The ideology lives on in the modern German system. Everyone covered by statutory insurance has an equal right to medical care. Baberg likens the difference between statutory and private health insurance in Germany to the difference between economy and business class on a commercial airline flight.
And the system imposes strict limits on out-of-pocket costs, greatly reducing the number of surprise medical bills. Helene and Michael Sula, both originally from Dallas, are also expatriates like Reich. Unlike Reich, however, they pay for private health insurance. The couple said Helene Sula was lucky to find a doctor who could do an MRI quickly once back in Germany; most places they called were booked for weeks — a common disadvantage for elective procedures.
They credited their private health insurance not only with getting a swift diagnosis, but also insisting on having the best surgeon available to do the operation necessary to repair her injured knee. Despite some language barriers, the Sulas said the German health care system was easy to navigate. Health care industry experts in the United States say the German system is a good example of an employer-based model of medical insurance.
But Osborn does not recommend the U. We have pockets of excellence. The U. Government, not — for — profit, and for — profit institutions all play a role in health care markets. Primary care physicians in the United States function in the private for — profit sector and operate in group practices, although some physicians work for not — for — profit clinics or in public organizations.
In the hospital industry, the not — for — profit is the dominant form of ownership. Not — for — profit hospitals control about 70 percent of all hospital beds.
A different picture can be seen in the nursing home industry, where 70 percent of all nursing homes are organized on a for — profit basis Santerre and Neun 52 5.
Up to the early s most insured individuals had full choice of health care providers in the United States. Consumers could choose to visit a primary care giver or the outpatient clinic of a hospital, or see a specialist if they chose to. The introduction of various Managed Care Organizations and such new government policies as selective contracting a situation when a third party contracts exclusively with a preselected set of medical providers have limited the degree to which consumers can choose their own health care provider.
For example, those individuals belonging to a staff HMO must receive their care exclusively from that organization; otherwise they are fully responsible for the ensuing financial burden.
The primary care giver acts as a gatekeeper and must refer the patient for additional care. The lower premiums of a staff HMO compensate consumers at least to some degree for the restriction of choice. Even those individuals belonging to the less restrictive PPO face a financial penalty when choosing health care providers outside the network. Unlike in Canada and Europe, where a single payer — system is the norm, the United States possess a multiplayer system in which a variety of third — party payers, including the federal and state governments and commercial health insurance companies are responsible for reimbursing health care providers.
Reimbursement takes on various forms depending on the nature of the third party payer. The most common form of reimbursement is fee — for — service, although prospective payment a method of payment used by third — party payers in which payments are made on a case by case basis and prepaid health plans are becoming more popular.
Most traditional health insurance plans reimburse health care providers on a fee for service basis. Health care providers contacting with most MCOs are paid on a fee — for — service basis. Physician services under Medicare and for the most part Medicaid as well are also reimbursed on a fee for service basis, but the fee is fixed by the government. This means the fee was limited to the lowest of the three charges: the actual charge of the physician, the customary charge of the physician, or the prevailing charge in the local area.
The RVS is transformed into a schedule of fees when it is multiplied by a dollar conversion factor and a geographic adjustment factor that allows fees to vary in different locations Santerre and Neun Under both Medicare and Medicaid, the physician can choose to accept assignments of patients.
If the physician accepts the assignment, he or she agrees to accept the government determined fee in full and cannot charge the patient an additional amount beyond the normal 20 percent co-payment. The physician must also agree to treat all Medicare patients for all services. A physician who does not accept assignment can charge patients a price higher than the Medicare fee and accept patients on a case-by-case basis.
In contrast to the fee — for — service method, some health care providers are paid on a fixed — fee or prospective basis. For example, the consumer prepays the staff HMO, and physicians are paid on a salary basis. The consumer also prepays the individual practice association HMO, however, health care providers are usually paid on a fee — for service or capitation basis.
Since , the federal government has reimbursed hospitals on a prospective basis for services provided to Medicare patients. A prospective payment is established for each DRG.
The prospective payment is claimed to provide hospitals with an incentive to contain costs. Beginning in the early s, many states instituted selective contacting, in which various health care providers competitively bid for the right to treat Medicaid patients. Under selective contracting, recipients of Medicaid are limited in the choice of health care provider.
The advanced state of technology is the greatest strength of the U. Premature babies for example, face relatively good chance of surviving if they are born in the United States because of the state of technology. A relatively high life expectancy after age 80 is another reflection of the advanced state of health care technology in the United States. People 80 years and older in the U. Also the United States continues to be the world leader in pharmaceutical innovation.
