The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World

Critics of the U.S. health care system frequently point to other countries as models for reform. They point out that many countries spend far less on health care than the United States yet seem to enjoy better health outcomes. The United States should follow the lead of those countries, the critics say, and adopt a government- run, national health care system.

However, a closer look shows that nearly all health care systems worldwide are wrestling with problems of rising costs and lack of access to care. There is no single international model for national health care, of course. Countries vary dramatically in the degree of central control, regulation, and cost sharing they impose, and in the role of private insurance. Still, overall trends from national health care systems around the world suggest the following:

Although no country with a national health care system is contemplating abandoning universal coverage, the broad and growing trend is to move away from centralized government control and to introduce more market-oriented features.

"There are several reasons to be skeptical of these rankings. First, many choose areas of comparison based on the results they wish to achieve, or according to the values of the comparer. For example, SiCKO cites a 2000 World Health Organization study that ranks the U.S. health care system 37th in the world, “slightly better than Slovenia.

This study bases its conclusions on such highly subjective measures as “fairness” and criteria that are not strictly related to a country’s health care system, such as “tobacco control.” For example, the WHO report penalizes the United States for not having a sufficiently progressive tax system, not providing all citizens with health insurance, and having a general paucity of social welfare programs. Indeed, much of the poor performance of the United States is due to its ranking of 54th in the category of fairness. The United States is actually penalized for adopting Health Savings Accounts and because, according to the WHO, patients pay too much out of pocket.19 Such judgments clearly reflect a particular political point of view, rather than a neutral measure of health care quality. Notably, the WHO report ranks the United States number one in the world in responsiveness to patients’ needs in choice of provider, dignity, autonomy, timely care, and confidentiality.

Difficulties even arise when using more neutral categories of comparison. Nearly all cross-country rankings use life expectancy as one measure. In reality though, life expectancy is a poor measure of a health care system. Life expectancies are affected by exogenous factors such as violent crime, poverty, obesity, tobacco and drug use, and other issues unrelated to health care. As the Organisation for Economic Co-operation and Development explains, “It is difficult to estimate the relative contribution of the numerous nonmedical and medical factors that might affect variations in life expectancy across countries and over time.”21 Consider the nearly threeyear disparity in life expectancy between Utah (78.7 years) and Nevada (75.9 years), despite the fact that the two states have essentially the same health care systems.22 In fact, a study by Robert Ohsfeldt and John Schneider for the American Enterprise Institute found that those exogenous factors are so distorting that if you correct for homicides and accidents, the United States rises to the top of the list for life expectancy.

Similarly, infant mortality, a common measure in cross-country comparisons, is highly problematic. In the United States, very low birth-weight infants have a much greater chance of being brought to term with the latest medical technologies. Some of those low birthweight babies die soon after birth, which boosts our infant mortality rate, but in many other Western countries, those high-risk, low birth-weight infants are not included when infant mortality is calculated.24 In addition, many countries use abortion to eliminate problem pregnancies. For example, Michael Moore cites low infant mortality rates in Cuba, yet that country has one of the world’s highest abortion rates, meaning that many babies with health problems that could lead to early deaths are never brought to term.25

When you compare the outcomes for specific diseases, the United States clearly outperforms the rest of the world. Whether the disease is cancer, pneumonia, heart disease, or AIDS, the chances of a patient surviving are far higher in the United States than in other countries. For example, according to a study published in the British medical journal The Lancet, the United States is at the top of the charts when it comes to surviving cancer. Among men, roughly 62.9 percent of those diagnosed with cancer survive for at least five years. The news is even better for women: the five year-survival rate is 66.3 percent, or two-thirds. The countries with the next best results are Iceland for men (61.8 percent) and Sweden for women (60.3 percent). Most countries with national health care fare far worse. For example, in Italy, 59.7 percent of men and 49.8 percent of women survive five years. In Spain, just 59 percent of men and 49.5 percent of women do. And in Great Britain, a dismal 44.8 percent of men and only a slightly better 52.7 percent of women live for five years after diagnosis.26

