International Comparison of Health Care Access, Out-of-Pocket Expenses, and Drug Pricing Policies

Which Country Has the Best Health Care by former National Institutes of Health executive, Ezekiel Emmanuel, attempted to rank global health care, albeit he and his team only reviewed eleven nations. (Emmanuel, 2020) Yet his findings were interesting and this article delves into several aspects of health systems, including patient choice of health care provider and hospital, the burden of expenses paid by the patient, and pharmaceutical pricing policies. Each of these criteria are extremely important to American health care consumers and their concerns are influential in government elections.

Choice of Clinician

Americans assume that private sector healthcare plans provide a greater choice of clinician and facility, but Emmanuel shows this isn’t the case. France, Germany, the Netherlands, Norway, and Taiwan all have greater choice than the United States and they are all versions of socialized medicine. Switzerland, which is somewhat similar to the U.S. with its requirement to purchase private insurance as the funding mechanism for healthcare, offers greater provider choice than the U.S. because of its government regulations.  This table shows how these top scoring nations regulate patient choice in comparison to the U.S.

Nation	Choice of Physicians	Waiting Times
France	Individual choice, physician private practices dominate, MD's make house calls	No wait times, Availability of care depends on location
Germany	No gatekeepers, patients have free choice	Abundance of hospitals- no wait times
Netherlands	Driven by primary care providers, GP must provide specialist referral	Only 15% exceeded targeted wait times in 2014
Norway	Individuals choose provider and can switch twice each year	Significant queues and travel to specialty centers
Taiwan	Any clinician or hospital, patient chooses	Minimal queues for services
United States	Patient choice is restricted by insurance companies; surprise bills are common for non-network services	Minimal waits, but availability of care depends on location

 Out of Pocket Costs

The U.S. spends vastly more per person on health care than any other nation and individuals pay a significant portion of their health care expenses.  This table shows the healthcare burden per person (including children) and the proportionality based on median household income. Median represents the income that is truest to a representative average when outliers for highest (Elon Musk) and lowest incomes (incomes of $1,000 for example) are removed. Using the same data set for 2017 from the Commonwealth Fund.org report in 2020, I drew the per-person-out-of-pocket expenses for these countries. (The Commonwealth Fund.org, 2017) The final data comes from the latest per person income from World Population Review.com, which used World Bank data to arrive at its statistics. (World Population Review, n.d.). As you can see Americans have greater income than most Europeans, but must devote two or three times as much of their income toward paying health care expenses and this is on top of paying for insurance premiums. According to the Kaiser Family Foundation, the average medical insurance cost was $6,690 for private employer plans in 2017, which is typically paid by the employer. However, if you have spouse or children, 60% of employers surveyed required employees to pay the entire cost of their insurance assessment for family members.[1]  

Nation	Cost of Healthcare per person (2017 data)[2]	Out of pocket expenses per person cap (2017)[3]	Median Income per person (US$)[4]
France	$ 4,600	$ 463	$16,372
Germany	$ 6,200	$ 731	$16,845
Netherlands	$ 5,000	$ 572	$17,154
Norway	$ 7,400	$ 860	$22,684
Taiwan	$ 1,500	Not Available	$13,605
United States	$10,700	$1,122	$19,300

U.S. Insurance Cost to Employees

This table shows the potential pass-through costs to employees with families for employer medical plans in 2017 and 2020. There are many families who must choose between covering a spouse and children because they cannot afford to pay for the insurance for both. (Kaiser Family Foundation, 2020)

Premiums	2017	2020
Employee	$ 6690	$ 7,470
Employee and Family	$18,764	$21,342
Pass through cost to Employee	$12,074	$13,870

 Drug Pricing Policy

The United States uses more prescription drugs per person than any other nation and also pays more for their medicines. This table shows international drug pricing policies drawn from Ezekiel Emanuel’s 2020 analysis. (Emmanuel, 2020) It’s no accident residents of the U.S. are paying more for their medications; the system was designed to promote a capitalist drug system. The pharmaceutical industry maintains changing this policy will harm innovation, but major drug companies are located in nations with controlled drug pricing policies and they sell their medications to nations with restrictions on price setting.