These products save, extend and improve the quality of lives. Unfortunately, the U. Its most glaring weakness is exemplified by the fact that more than 42 million people are without health insurance.
The inability to successfully control costs is another major weakness of the U. The growth of health care costs continues unabated, although the pace has slowed in recent years mostly due to the influence of managed — care organizations.
Whether managed care can continue to slow the growth of health care costs remains questionable. Eliminating the weaknesses while maintaining the strengths is a challenge faced by any plan for changing the U. Empirical Evidence and International Comparisons.
From the table we can see that the United States has the largest GDP per capita and the largest health care spending per capita. The number of physicians per , number of hospital beds per and average length of stay days are largest in Germany.
The United States is ranked at the bottom of the list in terms of hospital beds per at 3. Medical care spending in the U. Comparative Health Care System statistics for these three countries show that the United States has the highest infant mortality 7. The mortality rate in Canada is 5. The percent of population greater than 65 years according to data is One interesting question is whether people in various nations are satisfied with their current health care system.
From the data several conclusions are worth mentioning. The first is that Canadians are most satisfied with their health care system. The Canadian health care system offers national health insurance financed by taxes, private production of health care services, and regulated budgets and fees for health care providers.
The second conclusion to be drawn is that people in the United States are the least satisfied with their current health care system. In addition, 3 out of every 10 respondents in the United States believed the health care system requires a complete restructuring.
The surveyors speculated that the dissatisfaction with the present U. The third conclusion is that the presence of a national health care or socialized medicine plan does not guarantee high levels of consumer satisfaction. Source: Robert J. The data suggests that the Canadian and German systems appear to be more effective than the U. Costs are lower, more services are provided, financial barriers do not exist, and health status as measured by mortality rates is superior.
Canadians and Germans have longer life expectancies and lower infant mortality rates than do U. However, the comparisons do not tell the whole story, nor do they necessarily imply that the United States should adopt the Canadian or German approach. Some have argued that a system that is manageable for a population of 30 or 80 million people cannot easily be adapted to a more pluralistic, heterogeneous country with a population of nearly million.
Many Canadians are no longer confident that the provinces will be able to afford their current systems. As a result of unprecedented federal deficits the Canadian government has reduced substantially its cash transfers to the provinces. A recent government study indicated that 4. Overworked technology is one reason for the long lines; others include a shortage of nurses and inefficient management of hospital and other health care facilities, according to several studies Krauss 3.
Waiting times have also increased because an aging population has put more demands on the system, while the current generation of doctors is working fewer hours than the last. Waiting can occur at every step of treatment. A study by the conservative Fraser Institute concluded that patients across Canada experienced average waiting times of In an effort to reduce waiting lists, some Canadian provinces Alberta, Nova Scotia and Ontario have established about 30 private MRI and CT clinics, some of which offer non emergency services to be paid for by private insurance.
But in the context of slower economic growth, stagnant incomes, and a consensus that labor costs cannot rise much more without disastrous effects on competitiveness and employment, payroll based financing is not a sufficient revenue based Giaimo Even if payroll taxes were permitted to rise, the resultant unemployment and inactivity could, in the end, lead to a financing crisis of the social insurance system. A number of proposals aimed at putting health care financing on a sounder and more equitable footing were presented in the late s.
These included raising the income ceiling for contributions, bringing civil servants and the self employed into statutory health insurance, and bringing non—wage income and assets under the contribution levy.
Other proposals would have simply shifted costs from employers to employees. However, there was no real political support for this proposal and the immediate outcome was political paralysis. Future German governments face difficult choices in continuing to ensure that all individuals have access to high quality care at an affordable cost.
Thus far, however, the political and sectoral configurations underlying German health politics have impeded radical changes in governance or financing. Most stakeholders still want to maintain the status quo. However, the situation is dynamic, not set in stone.
The power of preferences of politicians could change in the future in ways that would tolerate a bolder departure from the present governance system or radical changes in financing. Such changes could either expand or undermine solidarity — or they might prompt a search to redefine it.
Given the presence of powerful countervailing forces in the health sector and in the political arena, successful adjustment will likely hinge on forging a consensus with these stakeholders over a new conception of solidarity that continues to ensure broad provision, spreads the burden of adjustment fairly, and shelters the most vulnerable from harm Giaimo From the discussions that were presented above we can see that the prices and expenditures on various medical services continue to rise in the US, although at a slower rate than in the past.
The transition to managed care health care system has helped to promote some cost savings in various medical care markets but has also resulted in some rationing of care. Choice of physician, physician autonomy and income, hospital inpatient admissions, and selection among pharmaceutical products have all been greatly limited by the movement to a managed care health care system in the United States.
