USA | Ted Marmor
Healthcare inflation in the US is twice or more the rate of general inflation – and labour and management complaints about rising health insurance premiums are omnipresent.
The US is the world’s highest spender on medical care, whether per capita or total costs. A safe guess is that 16% of the nation’s income went on medical care last year. American doctors are the best paid in the world, among the angriest and include an overwhelming proportion of specialists. They are angry because they are the objects of more extensive regulation by private health insurance payers than would be imaginable in the UK.
The public sector pays at least half of all healthcare expenditure, both for Medicare (the major social insurance scheme covering the elderly and disabled), and Medicaid (the comparable state-administered programme for many of America’s poor). When tax relief for private health insurance is added on, public financing for US healthcare is more than 50%.
American medicine includes the most advanced technical interventions, yet there is a widespread sense of malaise. Overwhelming proportions of citizens and leaders list healthcare as the most important domestic problem.
Ted Marmor is Professor of Public Policy and Management, Yale School of Management
Holland | Kieke Okma
In January 2006, the Dutch health insurance system shifted from a dual system (65% mandatory social insurance and 35% voluntary private health insurance) to one universal health insurance – or rather, one mandate for all to take out private insurance.
Average premiums are about €100 per person per month. The maximum amount of subsidy is €35 per month. That premium covers about 50% of costs. The remaining 50% is channelled as earmarked employment taxes, with other social insurance contributions. Citizens can switch insurer every year, and insurers have to accept everyone for basic coverage at community-rated premiums.
The extent of competition is new, so insurance agents can now act as ‘for profit’ companies who can selectively contract health services for their insured.
The changeover went remarkably smoothly. Most citizens seem to have adjusted to the new situation, and many have developed skills to compare insurance options.
As elsewhere, Dutch citizens seem less keen to embrace ‘consumer choice’ once it curtails their access to health services (when their new insurer happens to not have contracted their family physicians or dentist). Most experts expected major premium hikes in 2008, but early signs suggest that average premiums will rise less than 10%. The true proof of the competition pudding – whether competing health insurance agencies will engage in actively contracting health services to improve quality and patient-friendliness of care, while reining in costs – remains to be seen.
Kieke Okma is Visiting Professor at Mailman School of Public Health, Columbia University. She held senior advisory roles to the Hague health ministry 1989-2004
South Africa | Di McIntyre
Many would consider the South African health system as striving to emulate the least desirable system in the world – that of the US. More funds (nearly 50% of all healthcare funding) flow via hundreds of private voluntary insurance schemes than any other financing intermediary, but these schemes only cover about 15% of the population.
Despite, or maybe because of, investing in American-style ‘managed care’, members of these schemes pay a high price for limited service benefits. Some of those who are not members of these schemes pay out-of-pocket to use private general practitioners and purchase medicines at private pharmacies, but most South Africans depend on under-funded publicly provided healthcare, particularly at hospital level.
Since the first democratic elections in 1994, much has been done to improve public sector services (for example, building of new clinics, improved staffing of rural facilities and removing fees for primary healthcare at public facilities), but even more remains to be done.
Di McIntyre is Associate Professor of Public Health, University of Cape Town, South Africa
