In the U.S. today, Democratic presidential candidates and the Trump administration alike are measuring their health insurance proposals by a single yardstick: whether or not it uses Medicare for All.
“We need Medicare for All to make high-quality, universal, affordable health care a reality for everyone,” says Sen. Kirsten Gillibrand (D-N.Y.) on her presidential campaign website.
Administration officials, meanwhile, want no part of it.
“The impact of Medicare for All on physicians would be particularly detrimental,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a speech to the American Medical Association in June. “Now, I know that our system isn’t perfect, but it does afford you some ability to choose which payers you want to do business with, and what payment terms you’re willing to accept. Medicare for All would take away that choice.”
Victor Rodwin, PhD, professor of health policy and management at New York University, isn’t surprised that the conversation in the U.S. has focused on Medicare for All. “Medicare for All is such a vague thing … It’s not really one model,” he said in a phone interview.
Rodwin noted that the Medicare for All proposal from Sen. Bernie Sanders (I-Vt.), another candidate for the Democratic nomination, “is a model that doesn’t exist anywhere in the world. He proposes to do it by eliminating completely the private insurance industry, by eliminating pretty much all coinsurance; that model doesn’t exist anywhere, even in Canada.”
Even in Britain, with its government-run National Health Service, “15% of the population has private insurance, which allows them to jump the queue and go to private hospitals,” Rodwin said. “Most other countries have found a way to cover entire population without completely excluding private insurance.”
Making Room for Private Insurers
Jamie Daw, PhD, assistant professor of health policy and management at Columbia University’s Mailman School of Public Health in New York City, noted that when other countries’ health systems are discussed, “a lot of the focus has been on the Canadian model, which is a full single-payer system where the government is the sole payer for all core hospital and physician services … Private insurance has a limited role and can’t cover anything the government covers. The focus on that seems to be one of the most extreme departures from the existing U.S. healthcare system.”
Other models that aren’t so extreme might be worth looking at, Daw said in a phone interview. She wrote about one of those models in a New York Times article: the German system. “Germany offers a health insurance model that, like Canada’s, results in far less spending than in the United States, while achieving universal, comprehensive coverage,” she wrote. “The difference is that Germany’s is a multipayer model, which builds more naturally on the American health insurance system.”
Under the German model, people are required to have health insurance, but they can choose between more than 100 private nonprofit insurers called “sickness funds,” Daw explained in her article. “Workers and employers share the cost of insurance through payroll taxes, while the government finances coverage for children and the unemployed. Insurance plans are not tied to employers. Services are funded through progressive taxation, so access is based on need, not ability to pay, and financial contributions are based on wealth, not health.”
This model “introduces competition and choice for the German people and seems to be a lot more of a natural build on the U.S. healthcare system,” she told MedPage Today. In the U.S., even within the public programs, “70% of Medicaid enrollees get their insurance from private plans [that contract with Medicaid] … and 30% of Medicare beneficiaries have Medicare Advantage, and that’s been growing. So just the idea of eliminating the private insurance system … seems politically really impossible.”
In France, as in Germany, all French citizens are covered under a health insurance program that is run by tightly regulated private organizations that contract with the government. Unlike Germany, though, only a handful of such plans are available, with 80% of the French population covered by the general national health insurance program and the rest covered under smaller plans. Everyone is automatically assigned to one of the plans, although they can also choose to buy supplemental insurance for items the plan doesn’t cover.
Rodwin is a fan of the French system. “In the French model, everybody’s in the same boat, with no choice of who covers you, and that’s the model I’d favor,” he said.
Setting Payment Rates
Michael Gusmano, PhD, associate professor of health systems and policy at Rutgers University in Piscataway Township, New Jersey, agreed. “The American left gets a bit of a fetish when they talk about single-payer, but most national health systems aren’t single-payer,” he said in a phone interview. “There are a handful of those like Korea, and Taiwan, and in Canada it’s single-payer per province, but what’s similar [in all of them] is you have an all-payer rate regulation system.”
In addition, “they all use a fee-for-service system, predominantly, so while they may use [global] budgeting for some types of hospitals, when [it] comes to paying doctors, although some are salaried in academic medical centers, community-based doctors are almost exclusively paid some form of fee-for-service payment, just like the U.S.,” he said.
These systems also have another thing in common: the way they set their rates. “Insurance funds, physicians’ unions, and hospital unions get together and they have budget projections set by [their federal government], and expectations about the volume of service,” said Gusmano. “Exactly how this process works differs [by country] — it’s much more decentralized in Germany, so if doctors start ordering too many tests or performing too many procedures, it’s the local physician association that gets on their case, because the sickness funds have a pot of money they give to the physician association, which pays that to the doctors … so they self-regulate.”
Satisfied Physicians
No matter which of these universal systems are used, physicians are largely happy with them, said Gusmano. “In any system like this, professionals are going to complain about how much money they’re making, and occasionally they do, but generally speaking, physicians I’ve interviewed in every single one of these countries are extremely satisfied in their practice,” he said. “They’re among the most highly paid professionals in the country. Do they have the opportunity to make the astronomical salaries that some doctors in the U.S. do? No, but usually they have their medical school paid for by the government, and less interference from payers in clinical decisions.”
A 2015 international primary care physician survey from the Commonwealth Fund seems to bear this out. In the survey, which included responses from a total of 11,000 physicians spread among nine foreign countries and the U.S., the percentages of physicians reporting that they were satisfied or very satisfied with their practice of medicine ranged from 91% in Norway to 63% in Germany, with the U.S. coming in next to last at 65%.
However — at least in some countries — the system as a whole was another matter. In another survey question, 67% of Norwegian physicians agreed that their country’s healthcare system worked well with only minor changes needed, compared with 50% of Dutch physicians, 27% of German physicians, and 16% of U.S. physicians.
“There’s so much we can learn from other countries, and it’s a lost opportunity to look around at other … particularly industrialized countries,” Robin Osborn, senior advisor at the Commonwealth Fund’s International Program in Health Policy and Practice Innovations in New York City, said in a phone interview. “The standard of living and the economic structures are similar, and the expectations of the public are similar to the U.S., so we can sort of see the things that they do and the features of their healthcare system that look really thoughtful and effective and say, ‘Well, why aren’t we doing that?'”
“I don’t think we’ve really had this conversation correctly here,” she added. “It’s always been a conversation about expanding coverage or making Medicare available to everyone or adding a public option. If you think of [the start of] Medicare, that conversation was really clear; everyone over 65 was entitled to healthcare coverage regardless of what their condition was, and it would be affordable, and the government would have a role to make sure it worked for them. So we’re having that conversation [again now], but not quite so clearly.”
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