I recently talked about what ‘free’ health care in countries like Britain, Canada, and Norway actually costs and showed that not only are they not free, they can also involve significant out of pocket costs. But the world has a lot of systems other than single payer and these systems too have important lessons for the US on controlling, or failing to control, citizens’ health care costs. As models for the US, they are far more instructive examples than single payer systems, since they share elements of the existing American system.
France has a two tier system with both government funded care and privately purchased insurance. Employers pay around 12.8 percent of payroll for health care. Employees pay 0.75% of their salaries towards health care, plus a 7.5 percent General Social Contribution, the majority of which is earmarked for the health system. This base coverage reimburses people for the majority of costs for visits to the doctor, usually 75-80 percent and for a portion of the costs of medications, with how much depending on the type of drug. On top of the government coverage, almost all French residents have supplementary coverage from a mutuelle, often also through their workplaces. While the cost of these plans varies based on a number of factors, it is approximately 2.5 percent of salary. The mutuelle reimburses much of the leftover cost of care. In total, an estimated 10 percent of household income is spent on health care, plus remaining un-reimbursed costs and money spent on treatments not eligible for coverage under the system.
In Germany, most people have coverage through work via a non-profit insurance company called a sickness fund. There is a public system and a private one that serves about 10 percent of the population. Prior to 1 January 2009, coverage from a public sickness fund could range significantly in cost, from around 12.2 to 16.7 percent and in 2007, an average German might pay 6.65 percent of income to the sickness fund and his employer would by 7.55 percent. As of fall 2008, premiums were standardized on the federal level at 15.5 percent. Due to the economic downturn, on 1 July 2009, they are reduced to 14.9 percent. Private sickness funds generally charge more. Germans also pay small co-pays for doctor’s visits and on drugs. Health insurance in the Netherlands is linked to employment. Each person pays an “income-related contribution,” 7.2 percent of income up to €31,200 for 2008, which is reimbursed by their workplace. This reimbursement money is taxable income. On top of this, the Dutch pay a premium per adult (children are free). They also pay taxes that are used to subsidize people who cannot afford health insurance on their own. Premiums for basic coverage cost around €1,028 in 2006 per adult, €1,100 in 2008 (~$1600) and usually has a deductible of €150, although those willing to accept higher deductibles can get lower premiums. However, around 90 percent of people in the Netherlands opt to get more expensive plans that offer greater coverage.
Finally, let’s look at Switzerland, where the system is unusual because it dispenses with employer provided health care and has residents buy their coverage themselves. It also is rare in that like the US insurance companies are allowed to be for profit. There are a wide variety of plans, but all insurers a basic plan, the components of which are federally determined. Families pay a premium for each person, with the prices varying by age, which comes out to an average $680 per month or around $8,167 annually for four people on the basic plan. Premiums are lower or higher depending on the deductible, which can be anywhere from around $250 to about $2000. Those who want more coverage (about 40 percent of the population), pay more, those who need help affording insurance are subsidized. Co-payments on drugs once the deductible has been reached are generally 10 percent and 20 percent if there is a comparable generic for those with the basic plan, up to 933 Swiss francs (~$745) annually in 2006.
Both structurally and in terms of priorities, countries like those discussed above are far more useful comparators for those determining how the US system can be made better than the UK and Canada are. And they are also proof that there is no panacea to the problems of balancing technology and choice with cost and access.
