1

“Is a National Health Care Plan that establishes Full

Health Insurance for all Citizens more beneficial for

Patients, Doctors, and the Economy than Health Care in

a Private, Competitive Market?”

By

XXXXXXXXXXXX

Somewhere in (Germany)

Datum: 30.10.2009

2

Abstract

With 45 million citizens of the world’s richest country (in terms of GNP) without adequate

access to healthcare – resulting in an estimated 45,000 deaths a year – an examination of the

different solutions available to the US government is more than overdue.

This paper examines the benefits and shortcomings for patients and doctors as well as

economical aspects of the three generic healthcare systems (that of the UK, US and Germany). The

three archetypal systems studied are representative of the different existing healthcare systems. In

particular, the effects of a privatised as opposed to public system are elucidated upon.

The Commonwealth Fund as well as the United States Congress recently commissioned

papers on the state of the US healthcare system and that of other countries. Using these papers as a

basis, a variety of studies, journal and newspaper articles, and reports from practitioners and

academics were analysed. The various figures and main differences of the three systems expounded

in these sources were then summarised - especially concerning their respective benefits and

shortcomings.

This paper concludes that although no system is perfect, Germany’s healthcare is the best

compromise between costs and efficiency, level of care and coverage (though the UK’s NHS has also

received a multitude of praise). This opinion is shared by several of the institutions analysing the

best practical approach to healthcare. Trying to set up a healthcare system that provides everyone

with everything anytime is impossible and so governments will have to adopt a more pro-active

stance on diseases and ailments that are completely preventable and imputable to a lifestyle choice.

Due to constraints of brevity, sections of the essay were moved to Appendices A-D and it is

recommended to read them in order to gain some additional information.

3

Table of Contents 1.0 – Introduction ................................................................................................................................... 4

2.0 - UK .................................................................................................................................................... 5

3.0 - USA .................................................................................................................................................. 8

4.0 - Germany ....................................................................................................................................... 11

5.0 - Evaluation ..................................................................................................................................... 13

5.1 - Patients ......................................................................................................................................... 14

5.2 - Doctors .......................................................................................................................................... 15

5.3 - Economy ....................................................................................................................................... 16

6.0 - Conclusion ..................................................................................................................................... 18

Bibliography .......................................................................................................................................... 20

Appendix A: Healthcare as a human right ............................................................................................ 21

Appendix B: UK Healthcare System ...................................................................................................... 22

Appendix C: US Healthcare System ....................................................................................................... 22

Appendix D: German Healthcare System .............................................................................................. 23

Glossary:

ED: Emergency Department

GP: General Practitioner

NHS: National Health Service

OECD: Organisation for Economic Co-operation and Development

SCHIP: State Children's Health Insurance Program

VA: US Department of Veterans Affairs

BMA: British Medical Association

WHO: World Health Organization

Note: The figures provided in the sections 5.1-5.3 are all taken from Mirror, Mirror on the Wall: An

International Update on the Comparative Performance of American Health Care by the

Commonwealth Fund, 2007.

4

1.0 – Introduction In spite of the world’s highest US$/citizen healthcare spending, currently an estimated 45.7

million US citizens are without health insurance1, i.e. without access to medical care (with an

estimated 45,000 deaths per year directly attributable to lacking health insurance!2). Such

circumstances make the evaluation and rethinking of the status quo a very real life or death issue.

While the US debate has focussed mainly on the financial aspects of healthcare as well as

sensationalist bipartisanship, several institutions – most notably the Commonwealth fund – have

polled patients and doctors from across several countries to gauge their perspectives.

This essay will examine the healthcare systems provided in the US, UK and Germany –

beginning each section with a brief description of the system in place followed by the benefits and

shortcomings identified by practitioners and academics. Subsequently, an evaluation of the different

systems will answer the question posed in this paper’s title.