Nation	Policy	Drug Prices
France	Type of drug determines who can prescribe it; gatekeeper approach; some preapproval for exceptional drugs	All drugs deemed irreplaceable are paid 100%
Germany	Physicians can’t prescribe off-label drug use, except for special circumstances; no cost effectiveness requirement but RX prices are reviewed every 12 months and prices are determined after analysis of similar drugs; clinician prescribing policies are scrutinized	Everyone pays the same price for a drug; RX markups are limited for pharma
Netherlands	Preferred formularies are used to control prices; new drugs must be authorized by the Medicines Evaluation Board which accounts for efficacy of the drug and whether or not there is an equivalent already available; hospitals and pharmacists play a role in RX price control	Most drugs are free for patients
Norway	Ministry of Health and Care Services authorizes drugs for a 5-year period, prices are subject to approval after a health technology assessment; drugs are evaluated on quality-of-life impacts and scientific value; centralized procurement for hospital drugs	Blue list drugs have $58 copay for 3-month supply, subject to $275 out of pocket max/yr
Taiwan	Drugs are purchased through clinics and hospitals; Federal Drug Administration approves drugs but the National Health Insurance Administration does secondary review for prices and reimbursement policy; Drug costs are 50% of other industrialized countries	Co-pays between $7 and $32 depending on the drug
United States	No price controls- whatever the market will bear; government is prohibited from negotiating with drug companies; private sector restricts formularies to control costs	Copayments depend on the insurance plan; seniors bear significant RX costs

 In conclusion, people living in countries with some version of socialized medicine have lower out of pocket expenses than Americans and it appears, equal or much better access to care. Also, France, the Netherlands, Germany, and Switzerland all use private sector insurance along with public health programs, so there is some similarity to the U.S. method of financing health care. The difference is how they regulate price setting for drugs, approval of drugs, as well as benefit mandates for insurance plans. These countries demonstrate it is feasible to have effective healthcare programs through the use of smart regulations driven by efficacy, cost of care and method of delivery. What are Americans afraid of?

 And this the healthpolicymaven signing off encouraging you not to sign blanket medical releases when checking-in for medical procedures, do specify that for which you consent and decline.

 Roberta Winter is an independent journalist who accepts no money from any sector of the healthcare industry. Opinions expressed here are her own.  This column has been in continuous publication since 2007. In 2013, Rowman and Littlefield published her guidebook to the US healthcare system. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 

References

Emmanuel, E. J. (2020). Which Country Has the World's Best Health Care? In E. J. Emmanuel, Which Country Has the World's Best Health Care? Hachette Book Group. Retrieved November 2021

Kaiser Family Foundation. (2017, September 9). Employer Health Benefits Survey-2017. Retrieved December 2, 2021, from Kaiser Family Foundation.org: https://www.kff.org/report-section/ehbs-2017-summary-of-findings/

Kaiser Family Foundation. (2020, October 8). 2020 Employer Health Benefits Survey. Retrieved December 2, 2021, from Kaiser Family Foundation.org: https://www.kff.org/report-section/ehbs-2020-summary-of-findings/

The Commonwealth Fund.org. (2017). Out-of-Pocket Health Care Spending Per Capita. commonwealthfund.org. Retrieved December 1, 2021, from https://www.commonwealthfund.org/out-pocket-health-care-spending-capita

World Population Review. (n.d.). Median Income By Country 2021. Retrieved December 1, 2021, from World Population Review.com: https://worldpopulationreview.com/country-rankings/median-income-by-country

 

 

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[1] https://www.kff.org/report-section/ehbs-2017-summary-of-findings/

[2] https://www.nyjournalofbooks.com/book-review/which-country

[3] https://www.commonwealthfund.org/out-pocket-health-care-spending-capita

[4] https://worldpopulationreview.com/country-rankings/median-income-by-country

How the US Healthcare System Compares to Other Large Democracies

Comparison of Large Democracy Health Systems

Continuing the informed conversation on health systems from the previous post[1], this table shows how the US compares to several large democracies with national healthcare systems which include private insurance and clinics.

