Slightly off topic but is there is a such thing as universal affordable good healthcare?
I've talked to a few U.S. citizens that worked abroad who said healthcare in European countries is universally available but the demand outstrips the supply causing longer wait times to get treated than in the U.S. and that they prefer the U.S. system. These are of course people who have good jobs in the U.S. with company provided coverage. Is that true?
Is there any system that can both cover everyone without making healthcare worse for people who already have good coverage?
The Australian system is far from perfect but does come some way to solving this. It is effectively 2 tiered:
1) Public Medicare, the publicly funded system available to everybody.
2) Private insurance, paid for by the individual and tailored to their needs.
To pay for the public system everybody pays a Medicare levy as part of their income tax. The levy is coarsely means tested. If you have private insurance then this levy is reduced somewhat.
The real critical differentiation between the public (Medicare) and private offerings are that any services deemed as elective in nature (ie, non life threatening conditions such as surgeries to treat injuries, etc) can be completed by the public system but there is a wait list which can often be quite long. If you have private insurance then you can get in very quickly with the surgeon you want.
Having private in no way restricts your usage of the public system so there is no downside to having private except that it costs more. There are also fee structures in place to encourage people to take up private when they're younger and the saving on the medicare levy.
As I said, it's far from perfect, but the 2 tiers offer a high level of customized cover for people willing and able to afford it while offering an acceptable level of cover for those who can't.
One thing I don't like about the Australian system is I think it is wasteful in someways. For example under my private cover I'm subsidized for ~$300 a year in optical expenses (split between lenses and frames).
From anecdotal conversations I know there are many people who purchase a new pair of glasses every year just because the system is basically set up to encourage this which smells like very wasteful consumption to me. I don't need a pair of glasses every year. I have gone through 3 sets of glasses in 15 years.
If I wanted to I could opt to exclude optical from my cover and save some money every month but then I'd worry about what happens if I lose my glasses or sit on them and I'd end up out of pocket so I keep paying for optical cover I don't use and feel like a sucker every year for not taking advantage of subsidized glasses.
Same thing with trips to dentist I know people who insist on general dental (unnecessary cleaning etc) because they are subsidized so they "need to take advantage to get their money's worth".
I suggest you stop thinking about it as a benefit and think about what it actually is, which is insurance.
My travel insurance is cheaper if I don't cover any lost property, but what if I need it? Anecdotally many young travellers who head overseas 'lose' their $1500 DSLR or their 6 year old macbook when in South America in order to make use of their $300 travel insurance
Agreed exactly why I pay for it. The fact it is advertised as a benefit probably contributes to this.
My insurer has gone as far as cold calling me last year "I notice you haven't been claiming any of these benefits, would you like to review your policy."
Having worked in both Public and Private Australian systems as a Dr, and as a Medical Student in the US, I agree with your comments - we have a 'reasonable balance' of a system that does a reasonable job of allocating resources in a reasonable manner.
As you say, nothing is perfect and in anything as complicated as healthcare there are going to be inequalities and problems... But even on the healthcare investment side, our Government has made some really intelligent decisions and built some beautiful facilities recently. It is rare that I work in a hospital that has not had a major renovation within the last 5-10 years (or about to undergo a rebuild)
I've talked to a few U.S. citizens that worked abroad who said healthcare in European countries is universally available but the demand outstrips the supply causing longer wait times to get treated than in the U.S. and that they prefer the U.S. system.
Whether we want to ration care by ability to pay or by another means, such as severity of illness, care will have to be rationed -- and the degree to which it must be rationed is inversely related to what percentage of people are covered by it.
So of course well-off folks will perceive a system with a greater percentage of people covered and with care rationed in a way other than 'ability to pay' as being worse than a capitalist system -- they have to wait longer because they're standing in line alongside folks who, in the healthcare system they are used to, could not afford to be standing in line with them at all.
The question is whether that drawback is worth providing access to care to folks who otherwise would not be able to access it.
Well to begin with, the availability of free universal health care - like the NHS helps ensure a pretty competitive private healthcare market.
For example, I know that if my wife becomes pregnant or if there are complications we won't be hit with thousands or tens of thousands in medical bills on leaving the hospital.
However on the flip side, it's very difficult to find a decent NHS dentist where we live, so we'll pay about £300-600 in dental checkups or dental work per annum.