1 http://news.bbc.co.uk/1/hi/health/8201711.stm

2 http://prescriptions.blogs.nytimes.com/2009/09/17/harvard-medical-study-links-lack-of-insurance-to-45000-

us-deaths-a-year/

5

2.0 - UK In its own words, the NHS has as its core principles “*meeting+ the needs of everyone;

[being] free at the point of delivery and ... [being] based on clinical [necessity], not ability to pay.” A

full-scale modernisation program in 2000 has added several more principles aimed at improving

quality, employee satisfaction and communication inside the NHS as well as with the general public

and patients.3 Correspondence with the NHS via telephone as well as email regarding their level of

coverage was met with prompt and detailed answers – a testament to the success of an ongoing

initiative to improve popularity and efficiency4.

Among the UK public, the NHS enjoys widespread support and a variety of popularity polls

show strong support for the NHS. One poll revealed that 89.9% of respondents would prefer to be

treated under the NHS5 than privately, another had 93% of respondents which “agreed or strongly

agreed that the NHS should continue to be funded from UK taxes and remain free”6 and an

astonishing 40% willing to pay more taxes to protect the growth of the NHS during the recession7.

When 95% of UK poll respondents stated that NHS “doctors and nurses *can] do the job of

safeguarding the NHS in the recession” 8 – this shows a high level of trust in the NHS by the UK

public.

A BMA poll revealed that more than “nine out of ten ... respondents *working in the medical

profession] ... said they were worried about the future of their local health services if they were left

to market forces”9 while 58% of respondents to another BMA poll disagreed “with commercial

companies making a profit (for shareholders) from providing NHS care”10. These polls illustrate the

sanctity with which the UK populace and politicians treat the NHS – where the withholding of

treatment due to financial concerns is considered immoral and unconscionable.

However, not all is golden with the NHS. Multiple scandals in recent years have caused

increased scrutiny and calls for more funds to be made available. Second-hand medical equipment11,

deaths resulting from superbug infections12 and incidents of tainted blood have all received

3 http://www.nhs.uk/NHSEngland/aboutnhs/Pages/NHSCorePrinciples.aspx

4 http://findarticles.com/p/articles/mi_m0JQT/is_2004_April/ai_n25087704/

5 http://www.guardian.co.uk/commentisfree/poll/2009/aug/14/nhs-health

6 http://www.european-hospital.com/topics/article/4142.html

7 http://www.dailypost.co.uk/news/uk-world-news/2009/06/28/nine-out-of-10-fear-nhs-cuts-poll-55578-

24005656/ 8 http://www.dailypost.co.uk/news/uk-world-news/2009/06/28/nine-out-of-10-fear-nhs-cuts-poll-55578-

24005656/ 9 http://www.medicalnewstoday.com/articles/155401.php

10 http://www.european-hospital.com/topics/article/4142.html

11 http://www.dailymail.co.uk/news/article-393872/Re-used-medical-equipment-widespread-NHS.html

12 http://news.bbc.co.uk/1/hi/england/bristol/8125170.stm

6

extensive coverage in the UK media and often hint at structural deficiencies of which theses scandals

are symptoms. The extensive remodelling of the NHS has improved patient care, increased the

support and supplies doctors have available to them and included a major IT overhaul which ensures

that, e.g. medications - which when combined are toxic - are not prescribed. Nonetheless, a recent

representative poll showed that 78% of the public wished for increased accountability and “in

conjunction with the Patients Association *representing patients’ interest+, for an independent

inquiry into the supervision of NHS hospitals”13 – indicating some distrust of government handling.

For patients, the ability to access the NHS without having to pay is a major benefit. In

practice, GPs act as gatekeepers and individuals with non-emergency injuries/diseases must be

referred to hospitals through them. The NHS even reimburses travel expenses incurred on the way

to the hospital – greatly improving not only healthcare accessibility but also the likelihood of

individuals visiting the NHS rather than ‘waiting it out’. The care received under the NHS matches

the standards of any Western European country and patients benefit from the adoption of new

technology which is purchased by the NHS at the suggestion of practitioners. Nonetheless, a recent

command paper stressed the “need to continue the NHS journey of improvements ... improving

the quality of care”14 – though equally praising the high standard of care achieved thus far. One

of the downsides of the NHS is that, in the case of non-urgent surgeries, patients can face

waiting lists of up to two years – though recent initiatives have begun successfully reducing

waiting list times. Similarly, the sheer magnitude of visitors to a NHS facility and the finite

number of specialists can mean that diagnoses are made in haste as opposed to a detailed

examination of the patient and his/her medical history.