Criteria	France	Germany	Australia	USA
National mandate for healthcare access and insurance protection	Insurance is provided to up to 99% of residents; hospitals are owned by the government; clinics can be public or private; health insurance is required, through three government run companies; workers pay up to 8% of income and employers pay 13% as a wage tax	Insurance is mandated for all and residents pay up to 8% of gross income into the nonprofit state-run insurance program;employers and employees contribute to a comprehensive health, long term care, and accident protection program; insurance may be either public or private; group healthcare was standardized here in 1883	Has a national healthcare system called Social Security, which provides hospital coverage, but not  all of outpatient care; financed by 1.5% tax on gross income (2.5% if you lack private supplemental insurance)	Hodge podge system, VA and private insurance varies widely by region; medical insurance was mandated under the PPACA but was reversed by Trump; Medicare is paid by a 1.45% payroll tax on workers and employers; lack of hospital price transparency
Public versus private care hospital overview	62% are Public 24% are private nonprofit and 12% are for-profit hospitals	50% are Public hospitals and the rest are a mix of nonprofit and for profit	66% are public hospitals, 33% private; public hospital care is free to residents	20.% government owned hospitals, 58.5% are nonprofit and 21.3% are for profit
Specialty care is readily available	Yes, doctors even make house calls	Yes	Yes, in western Australia, less so elsewhere	Yes, if you have the money to pay
Hospital bill per discharge	$11,149	$6,122	$10,874	$21,186
Private insurance is available	Yes	Yes	Yes	Yes, and is a must if you want care
Cost of healthcare per capita	$4,600	$5,551	$4,708	$9,892
Cost of care born by government	86%	85%	69%	51%
Average cost of health care paid by residents per month	10€ or $11, very small co-payments; referrals may be required for specialists in order to get max benefits	Germany limits cost-sharing to a 2% max of income, which is a little over $100 per month; All Germans contribute to the healthplan, roughly 400€ or $500	$167/person is the average cost for private insurance/person; co-payments are limited to $25	CMS estimates Americans spend $267 in out of pocket expenses and over $500 for insurance premiums
Per capita spend for insurance administration	$272	$255	$123	$787

Conclusions

The American people pay a much higher percentage of total health system costs than residents in the other democracies. And residents of the US are not getting better quality care for that huge disparity. Considering the average cost for unreimbursed care and the typical insurance contribution born by an American worker, totals $9,200 per year, this money could be invested for a healthy retirement savings or to purchase a home. Voters of millennial-age are realizing this rip-off, which is why they support transformation in the government through Bernie Sanders and Elizabeth Warren. It has taken a few decades but the majority of Americans are finally realizing the current system of healthcare in the US is failing them.

And this is the healthpolicymaven signing off, encouraging you NOT to sign blanket releases when you have inpatient procedures done, do indicate that for which you consent and that for which you decline. If you are intimidated by medical jargon and administration procedures, bring an advocate.

References

Institute for Quality and Efficiency in Health Care. (2018). Health Care in Germany; The German Health Care System. NCBI, NLM,National Institutes of Health.gov. Informed Healthcare.org. Retrieved September 30, 2019, from https://www.ncbi.nlm.nih.gov/books/NBK298834/

Petersen-Kaiser Health System Tracker. (2019, September 30). Petersen-Kaiser Health System Tracker. Retrieved from Henry J. Kaiser Foundation.org: https://www.healthsystemtracker.org/indicator/access-affordability/percent-insured/

The Commonwealth Fund.org. (2019, September 30). International Health Care System Profiles. Retrieved from The Commonwealth Fund.org: https://international.commonwealthfund.org/countries/

Tikkanen, R. (2019, September 30). Multinational Comparison of Health Systems Data, 2017. Retrieved from Commonwealth Fund.org: https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_chartbook_2017_multinational_comparisons_of_health_systems_data_2017_rtikkanen_pdf.pdf

Transferwise.com. (2019, September 30). Healthcare in France: A Guide to the French Healthcare System. Retrieved from Transferwise.com: https://transferwise.com/us/blog/healthcare-system-in-france

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[1] https://healthpolicymaven.blogspot.com/2019/09/debunking-myths-about-national.html