Notably, when former Italian prime minister Silvio Berlusconi needed heart surgery last year, he didn’t go to a French, Canadian, Cuban, or even Italian hospital—he went to the Cleveland Clinic in Ohio.27 Likewise, Canadian MP Belinda Stronach had surgery for her breast cancer at a California hospital.28 Berlusconi and Stronach were following in the footsteps of tens of thousands of patients from around the world who come to the United States for treatment every year.29 One U.S. hospital alone, the Mayo Clinic, treats roughly 7,200 foreigners every year. Johns Hopkins University Medical Center treats more than 6,000, and the Cleveland Clinic more than 5,000. One out of every three Canadian physicians sends a patient to the Unites States for treatment each year,30 and those patients along with the Canadian government spend more than $1 billion annually on health care in this country.31

Moreover, the United States drives much of the innovation and research on health care worldwide. Eighteen of the last 25 winners of the Nobel Prize in Medicine are either U.S. citizens or individuals working here.32 U.S. companies have developed half of all new major medicines introduced worldwide over the past 20 years.33 In fact, Americans played a key role in 80 percent of the most important medical advances of the past 30 years.34 As shown in Figure 2, advanced medical technology is far more available in the United States than in nearly any other country.35

The same is true for prescription drugs. For example, 44 percent of Americans who could benefit from statins, lipid-lowering medication that reduces cholesterol and protects against heart disease, take the drug. That number seems low until compared with the 26 percent of Germans, 23 percent of Britons, and 17 percent of Italians who could both benefit from the drug and receive it.36 Similarly, 60 percent of Americans taking anti-psychotic medication for the treatment of schizophrenia or other mental illnesses are taking the most recent generation of drugs, which have fewer side effects. But just 20 percent of Spanish patients and 10 percent of Germans receive the most recent drugs.37

Of course, it is a matter of hot debate whether other countries have too little medical technology or the Unites States has too much.38 Some countries, such as Japan, have similar access to technology. Regardless, there is no dispute that more health care technology is invented and produced in the United States than anywhere else.39 Even when the original research is done in other countries, the work necessary to convert the idea into viable commercial products is most often done in the United States.40

By the same token, not only do thousands of foreign-born doctors come to the United States to practice medicine, but foreign pharmaceutical companies fleeing taxes, regulation, and price controls are increasingly relocating to the United States.41 In many ways, the rest of the world piggybacks on the U.S. system."---Pages 3-5

"France provides a basic level of universal health insurance through a series of mandatory, largely occupation-based, health insurance funds. These funds are ostensibly private entities but are heavily regulated and supervised by the French government. Premiums (funded primarily through payroll taxes), benefits, and provider reimbursement rates are all set by the government. In these ways the funds are similar to public utilities in the United States.

In 2006, the health care system ran a €€10.3 billion deficit. This actually shows improvement over 2005, when the system ran an €€11.6 billion deficit.49 The health care system is the largest single factor driving France’s overall budget deficit, which has grown to €€ 49.6 billion, or 2.5 percent of GDP, threatening France’s ability to meet the Maastricht criteria for participation in the Eurozone.50 This may be just the tip of the iceberg. Some government projections suggest the deficit in the health care system alone could top €€29 billion by 2010 and €€ 66 billion by 2020.51

Most services require substantial copayments, ranging from 10 to 40 percent of the cost. As a result, French consumers pay for roughly 13 percent of health care out of pocket, roughly the same percentage as U.S. consumers. 53 Moreover, because many health care services are not covered, and because many of the best providers refuse to accept the fee schedules imposed by the insurance funds, more than 92 percent of French residents purchase complementary private insurance.54 In fact, private insurance now makes up roughly 12.7 percent of all health care spending in France, a percentage exceeded only by the Netherlands (15.2 percent) and the United States (35 percent) among industrialized countries.55

Much of the burden for cost containment in the French system appears to have fallen on physicians. The average French doctor earns just €€ 40,000 per year ($55,000), compared to $146,000 for primary care physicians and $271,000 for specialists in the United States. This is not necessarily bad (there is no “right” income for physicians) and is partially offset by two benefits: 1) tuition at French medical schools is paid by the government, meaning French doctors do not graduate with the debt burden carried by U.S. physicians, and 2) the French legal system is tort-averse, significantly reducing the cost of malpractice insurance.64 The French government also attempts to limit the total number of practicing physicians, imposing stringent limits on the number of students admitted to the second year of medical school.65