For doctors, the NHS has a larger budget than most private hospitals and so has more

buying power – ensuring that prices for machinery and medication are kept low. Professional

associations and extensive support systems are in place to ensure that doctors can legitimately

defend themselves from lawsuits – as opposed to the litigious US medical field. Though salaries

are not as high as for private practitioners, the average salary of 60,000 GBP for a NHS specialist

is far above the European average15. The high status which NHS doctors enjoy among UK society

is the result of their ‘altruistic’ profession but also the result of the public nature of the NHS.

Doctors and nurses from abroad are increasingly being attracted to the NHS and so the amount

13

http://www.telegraph.co.uk/health/heal-our-hospitals/5067046/Poll-reveals-public-distrust-of-NHS.html 14

P.6 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825 15

http://www.nhscareers.nhs.uk/details/Default.aspx?Id=553

7

of patients per doctor has been steadily decreasing16.The setting of targets and quotas for

doctors by the UK government has resulted in doctors complaining of insufficient freedom/time

to adequately treat patients up to the standards they desire. This goal-setting approach

penalises doctors which fall below certain targets while rewarding those that surpass their goals

– leading to doctors seeking desperate measures (such as bribing17, insufficient care18) to meet

their targets. The freedom a private practitioner has to turn down patients is not enjoyed by

NHS doctors and the target setting by the government has lead to allegations that the NHS has

turned into a “game to make money”19 for NHS doctors.

An analysis of the economic benefits and costs of the NHS will be left to section 5.3 once the

US and German healthcare systems have been explored.

16

http://www.dailymail.co.uk/health/article-300046/Record-number-doctors-join-NHS.html 17

http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-doctors-bribed-to-hit-targets-on-smoking-567940.html 18

http://www.dailymail.co.uk/news/article-1207560/Blunders-cost-NHS-807m-Targets-blamed-payouts-rise-quarter.html 19

http://www.telegraph.co.uk/health/healthnews/3478550/Government-GP-targets-turn-the-NHS-into-a-game-to-make-money.html

8

3.0 - USA For US citizens covered by private health insurance, receiving treatment is not necessarily

easy – with many insurance contracts containing terms and conditions excluding treatments which

would be covered under the NHS. This has led to scandals where individuals have died as a result of

not reading the fine print on their insurance contracts20 - a massive 21% of claims in California are

rejected by private insurers21. The profit-driven running of companies that are essentially meant to

provide coverage guaranteeing the maintenance of health has seen managers receiving salaries

exceeding 13 million dollars22 - compared with the NHS’s top salary of less than half a million US$.

Not covering an individual for expensive treatment thus saves the company money and provides

stockholders with dividends or capital gains – a very dangerous approach to the provision of

healthcare coverage. An estimated 62% of individuals’ bankruptcies are related to healthcare bills23,

and of these, 80% had health insurance24 – numbers which would cause widespread revolt among

Europeans.

The private nature of US healthcare has resulted in pharmaceutical companies directly

advertising to consumers –the infamously endemic “ask your doctor if MagicMarioMix is suitable for

you” tagline. Consumers thus ask their doctors about the advertised drug, and every 1US$ spent on

advertising by pharmaceutical companies results in 4.20$ of sales25. The quick-fix or one-pill solution

approach, rife among Americans, is reflected in the beliefs that pills can solve obesity rather than

nutrition or exercise. The cost of drugs in America is much higher than in Canada: each citizen

spends an average of 792US$ per year on medicine, accounting for more than 45% of the world’s

total pharmaceuticals spending26.