Just by having the NHS provide dental or any medical care there is downward pricing pressure on private competitors so however flawed a system like the NHS is it certainly has a very important pricing function even if you choose to go completely private.
So far, I'm quite pleased with the Norwegian health care system - though to be honest, most of my experience has been through "working" as a CNA (it was actually part of language classes), classroom learning, a few doctor's visits, and the stories of other immigrants.
Everyone is covered by the national health insurance. No more worries about getting hit with a huge health care bill. Children have a lot of free stuff - most health care and dental (braces are an exception). I can change my doctor a couple times a year if I want. Some things just make sense: For example, the government sends me a letter to remind me to get cancer screenings every 3 years (I'm female) - and this stuff isn't as possible with the fragmented system in the states.
Now, the downsides are things like longer wait times. This does suck, for sure. Some of this is simply being cost-effective, I'm sure. But other cost effective things work out: For example, if you need a home nurse, you get one covered up to 6 times a day. Free, because it is cheaper than a nursing home. Dental can tend to be expensive and folks have some odd ways of going about this. For example, I've heard of a group of Norwegian dentists in... Poland?... that cater to Norwegians. The cost is often cheaper, even when factoring in the travel costs.
There is a private health care system. The government still pays their normal rate to the private provider and the patient pays the difference. Some folks use this to go around the waiting times and I'm guessing this option would seem more similar to the American system for folks with insurance - though I'm not sure it is ever like the nearly on-demand medical care one comes to expect in the states. The system is vastly better for those with poor coverage or those that have good coverage but can't afford to use it.
Hopefully, if the US does a single-payer system, they take a look at some of the downsides and try some things to lessen them.
I've talked to a few U.S. citizens that worked abroad who said healthcare in European countries is universally available but the demand outstrips the supply causing longer wait times to get treated than in the U.S. and that they prefer the U.S. system. These are of course people who have good jobs in the U.S. with company provided coverage. Is that true?
This can be all over the place, depending on what you look at (GP appointments, specialist appointments, emergency and urgent care, elective surgeries, etc.) [1]. In general, the US outperforms some countries, but never all of them, and this is not taking into account that people without access to healthcare may suffer de facto infinite waiting times or that in many countries, people seek out their doctors far more frequently than in the US [2]. "Europe" is definitely not a homogeneous blob (just think of, say, France vs. Bulgaria) and there are great variations between even the affluent EU member states; it is pretty much impossible to generalize.
What we do know is that the US has a fairly low physician density for a developed country [3], though that's not the only factor that goes into waiting times.
[1] Google will show you a fairly large number of studies, but few that cover more than a handful or so of countries and/or more than a few metrics, so it's difficult to get a truly comprehensive overview.
Typically demand outstrips supply for very simple exams but the private sector covers it pretty well without making you pay a lot more.
For example, here in Italy I can look for: public sector, private public-affiliated sector and full private sector.
When I needed a full low abdomen echography I first contacted the public sector, they told me they had a wait list of 2.5months for that common exam, but I could call a private public-affiliated clinic and do it there (they also gave me suggestions on which clinics were available). Cost ~23euros (not all the exams have this waiting time, when I needed just physiotherapy or to see a psychologist I had <7 days wait time)
Called three private public-affiliated clinics. These are clinics where all the staff is private and is managed like a normal company, but if they do an exam and you have the paper from your GP they can fill a form and get a part payed from the public sector (in a sort of exchange for helping reducing the wait time) In all of three they could visit me in 2-4 days, paying just ~30e.
Lastly there was the full private clinic, those are not subsidized in any way but they have a very short list and if you want you can make a private insurance that cover basically whatever exams you will ever need from them. They could visit me in the next 2 hours for just ~80e.
Note I was not in a emergency, if that was the case I could just run to the hospital and they would visit me instantly without making me pay anything (you can also run to the hospital without an ongoing emergency... they usually don't make you pay nothing anyway and do the exams but make you wait hours until they have no more urgent cases). Note also that if you have a serious condition (cancer like or anything with high risk of fatality) you will get ahead of any list and be visited asap, no money asked.
And Italy is considered one of those "long list countries" in EUW.
I'd say it depends on what you mean by "good". E.g. the Swedish system probably compares well to the US one in terms of (average) medical outcomes [1], but in terms of "customer satisfaction"... that's a different story.
(Personally I feel "real" / objective health is more important than the subjective "customer satisfaction" aspect of health care, but yea, I guess that's politics.)