Of more immediate concern, global budgets and fee restrictions for hospitals have led to a recurring lack of capital investment, resulting in a shortage of medical technology and lack of access to the most advanced care. For example, the United States has eight times as many MRI units per million people and four times as many CT scanners as France.69 This partially reflects the more technology-reliant way of practicing medicine in the United States, but it has also meant delays in treatment for some French patients. Also, strong disparities are evident in the geographic distribution of health care resources, making access to care easier in some regions than others.70 Thus, while the French system has generally avoided the waiting lists associated with other national health care systems, limited queues do exist for some specialized treatments and technologies. In some cases, hospitals in danger of exceeding their budgets have pushed patients to other facilities to save money.71

Finally, the government has tried to curtail the use of prescription drugs. The French have long had an extremely high level of drug consumption. French general practitioners (GPs) prescribe on average €€ 260,000 worth of drugs a year.72However, the National Health Authority has begun de-listing drugs from its reimbursement formulary.73 Many French patients have responded by switching to similar, reimbursable drugs, but some patients may not be getting the medicine they need. For example, one study found that nearly 90 percent of French asthma patients are not receiving drugs that might improve their condition.74---Pages 8-10

"Italy’s national health care system is rated second in the world by the WHO.89 Yet a closer examination shows the system to be deeply troubled, plagued with crippling bureaucracy, mismanagement and general disorganization, spiraling costs, and long waiting lists.

The Italian government does not provide official information on waiting lists, but numerous studies have shown them to be widespread and growing, particularly for diagnostic tests. For example, the average wait for a mammogram is 70 days; for endoscopy, 74 days; for a sonogram, 23 days.104Undoubtedly, this is due in part to a shortage of modern medical technology. The United States has twice as many MRI units per million people and 25 percent more CT scanners.105 Ironically, the best-equipped hospitals in northern Italy have even longer waiting lists since they draw patients from the poorer southern regions as well.106

Italy has imposed a relatively strict drug formulary as well as price controls, and has thereby succeeded in reducing pharmaceutical spending, long considered a problem for the Italian health care system. In 2006, Italian drug prices fell (or were pushed) 5 percent, even as drug prices rose in the United States and much of the rest of the world. However, the savings came at a cost: the introduction of many of the newest and most innovative drugs was blocked.107

Conditions in public hospitals are considered substandard, particularly in the south. They lack not just modern technology, but basic goods and services; and overcrowding is widespread. Conditions are frequently unsanitary. For example, one of the largest public hospitals in Rome was recently found to have garbage piled in the hallways, unguarded radioactive materials, abandoned medical records, and staff smoking next to patients.108 Private hospitals are considered much better and some regions have contracted with private hospitals to treat NHS patients.

Dissatisfaction with the Italian health care system is extremely high, by some measures the highest in Europe.109 In polls, Italians say that their health care system is much worse than that of other countries and give it poor marks for meeting their needs. Roughly 60 percent of Italians believe that health care reform is “urgent,” and another 24 percent believe it is “desirable.” In general, Italians believe that such reform should incorporate market-based solutions. More than two-thirds (69 percent) believe that giving patients more control over health care spending will improve the system’s quality. And 55 percent believe that it should be easier for patients to spend their own money on health care.110"---Pages 12-14

"Spain’s national health care system operates on a highly decentralized basis, giving primary responsibility to the country’s 17 regions. The Spanish Constitution guarantees all citizens the “right” to health care, including equal access to preventive, curative, and rehabilitative services; but responsibility for implementing the country’s universal system is being devolved to regional governments. The degree and speed of devolution is uneven, however, with some regions only recently achieving maximum autonomy.111

Not surprisingly, health care spending varies widely from region to region. The differences in expenditures, as well as in spending priorities, lead to considerable variance in the availability of health resources. For example, Catalonia has more than 4.5 hospital beds per 1,000 residents, while Valencia has just 2.8.113