Among Americans, the dissatisfaction with healthcare is reflected in polls, with one survey

having only 49% of respondents agreeing that “they currently have access to all of the healthcare

services they need without it costing them more than they can afford”27, another having a mere 39%

of respondents believing their healthcare system was superior to other industrialized nations’

systems28, and more than 90% in a CBS poll thinking the US system needed fundamental change or

to be rebuilt completely29. 64% of respondents stated that US healthcare needed universal

20

http://cbs2.com/local/nataline.sarkisyan.CIGNA.2.615167.html 21

http://www.reuters.com/article/pressRelease/idUS202570+02-Sep-2009+PRN20090902 22

http://www.allbusiness.com/legal/banking-law-banking-finance-regulation/11880255-1.html 23

http://www.cnn.com/2009/HEALTH/06/05/bankruptcy.medical.bills/ 24

http://voices.washingtonpost.com/health-care-reform/2009/06/new_study_shows_medical_bills.html 25

http://www.kff.org/rxdrugs/6084-index.cfm 26

http://www.naturalnews.com/024870_health_health_care_drugs.html 27

http://www.ipsosna.com/news/pressrelease.cfm?id=4467 28

http://www.dailypress.com/health/20090731_health_care_poll,0,5618895.graphic 29

http://www.cbsnews.com/htdocs/CBSNews_polls/health_care.pdf

9

coverage30 and among the issues surrounding the American healthcare debate, universal coverage

was the top issue31. A further poll found 78% of Americans “dissatisfied with the cost of the nation's

health care system, including 54% very dissatisfied”32. Nonetheless, of those covered privately by

health insurance 82% rated it positively33 - indicative of the good level of care the high average

spending per citizen buys. Waiting lists for private treatment are rarely encountered and private

ownership often translates into bigger budgets for individual clinics as well as the running of a ‘taut

ship’. The incentive to reduce the illnesses and diseases of individuals covered also causes private

health insurance companies to take proactive steps including regular checkups and screenings.

The ethicality of rich people outliving their poorer brethren, of healthcare being a profit-

driven enterprise makes the maintenance of such a system highly suspect – with President Obama

pursuing the universal coverage provided by all other OECD countries except Mexico and Turkey

(both with a much smaller gross national product than the US)34. The WHO has also ranked the US

37th among international healthcare systems – indicative of the failure of a private approach to

healthcare35.

For patients covered by a private health insurance plan, costs are covered to a large extent

by the insurance company and although premium rise as a result, the level of care provided is very

high and waiting lists are rarely encountered. The fact that coverage costs individuals or their

employers from several thousand dollars upwards per year in premiums does not seem to bother

Americans - despite the free nature of healthcare in all other industrialized nations. Although private

health insurance is available in European countries as well, it is reserved for the wealthy or those

with conditions requiring more extensive or therapeutic care than can be provided under the public

system – i.e. a minority. For low-income or individuals not covered by any insurance plan, access to

the healthcare is costly and avoided unless drastically necessary. The coexistence of various

governmental programs – the S.C.H.I.P., the V.A., Medicaid/Medicare, as well as state-level

programs leads to confusion among patients, who must first find out under which program they are

eligible for health insurance. Not being able to access healthcare or not receiving healthcare to the

required degree leaves patients in the worst possible state and so unless individuals have the

fortune of having private health insurance, they face degrading conditions – amounting to a violation

30

http://www.cbsnews.com/htdocs/CBSNews_polls/health_care.pdf 31

http://findarticles.com/p/articles/mi_qn4191/is_20051029/ai_n15843396/ 32

http://abcnews.go.com/sections/living/US/healthcare031020_poll.html 33

http://abcnews.go.com/sections/living/US/healthcare031020_poll.html 34

http://www.oecd.org/document/38/0,3343,en_2649_37407_40320102_1_1_1_1,00.html 35

http://www.who.int/healthinfo/paper30.pdf

10

of one of the fundamental human rights that is good health36. The higher infant mortality for US

citizens as well as an average lifespan that is on average an entire year less than that of UK citizens is

a testament to the shortcomings patients face under the US system. The disparity between the

wealthy (who can afford high quality healthcare) and the uninsured/poor (who cannot) is vast – the

average lifespan of 78.1 is the average of long-living privately insured individuals and shorter-lived

uninsured/poor individuals.

