This article compares the health systems of four nations: the United States, Canada, France, and the United Kingdom. The dimensions of comparison include organization and structure, access and coverage, and financing mechanism. The political influences on the development of health systems are also briefly considered.
Keywords Health Care Access; Health Care Finance; Health Care Systems; Health Insurance; Medicare; National Health Insurance; National Health Service; Universal Coverage
Health Care Management: Comparative Health Systems
The financing and delivery of health services in the context of a national health care system is a vast and complicated enterprise. Despite its political and fiscal importance, no one nation has to yet to design and implement a health care system that meets everyone's needs — everyone being consumers, providers, insurers, and governments. No matter the system and no matter the relative satisfaction with the system by any one constituent's criteria, policymakers in all nations are always tweaking and tinkering with their systems to improve fiscal stability and health outcomes for their citizens (Klein, 2003).
Because the issue of health care is a complex one, comparing health systems requires selecting specific dimensions on which to provide comparison. For the purposes of this essay, health systems are compared on three dimensions:
- Structure and organization.
- Access and coverage.
- Financing mechanisms.
The countries for comparison are the United States, the United Kingdom, Canada, and France. These countries were selected because they are all economically developed nations and represent both similarities and differences on each of the three comparative dimensions. Less developed nations pose their own unique differences from nations with advanced economies and therefore would be less instructive for the purposes of this essay.
The structure and organization of a nation's health care system is composed of health care providers (physicians, nurses, dentists, pharmacists, and others) and health care facilities (hospitals, clinics, and long term care facilities). Providers and facilities can be either public (i.e. government owned and operated) or private (independently owned and operated). The United States has a primarily private system of providers and facilities, with the exception of Veteran's Administration hospitals and clinics and state-run hospitals for mental health care and in some cases long-term care. Doctors are free to operate solo practices as small businesses or form group practices of similar or diverse specialties. Hospitals are largely not-for-profit organizations governed by community boards of directors or trustees. There are a limited number of for-profit hospital networks.
In marked contrast to the essentially private business approach that characterizes the U.S. system, the National Health Service (NHS) of the United Kingdom is centrally controlled by the national government. The NHS evolved following World War II. During the war, a system of national Emergency Medical Services was established to control and organize medical services. Following the war, there was considerable public and government support for this system of medical services to continue and expand to provide universal coverage for all citizens. Establishing relationships among general practitioners, specialists, hospitals, and other providers to enact a national health system proved contentious. Aneurin Bevan, minister of health in 1944, was able to pull the factions together in a series of compromises that launched the NHS. The initial system used a three part organization (Light 2003):
- Hospitals and specialists were organized under fourteen regional boards.
- General practitioners worked under a contractual arrangement with the national government.
- Community health services such as home health care, long-term care, and midwives and maternal and child health were organized at the local level.
Since its inception following World War II, the NHS has undergone a series of incremental changes in its organization. A series of reforms in the late 1990s under Prime Minister Tony Blair emphasized creation of partnerships, with some devolving of responsibility from the national to the regional and local levels, and an integration of services. For example, community health services were combined with general practitioners to form primary care trusts, which were in turn replaced with clinical commissioning groups in mid-2013. The strength of the NHS is its emphasis on primary care. Physicians are offered incentives to establish primary care practices in underserved areas and to treat patients who have ongoing and complex medical management issues (Light 2003).
France has universal coverage in a system of compulsory national health insurance (NHI). Physicians establish their own private practices and are reimbursed under a fee-for-services arrangement. Hospitals can be either public or proprietary, and patients are free to choose among them. Proprietary hospitals have somewhat more limited services. Complex cases are generally treated in public hospitals (Rodwin, 2003).
Patients have extensive freedom of choice among physicians and hospitals, including proprietary hospitals. Prescription drug coverage is generous. French citizens also have the option of purchasing private supplemental insurance. Patients pay their doctors directly and are reimbursed through local health insurance funds (Rodwin, 2003).
The Canadian health system, sometimes known as Medicare, is a government-funded system organized by the individual Canadian provinces. Doctors operate in solo or group practices under a fee-for-service arrangement and are typically reimbursed by the provincial government. Physicians must comply with rates set by the government, based on a negotiated schedule of benefits. Hospitals are generally private non-profit organizations that receive reimbursement for operations through the provinces (Irving, Ferguson, & Cakett, 2005).
In France, universal coverage evolved as incremental changes were made to the program of National Health Insurance (NHI). Coverage was first extended to workers in industry and commerce whose income did not exceed a defined wage ceiling. In 1945, NHI was extended to all workers in commerce and industry regardless of salaries and wages. Expansion of NHI coverage progressed over the ensuing decades, with farmers and agricultural workers added in 1961 and independent professionals in 1966. In 1974, NHI was made universal. Despite the compulsory requirement for insurance coverage, there remains in France significant disparities in service access and delivery related to geography and social class (Rodwin, 2003).
(The entire section is 3097 words.)