Waiting lists vary from region to region but are a significant problem everywhere. On average, Spaniards wait 65 days to see a specialist, and in some regions the wait can be much longer. For instance, the wait for a specialist in the Canary Islands is 140 days. Even on the mainland, in Galacia, the wait can be as long as 81 days. For some specialties the problem is far worse, with a national average of 71 days for a gynecologist and 81 days for a neurologist.114 Waits for specific procedures are also lengthy. The mean waiting time for a prostectomy is 62 days; for hip replacement surgery, 123 days.115

Some health services that U.S. citizens take for granted are almost totally unavailable. For example, rehabilitation, convalescence, and care for those with terminal illness are usually left to the patient’s relatives. There are very few public nursing and retirement homes, and few hospices and convalescence homes.116

There are also shortages of modern medical technologies. Spain has one-third as many MRI units per million people as the United States, just over one-third as many CT units, and fewer lithotripters.121 Again, there is wide variation by region. For example, two regions, Ceuta and Melilla, do not have a single MRI unit.122 The regional variation is important because Spaniards face bureaucratic barriers in trying to go to another region for treatment.

As a result, Spain has fewer physicians and fewer nurses per capita than most European countries and the United States. The lack of primary care physicians is particularly acute.124"---Pages 14-15

"Norway has a universal, tax-funded, singlepayer, national health system. All Norwegian citizens, as well as anyone living or working in Norway, are covered under the National Insurance Scheme. Norwegians can, however, opt out of the government system by paying out of pocket. In addition, many Norwegians go abroad for treatment to avoid the waiting lists endemic under the government program.151

The Norwegian health care system has experienced serious problems with long and growing waiting lists.161 Approximately 280,000 Norwegians are estimated to be waiting for care on any given day (out of a population of just 4.6 million).162 The average wait for hip replacement surgery is more than four months; for a prostectomy, close to three months; and for a hysterectomy, more than two months.163 Approximately 23 percent of all patients referred for hospital admission have to wait longer than three months for admission.164"---Pages 18-19

"Almost no one disputes that Britain’s National Health Service faces severe problems, and few serious national health care advocates look to it as a model. Yet it appears in Moore’s movie SiCKO as an example of how a national health care system should work, so it is worth examining.

And that level of services leaves much to be desired. Waiting lists are a major problem. As many as 750,000 Britons are currently awaiting admission to NHS hospitals. These waits are not insubstantial and can impose significant risks on patients. For example, by some estimates, cancer patients can wait as long as eight months for treatment.236 Delays in receiving treatment are often so long that nearly 20 percent of colon cancer patients considered treatable when first diagnosed are incurable by the time treatment is finally offered.237

In some cases, to prevent hospitals from using their resources too quickly, mandatory minimum waiting times have been imposed. The fear is that patients will flock to the most efficient hospitals or those with smaller backlogs. Thus a top-flight hospital like Suffolk East PCT was ordered to impose a minimum waiting time of at least 122 days before patients could be treated or the hospital would lose a portion of its funding.238

The problem affects not only hospitals. There are also lengthy waits to see physicians, particularly specialists. In 2004, as a cost-cutting measure, the government negotiated low salaries for general practitioners in exchange for allowing them to cut back the hours they practice. Few are now available nights or weekends.240 Problems with specialists are even more acute. For example, roughly 40 percent of cancer patients never get to see an oncology specialist.241

The government’s official target for diagnostic testing is a wait of no more than 18 weeks by 2008. In reality, it doesn’t come close.242 The latest estimates suggest that for most specialties, only 30 to 50 percent of patients are treated within 18 weeks. For trauma and orthopedics patients, the figure is only 20 percent. Overall, more than half of British patients wait more than 18 weeks for care.243

Explicit rationing also exists for some types of care, notably kidney dialysis, open heart surgery, and some other expensive procedures and technologies.244 Patients judged too ill or aged for the procedures to be costeffective may be denied treatment altogether."---Pages 23-25

"Canada is another country that did not make the top 20 health care systems in the WHO rankings (it finished 30th), and few serious advocates of universal health care look to it as a model. As Jonathan Cohn puts it, “Nobody in the United States seriously proposes recreating the British and Canadian system here—in part because, as critics charge . . . they really do have waiting lines.”312 However, since the press still frequently cites it as an example, it is worth briefly examining.