Comments
Slightly off topic but is there is a such thing as universal affordable good healthcare?
I've talked to a few U.S. citizens that worked abroad who said healthcare in European countries is universally available but the demand outstrips the supply causing longer wait times to get treated than in the U.S. and that they prefer the U.S. system. These are of course people who have good jobs in the U.S. with company provided coverage. Is that true?
Is there any system that can both cover everyone without making healthcare worse for people who already have good coverage?
The Australian system is far from perfect but does come some way to solving this. It is effectively 2 tiered:
1) Public Medicare, the publicly funded system available to everybody. 2) Private insurance, paid for by the individual and tailored to their needs.
To pay for the public system everybody pays a Medicare levy as part of their income tax. The levy is coarsely means tested. If you have private insurance then this levy is reduced somewhat.
The real critical differentiation between the public (Medicare) and private offerings are that any services deemed as elective in nature (ie, non life threatening conditions such as surgeries to treat injuries, etc) can be completed by the public system but there is a wait list which can often be quite long. If you have private insurance then you can get in very quickly with the surgeon you want.
Having private in no way restricts your usage of the public system so there is no downside to having private except that it costs more. There are also fee structures in place to encourage people to take up private when they're younger and the saving on the medicare levy.
As I said, it's far from perfect, but the 2 tiers offer a high level of customized cover for people willing and able to afford it while offering an acceptable level of cover for those who can't.
One thing I don't like about the Australian system is I think it is wasteful in someways. For example under my private cover I'm subsidized for ~$300 a year in optical expenses (split between lenses and frames).
From anecdotal conversations I know there are many people who purchase a new pair of glasses every year just because the system is basically set up to encourage this which smells like very wasteful consumption to me. I don't need a pair of glasses every year. I have gone through 3 sets of glasses in 15 years.
If I wanted to I could opt to exclude optical from my cover and save some money every month but then I'd worry about what happens if I lose my glasses or sit on them and I'd end up out of pocket so I keep paying for optical cover I don't use and feel like a sucker every year for not taking advantage of subsidized glasses.
Same thing with trips to dentist I know people who insist on general dental (unnecessary cleaning etc) because they are subsidized so they "need to take advantage to get their money's worth".
I suggest you stop thinking about it as a benefit and think about what it actually is, which is insurance. My travel insurance is cheaper if I don't cover any lost property, but what if I need it? Anecdotally many young travellers who head overseas 'lose' their $1500 DSLR or their 6 year old macbook when in South America in order to make use of their $300 travel insurance
Agreed exactly why I pay for it. The fact it is advertised as a benefit probably contributes to this.
My insurer has gone as far as cold calling me last year "I notice you haven't been claiming any of these benefits, would you like to review your policy."
Having worked in both Public and Private Australian systems as a Dr, and as a Medical Student in the US, I agree with your comments - we have a 'reasonable balance' of a system that does a reasonable job of allocating resources in a reasonable manner. As you say, nothing is perfect and in anything as complicated as healthcare there are going to be inequalities and problems... But even on the healthcare investment side, our Government has made some really intelligent decisions and built some beautiful facilities recently. It is rare that I work in a hospital that has not had a major renovation within the last 5-10 years (or about to undergo a rebuild)
This sounds in some ways similar to Mark Cuban's solution.
Here's the post: http://blogmaverick.com/2017/03/08/some-thoughts-on-fixing-o...
Whether we want to ration care by ability to pay or by another means, such as severity of illness, care will have to be rationed -- and the degree to which it must be rationed is inversely related to what percentage of people are covered by it.
So of course well-off folks will perceive a system with a greater percentage of people covered and with care rationed in a way other than 'ability to pay' as being worse than a capitalist system -- they have to wait longer because they're standing in line alongside folks who, in the healthcare system they are used to, could not afford to be standing in line with them at all.
The question is whether that drawback is worth providing access to care to folks who otherwise would not be able to access it.
Well to begin with, the availability of free universal health care - like the NHS helps ensure a pretty competitive private healthcare market.
For example, I know that if my wife becomes pregnant or if there are complications we won't be hit with thousands or tens of thousands in medical bills on leaving the hospital.
However on the flip side, it's very difficult to find a decent NHS dentist where we live, so we'll pay about £300-600 in dental checkups or dental work per annum.