For doctors, the US healthcare system does not provide practitioners with the legal backing

that NHS doctors receive, and oftentimes doctors face lawsuits if their work is not meticulous. This

ever-present threat of litigation often causes an overenthusiastic approach towards surgery or over-

prescription of pharmaceuticals so as not to be accused of negligence. The extensive paperwork US

doctors must file in order to receive payment from insurance companies results in considerable

administrative fees compared to their UK counterparts. With hospitals in the US turning away sick

individuals, the imperative to help those in need is often broken due to cost considerations – at the

expense of the psychic wellbeing of doctors. Furthermore, the expensive nature of treatment for

uninsured or poor individuals compels them to wait until severe symptoms develop before visiting a

doctor – making the treatment much more extensive and high-priced than if it had been started at

an earlier stage.

Although a more detailed analysis follows, it should be stated that the average spending per

citizen for the US citizen is more than double that of the UK and Germany, while life expectancy

remains below that of these two European countries – indicating a systematic flaw within the US

system. Similarly, despite spending more on healthcare (as a percentage of the GNP), the US has

significantly higher infant mortality rates.37

36

According to Article 25.1 of the Universal Declaration of Human Rights - http://www.un.org/en/documents/udhr/ 37

https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

11

4.0 - Germany Polls among Germans as to their satisfaction concerning healthcare are not as numerous as

in the US and UK, perhaps due to complaints not being as widespread and damning. Nevertheless, it

is evident that Germans are, on the whole, very satisfied with their system. Polls uniformly report

high satisfaction rates: 86% are happy with their statutory level of coverage and 89% with private

coverage38; another study finds satisfaction rates of 83.6 and 85.3% for private and public health

insurance respectively39 while another reports rates of only 50% for the German healthcare system

(potentially due to an increase in premium rates dominating the public agenda)40. Even in 1994 it

was found that

“in cross-national opinion surveys conducted by the Louis Harris organization in conjunction with the

Harvard School of Public Health, both German patients and physicians express relatively greater satisfaction with their health care system than their American counterparts”

41.

Amusingly enough, “80 per cent of patients [sent by the NHS to Germany as part of a strategy to cut

waiting times+ said they were very satisfied”42 with the overall level of care and treatment.

For patients, the freedom to choose their doctor and place of treatment is a great benefit: a

“recent study of German consumers commonly [produced] reactions like this: 'I saw a long queue, so

I hopped on the tube and went to a different practice'; 'she was rather ill-tempered so I never went

back'; 'the facilities were drab, so I went to a different one next to my office'”43. The high level of

patient associations and feedback, as well as pressure on hospitals and doctors due to this ability of

patients to choose freely among them, results in increased competitiveness and thus in a higher

quality provision of care. This competition among hospitals and doctors is superior to the attempt

made by the NHS at an internal market where competitiveness was envisioned to spur

improvements in facilities and levels of care. Though the current premium of around 15.5% in 2009

is high44, government incentives reduce the effect this cost has on the average individual. The

commitment of both the German political body as well as the average German has resulted in over

14 health care reforms since 198045 - more than the UK or the US – and guarantees patients under

38

http://www.krankenversicherung-individuell.de/information/zufriedenheit-leistungsangebot-krankenkasse-415.html 39

http://www.insurance1.de/aktuell/2009-04-20/bundesbuerger-sind-zufrieden-mit-ihrer-krankenversicherung.html 40

http://de.statista.com/statistik/daten/studie/572/umfrage/zufriedenheit-mit-deutschem-gesundheitssystem/ 41

http://content.healthaffairs.org/cgi/reprint/13/4/22.pdf 42

http://www.york.ac.uk/admin/presspr/pressreleases/nhs.htm 43

http://www.civitas.org.uk/pubs/bb3Germany.php 44

http://www.mercer.com/referencecontent.htm?idContent=1346005 45

http://www.mercer.com/referencecontent.htm?idContent=1346005

12

the German system a high level of care. The most recent German healthcare reform stresses the

beneficial effect competition has on doctors and patients alike; the aim being to “provide more

choices, increase transparency and create competition among providers”46.