Although Canada is frequently referred to as having a “national health system,” the system is actually decentralized with considerable responsibility devolved to Canada’s 10 provinces and 2 territories. It is financed jointly by the provinces and the federal government, similar to the U.S. Medicaid program. In order to qualify for federal funds, each provincial program must meet five criteria: 1) universality—available to all provincial residents on uniform terms and conditions; 2) comprehensiveness—covering all medically necessary hospital and physician services; 3) portability—allowing residents to remain covered when moving from province to province; 4) accessibility—having no financial barriers to access such as deductibles or copayments; and 5) public administration—administered by a nonprofit authority accountable to the provincial government.

Waiting lists are a major problem under the Canadian system. No accurate government data exists, but provincial reports do show at least moderate waiting lists. The best information may come from a survey of Canadian physicians by the Fraser Institute, which suggests that as many as 800,000 Canadians are waiting for treatment at any given time. According to this survey, treatment time from initial referral by a GP through consultation with a specialist, to final treatment, across all specialties and all procedures (emergency, nonurgent, and elective), averaged 17.7 weeks in 2005.315 And that doesn’t include waiting to see the GP in the first place.

Defenders of national health care have attempted to discount these waiting lists, suggesting that the waits are shorter than commonly portrayed or that most of those on the waiting list are seeking elective surgery. A look at specialties with especially long waits shows that the longest waits are for procedures such as hip or knee replacement and cataract surgery, which could arguably be considered elective. However, fields that could have significant impact on a patient’s health, such as neurosurgery, also have significant waiting times.316 In such cases, the delays could be life threatening. A study in the Canadian Medical Association Journal found that at least 50 patients in Ontario alone have died while on the waiting list for cardiac catheterization.317 Data from the Joint Canada–United States Survey of Health (a project of Statistics Canada and the National Center for Health Statistics) revealed that “thirty-three percent of Canadians who say they have an unmet medical need reported being in pain that limits their daily activities.”318 In a 2005 decision striking down part of Quebec’s universal care law, Canadian Supreme Court Chief Justice Beverly McLachlin wrote that it was undisputed that many Canadians waiting for treatment suffer chronic pain and that “patients die while on the waiting list.”319

Clearly there is limited access to modern medical technology in Canada. The United States has five times as many MRI units per million people and three times as many CT scanners.320 Indeed, there are more CT scanners in the city of Seattle than in the entire province of British Columbia.321

Physicians are also in short supply. Canada has roughly 2.1 practicing physicians per 1,000 people, far less than the OECD average. Worse, the number of physicians per 1,000 people has not grown at all since 1990. And while the number of nurses per 1,000 people remains near the OECD average, that number has been declining since 1990.322

In addition, although national health care systems are frequently touted as doing a better job of providing preventive care, U.S. patients are actually more likely than Canadians to receive preventive care for chronic or serious health conditions. In particular, Americans are more likely to get screened for common cancers, including cancers of the breast, cervix, prostate, and colon.323

Canadians may jealously guard their system and resist “Americanizing” it, but even advocates of universal health care are coming to recognize that it does not provide a valid model for U.S. health care reform.---Pages 31-33

Note: these The excerpts were cherry-picked ... I thought they either highlighted interesting facts or made excellent points. I highly recommend you download the entire Policy Analysis.

Additionally, if you are seeking further research on socialized medicine, view my thread - High-Priced Pain: What to Expect from a Single-Payer Health Care System (SICKO?) or the try the original Heritage link.

Other good resources:

“Lives at Risk” by Goodman et al.

“Top 10 Myths of US Health Care” by Pipes.

“Your Doctor is Not In,” by Orient

Interessting. But if someone is interessted in a oppinion
from someone living in europe. It really looks like that both “sides” in the US tend to only pick out the negative (depends if people are pro or contra) or only the positive affects of so called “socialzied” health
care and ignore everything else. From a neutral observation i have yet to read a somehow “ballanced” observation. One side says “it´s the heaven on earth” (it´s not) the other side says it´s the worst thing that ever could happen (wich is not true too).

They point out that many countries spend far less on health care than the United States yet seem to enjoy better health outcomes.

The key word here is "seem."

Compare the life expectancy of blacks in the U.S. to that of blacks in Africa and then tell us how awful our healthcare is.