These limitations pertain not only to private managed care insurance plans but also to managed care plans under the auspices of the Medicare and Medicaid programs. Moreover, it seems that competition in the health care sector may have sown the seeds of its own destruction.
For instance, benefit denial and cherry picking behavior take place in the private health insurance industry because of competition. Induced demand in the physician services industry and the medical arms race in the hospital industry are argued to occur because of competition Santerre and Neun 9. In the discussion, it is important to compare the US health care system with health care systems in other advanced industrialized countries. Canada and Germany involve a single payer system rather than a multiple payer system like that of the US.
Their health care systems provide nearly universal access to medical care services and involve a greater financing and regulatory role for the federal government and less reliance on competition in health care matters. The available data suggests that the US spends more on medical care as a fraction of GDP than to the other two countries. Comparatively high health care expenditures coupled with low medical utilization rates have led some to believe that medical prices must be significantly higher in the US than in the other two countries.
The quality of medical services may be higher in the US and account for the alleged higher medical prices. Evidence suggests that waiting times are shorter for most medical services in the United States. Many analysts have concluded that health care costs and infant mortality are lower in other countries because a government plays a more dominant role in the health care sector and because there is universal access to health insurance.
Many health care policy analysts believe that a similar approach can produce better results in the US.
Many people in the US are dissatisfied with the performance of the health care system. The cost of health care in the United States is alleged to be rising faster than in any other country. Many worry that the health care monster will continue to devour an increasingly large slice of the economic pie.
Moreover, at any one point in time, critics note that one out of every six non—elderly citizens lacks insurance coverage for acute care. Many others in the US are seriously underinsured or lack proper long-term care insurance coverage. A number of health care analysts and policy makers are searching for ways to improve the American health care system. Various groups have advanced a large number of health care reform plans.
The plans differ in a number of respects, especially concerning the role the individual, employer and government play in the financing of medical insurance and the functions the government and marketplace serve in the allocation of health care resources.
Several distinctive new approaches and plans have been proposed to improve and reform the US health care system. Four different approaches have surfaced in recent times; those include medical savings accounts, individual mandates, managed competition and national health insurance Santerre and Neun Medical savings accounts programs are not designed to achieve universal coverage.
However, health insurance premiums should become more affordable when they become tax deductible and apply mainly to catastrophic plans. Tax credits and subsidies are used to make health insurance more affordable for poor individuals. The plan is financed primarily out of individual contributions to medical savings accounts.
The government expenditures on Medicare and Medicaid would end and the deficit should diminish accordingly. A reduction in administrative expenses also translates into cost savings The individual mandates plan is implemented through mandated insurance coverage and a guarantee by the government that basic medical coverage is available across the country.
Tax credits and subsidies are available to make coverage affordable to all. Under this plan near universal coverage would be attainable. The plan is financed largely by premium payments by consumers either directly or through employers.
A tax increase is necessary which negatively affects the budget deficit. Under this plan, both Medicare and Medicaid would be eliminated. Costs are contained through the maintenance of a highly competitive medical insurance market. Private insurance vendors are disciplined by the market place to provide competitive prices to consumers.
She visited her general practitioner, who wrote her a prescription. The problem hadn't gone away several days later, so the doctor referred her to a specialist for a gastroscopy. Everything was very efficient. Instead, the bill was paid by the Barmer GEK sickness fund, one of about such nonprofit insurance collectives in the country. Every German resident must belong to a sickness fund, and in turn the funds must insure all comers.
Workers pay half the cost of their sickness fund insurance, and employers pay the rest. The German government foots the bill for the unemployed and for children. It should, since this is very similar to the health-insurance regime that Americans are now living under, now that the Affordable Care Act is four years old and a few days past its first enrollment deadline. All Americans are now required to have health insurance or to pay a fine, and insurers cannot deny coverage to anyone, regardless of pre-existing conditions.
There are, of course, a few key differences. Co-pays in the German system are minuscule, about 10 euros per visit. Even those for hospital stays are laughably small by American standards: Sam payed 40 euro for a three-day stay for a minor operation a few years ago. Included in that price was the cost of renting the TV remote. In Germany, employees' premiums are a percentage of their incomes, so low-wage workers simply pay rock-bottom insurance rates.
But a small segment 13 percent of the population, generally the very wealthy, can opt-out and instead go with the private Krankenversicherung , which follows rules more similar the pre-Obamacare U. You can think of this setup as the Goldilocks option among all of the possible ways governments can insure health. It's not as radical as single-payer models like the U.
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