Just by having the NHS provide dental or any medical care there is downward pricing pressure on private competitors so however flawed a system like the NHS is it certainly has a very important pricing function even if you choose to go completely private.
So far, I'm quite pleased with the Norwegian health care system - though to be honest, most of my experience has been through "working" as a CNA (it was actually part of language classes), classroom learning, a few doctor's visits, and the stories of other immigrants.
Everyone is covered by the national health insurance. No more worries about getting hit with a huge health care bill. Children have a lot of free stuff - most health care and dental (braces are an exception). I can change my doctor a couple times a year if I want. Some things just make sense: For example, the government sends me a letter to remind me to get cancer screenings every 3 years (I'm female) - and this stuff isn't as possible with the fragmented system in the states.
Now, the downsides are things like longer wait times. This does suck, for sure. Some of this is simply being cost-effective, I'm sure. But other cost effective things work out: For example, if you need a home nurse, you get one covered up to 6 times a day. Free, because it is cheaper than a nursing home. Dental can tend to be expensive and folks have some odd ways of going about this. For example, I've heard of a group of Norwegian dentists in... Poland?... that cater to Norwegians. The cost is often cheaper, even when factoring in the travel costs.
There is a private health care system. The government still pays their normal rate to the private provider and the patient pays the difference. Some folks use this to go around the waiting times and I'm guessing this option would seem more similar to the American system for folks with insurance - though I'm not sure it is ever like the nearly on-demand medical care one comes to expect in the states. The system is vastly better for those with poor coverage or those that have good coverage but can't afford to use it.
Hopefully, if the US does a single-payer system, they take a look at some of the downsides and try some things to lessen them.
This can be all over the place, depending on what you look at (GP appointments, specialist appointments, emergency and urgent care, elective surgeries, etc.) [1]. In general, the US outperforms some countries, but never all of them, and this is not taking into account that people without access to healthcare may suffer de facto infinite waiting times or that in many countries, people seek out their doctors far more frequently than in the US [2]. "Europe" is definitely not a homogeneous blob (just think of, say, France vs. Bulgaria) and there are great variations between even the affluent EU member states; it is pretty much impossible to generalize.
What we do know is that the US has a fairly low physician density for a developed country [3], though that's not the only factor that goes into waiting times.
[1] Google will show you a fairly large number of studies, but few that cover more than a handful or so of countries and/or more than a few metrics, so it's difficult to get a truly comprehensive overview.
[2] https://www.statista.com/statistics/236589/number-of-doctor-...
[3] http://gamapserver.who.int/gho/interactive_charts/health_wor...
Typically demand outstrips supply for very simple exams but the private sector covers it pretty well without making you pay a lot more.
For example, here in Italy I can look for: public sector, private public-affiliated sector and full private sector.
When I needed a full low abdomen echography I first contacted the public sector, they told me they had a wait list of 2.5months for that common exam, but I could call a private public-affiliated clinic and do it there (they also gave me suggestions on which clinics were available). Cost ~23euros (not all the exams have this waiting time, when I needed just physiotherapy or to see a psychologist I had <7 days wait time)
Called three private public-affiliated clinics. These are clinics where all the staff is private and is managed like a normal company, but if they do an exam and you have the paper from your GP they can fill a form and get a part payed from the public sector (in a sort of exchange for helping reducing the wait time) In all of three they could visit me in 2-4 days, paying just ~30e.
Lastly there was the full private clinic, those are not subsidized in any way but they have a very short list and if you want you can make a private insurance that cover basically whatever exams you will ever need from them. They could visit me in the next 2 hours for just ~80e.
Note I was not in a emergency, if that was the case I could just run to the hospital and they would visit me instantly without making me pay anything (you can also run to the hospital without an ongoing emergency... they usually don't make you pay nothing anyway and do the exams but make you wait hours until they have no more urgent cases). Note also that if you have a serious condition (cancer like or anything with high risk of fatality) you will get ahead of any list and be visited asap, no money asked.
And Italy is considered one of those "long list countries" in EUW.
I'd say it depends on what you mean by "good". E.g. the Swedish system probably compares well to the US one in terms of (average) medical outcomes [1], but in terms of "customer satisfaction"... that's a different story.
(Personally I feel "real" / objective health is more important than the subjective "customer satisfaction" aspect of health care, but yea, I guess that's politics.)
1. E.g. http://www.nationmaster.com/country-info/compare/Sweden/Unit...