The data being cited by those who make this argument are not valid. But what do they care ... anything to make the U.S. sound like a horrible place.

Without the successful US system that subsidizes the rest of the world, things will only get worse in these countries-————————————
Sorry but this is not true the US does not subsidize
the rest of the world in health care.
If you are not a 3rd world country (they get some subsidize but not only from the US)
every country is on its own when we talk about health care.

"Now back in 1927 an American socialist, Norman Thomas, six times candidate for president on the Socialist Party ticket, said the American people would never vote for socialism. But he said under the name of liberalism the American people will adopt every fragment of the socialist program. One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It's very easy to disguise a medical program as a humanitarian project. Most people are a little reluctant to oppose anything that suggests medical care for people who possibly can't afford it."--Ronald Reagan

Heed Ronald Reagan's Warning

To me, if the government is controlling it and does so at the expense of my personal liberty, independence, and ability to decide what is best for my family, it is a nightmare.

Based upon all the evidence we have of everything the US government has taken over, whatever they touch turns to shit very soon.

I don’t want to risk that my family cannot find adequate medical care because of some effed up egomaniacal bureaucrat who deems me to be of the incorrect race or religion or income group or whatever other reason they have for making a decision that harms me or my family, and that should be a decision that I and my doctor make.

Well, I’d have to strongly disagree. Socialized health care is the worst thing that happen to health care if you believe in free markets, the Constitution, limited government, and liberty.

The problem in my personal oppinion is that there is no
generall definition that would fit for the so called socialized health care in europe for example.
Because the systems differ a lot from country to country.
And having acess to so called socialized health care does not necessarily mean that the state runs the show or that
you are forced to pay into this system.

One other funny note. In just about every country that has socialist medicine, it is next to impossible to sue a medical professional for malpractice. That is one way they keep costs down.

Of course, we're not doing anything to stop that here.

No, this is just a problem with affluence. People fail to appreciate the staggering advances we’ve had in the past 200 years ... America has the most advanced medical technology in the world or for that matter, in human history. Granted, there are incidents of medical mishaps, but that’s the the tendency of people to focus on bad forgetting the enormously positive stories that literally saved countless people. I am very aware that America’s system has problems, no doubt about it, but we could do worse to mimic other countries.

We have something they don’t that will make nationalized health care in this country much worse:

Lawyers

i do agree on the lawers. This really looks like it totally
got out of controll in the US. (Don´t get me wrong i´m not here to criticize the US system or to say there exists something better.) But as an foreigner it sometimes reallly looks bizzare how much money you can “earn” if you just sue
the “right company” with the “right” lawer.
But i guess this is more a legal “problem” (of course only if it is considered as a problem in the US because i really don´t know). So it definitely affects insurance companys and the “whole” system in a way. But to change this you would have to change some general laws too which have nothing to do with the current health care system.
greetings

Again i have to disagree. It´s not true that “America has the most advanced medical technology in the world “ The truth is america has acess to the “most advanced medical technology in the world” like every other industrialized western country if you are able to pay for it.
The only problem is that while “we all” have this technology it´s still limited because right now no one
has found a perfekt working system for every one.
The different systems have both winners and losers.

"Moreover, the United States drives much of the innovation and research on health care worldwide. Eighteen of the last 25 winners of the Nobel Prize in Medicine are either U.S. citizens or individuals working here.32 U.S. companies have developed half of all new major medicines introduced worldwide over the past 20 years.33 In fact, Americans played a key role in 80 percent of the most important medical advances of the past 30 years.34"

I posted this again from above...America has a very disproportionate share in the development of medical advances and maedications. We produce and invent more. Even the research in other countries...in order to be implemented...has to be done in the U.S. Further, every country can have access, but the American people have the greatest access in the entire world. As a "non-U.S. citizen," which is how you described yourself in a post above, you clearly miss the best system available (there isn't a perfect system) and that is to pursue a purely market-based solution for health care as opposed to the proposition that some how, some way there is a government with a group of politicans that plan health care for the rest of us. In fact, Government involvement usually centers around a false notion of a right to health care or that we must provide health care for people through the government when they prove themselves unable.

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