several years, and the health insurance exchanges launched in late 2013.

France and the United Kingdom

The French system evolved from the power of worker unions and guilds. Coverage was attained in small, incremental steps while maintaining a mix of public and private providers and services. The political palatability of this approach could be one reason why the French report higher levels of satisfaction with their health system, as well as higher measures of health status as compared to other nations (Rodwin, 2003).

The structure of individual governments also influences how health systems become established. Both the United Kingdom and France have parliamentary national governments. In a parliamentary system, the party in power controls both the legislative and executive branches. In contrast, in the United States, the party in power in Congress is not always the party of the president, which makes legislative initiatives more contentious and confrontational.

Canada

The organization of health care in Canada is based on a framework of fiscal federalism. The Canadian constitution, adopted in 1867, specifically delegates health care to the provincial governments. The national system "evolved incrementally within individual provinces as they responded to market failure" (Debner, 2003). Over time, the federal government has stepped in with programs of cost-sharing with the provinces to ensure access and universal coverage for all Canadian citizens.

Comparative Health Systems as a Discipline

The World Health Organization (WHO) is one of the leading organizations that attempt to compare the health systems of different nations. In 2000, WHO released a report with data on health systems of 191 member countries. The report maintained that there are at least three goals for what a good health system should do (Bureau of Labor Education 2001):

• Ensure good health: Making health status as good as possible across the lifespan.
• Encourage responsiveness: Responding to consumers' expectation of respectful treatment and a client orientation by health care providers.
• Fairness in financing: A just an equitable system of paying for health care.

According to WHO the ideal health system should include (Bureau of Labor Education 2001):

• Overall good health as measured by infant mortality and disability adjusted life expectancy.
• A fair distribution of health across the life span.
• A high level of overall responsiveness.
• A fair distribution of responsiveness across population groups.
• A fair distribution of financing health care (ensuring equal protection from the financial risk of disease and illness.

The 2000 WHO report has been critiqued by a number of health policy and public health scholars (Coyne 2002, Navarro, 2002). Critics argue that the report fails to take into consideration the socioeconomic conditions that impact the measures the report looks at. For example, a measure of life expectancy is influenced by a host of many factors beyond health system performance. Health systems do not function in a vacuum but are impacted by a nation's politics, values, and cultural forces. Thus, the study of comparative health systems must be approached with an eye to reliability, validity and confounding variables if lessons are to be drawn from each nation's experience. With international interest in cost containment as well as growing interest in quality indicators and outcomes in health care, the study of comparative health systems as an academic discipline is sure to grow.

Terms & Concepts

Health Care Access: The ability to obtain health care services unrestricted by provider availability or ability to pay.

Medicare: The national health system of Canada; also the name of the national health program for Americans who are over the age of sixty-five or have certain disabilities or conditions.

National Health Insurance: The national system of financing health care in France.

National Health Service: The health care system in the United Kingdom.

Universal Coverage: The provision of health care service to every citizen within a given nation.

Bibliography

Brown, L.D. (2003). Comparing health systems in four countries: Lessons for the United States. American Journal of Public Health, 93, 52–56. Retrieved October 23, 2007, from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=8859763&site=ehost-live

Bureau of Labor Education, University of Maine. (2001). The U.S. health care system: Best in the world or just the most expensive? Retrieved October 23, 2007, from http://dll.umaine.edu/ble/U.S.%20hcWeb.pdf

Coyne, J.S. & Hilsenrath, P. (2002). The world health report 2000. American Journal of Public Health, 92, 30–33. Retrieved October 23, 2007, from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=5801371&site=ehost-live

Deber, R.B. (2003). Health care reform: Lessons from Canada. American Journal of Public Health, 93 20–24. Retrieved October 23, 2007, from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=8859727&site=ehost-live

Irvine, B., Ferguson, S., & Cackett, B. (2005). Background briefing: The Canadian health care system. Retrieved October 30, 2007, from http://www.civitas.org/uk/pdf.Canada.pdf.

Kirkpatrick, I., Bullinger, B., Lega, F., & Dent, M. (2013). The translation of hospital management models in European health systems: A framework for comparison. British Journal of Management, 24S48–S61. Retrieved November 22, 2013, from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=89598704

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Light, D. W. (2003). Universal health care: Lessons from the British experience. American Journal of Public Health, 93, 25–30. Retrieved October 28, 2007, from Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=8859730&site=ehost-live

Navarro,V. (2002). Can health care systems be compared using a single measure of performance? American Journal of Public Health, 92, 31–34. Retrieved October 23, 2007, from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=5801372&site=ehost-live

Rodwin, V.G. 2003. The health care system under French National Health Insurance: Lessons for health reform in the United States. American Journal of Public Health, 93, 31–37. Retrieved October 23, 2007, from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=8859739&site=ehost-live

Wilkowsk, W., Ziefle, M., & AlagÖZ, F. (2012). How user diversity and country of origin impact the readiness to adopt e-health technologies: An intercultural comparison. Work, 412072–2080. Retrieved November 22, 2013, from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=71928626

Suggested Reading

Cantor, J.C. (2007). Aiming higher: Results from a state scorecard on health system performance. Medical Benefits, 24, 9–10. Retrieved November 14, 2007, from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=27142808&site=ehost-live

Forde, I., Morgan, D., & Klazinga, N. S. (2013). Resolving the challenges in the international comparison of health systems: The must do's and the trade-offs. Health Policy, 112(1/2), 4–8. Retrieved November 22, 2013, from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=90627713

Miller, L. & Miller, J.E. (2007). Health care quality data-the good news and the bad news. Benefits & Compensation Digest, 44, 16–23. Retrieved November 14, 2007, from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=27106184&site=ehost-live

Pooley, E. (2007). Medicare inc. Canadian Business, 80, 160–166. Retrieved November 14, 2007, from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=27090975&site=ehost-live

Viberg, N., Forsberg, B. C., Borowitz, M., & Molin, R. (2013). International comparisons of waiting times in health care —Limitations and prospects. Health Policy, 112(1/2), 53–61. Retrieved November 22, 2013, from EBSCO Online Database Business Source Complete. http://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=90627719

World Health Organization. 2000. The World Health Report 2000—Health Systems: Improving Performance. http://www.who.int/whr/en/