For doctors, the competitiveness of German healthcare ensures that pioneering technology

and equipment are readily adopted and that good practice is rewarded. Statutory insurers are given

certain budgets and have to recuperate any additional costs by raising premiums, so that in order to

remain competitive, treatments have to be efficient and costs kept under control. This cost-control

necessity results in proactive, preventive rather than reactive treatment, and by scheduling regular

check-ups and screenings doctors have the opportunity to treat ailments before they reach critical

levels. Doctors under the German system also avoid the ethical dilemma and the breach of their

professional responsibility due to cost concerns – a substantial problem in the US. In Germany, the

level of communication between practitioners and patient representatives allows for doctors to

benefit from rapid feedback and provide their patients with the best treatment possible.

Furthermore, doctors can be protected from litigation by membership in one of several private or

government provided Ärzteverbunde (doctors’ associations).

Economically, the fact that Germany excels in healthcare expenditure, although a much

larger proportion of its population requires long term care47 than either the US48 or the UK49 would

speak in favour of the cost-efficiency of German healthcare (definite figures will be presented in

section 5.3).

46

http://www.mercer.com/referencecontent.htm?idContent=1346005 47

http://www.indexmundi.com/germany/demographics_profile.html 48

http://factfinder.census.gov/servlet/STTable?_bm=y&-qr_name=ACS_2007_1YR_G00_S0101 49

http://www.statistics.gov.uk/census2001/pyramids/pages/uk.asp

13

5.0 - Evaluation The process of evaluating different countries’ healthcare systems is notoriously difficult as

the underlying causes of health-care related issues, e.g. lower life expectancy, may be due to non-

healthcare related factors, ranging from environmental to legislative issues, and statistics, showing

an unhealthy populace, may only be partially attributable to the dysfunction of the national

healthcare system. National eating habits, differing lifestyles, approaches to food/drug regulation

and training programs doctors receive may all indirectly affect both the general health of a nation’s

individuals as well as its healthcare capabilities.

Currently, the best comparison available is the annual Commonwealth Fund’s 2007

comparison of the UK, US and German healthcare systems in quantitative terms (the most recent

edition available to me without having to pay thousands of dollars in fees). As such, the various

figures and statistics provided with respect to patients, doctors and economic costs will be briefly

compared. The qualitative element of this analysis can be gauged from the previous descriptions of

the various healthcare systems.

14

5.1 - Patients

Patient Complaint/Status Germany

(in %)

United Kingdom

(in %)

United States

(in %)

Given the wrong medication or wrong dose by a

doctor, nurse, hospital, or pharmacist in past 2

years

10 10 13

Did not fill a prescription; skipped recommended

medical test, treatment, or follow-up; or had a

medical problem but did not visit doctor or clinic

in the past 2 years, because of cost

28 13 51

Out of pocket expenses for medical bills more

than $1000 in the past year, U.S. $ equivalent 8 4 34

Waiting time of 4 months or more for elective/

non-emergency surgery 6 41 8

Has a regular doctor, been with same doctor 5

years or more 78 69 50

As can be seen, the US healthcare system is overburdened and inefficient when compared to

patients’ care in the UK and Germany. Although the amount of incidents involving wrong

medication/doses given to patients is only minimally larger in the US, more than half of Americans

skip recommended medical costs because of costs – compared with 28% (Germany) and 13% (UK).

Similarly, over a third of Americans faced out of pocket medical expenses over 1000US$, while only

8% of German and 4% of UK citizens had such costs. When the richest country’s citizens have to

sacrifice their health due to cost concerns, the question of how smaller countries such as the UK and

Germany are able to provide cost-efficient healthcare becomes all the more compelling.

The chaotic system as well as the constant reappraisal and changing of health care insurance

contracts due to changing costs results in only half of Americans having a regular doctor as UK and

German citizens do – possibly making diagnosis more difficult due to a lacking medical and personal

history of the patient. The political hot potato that is the time spent waiting for surgery in the UK can

be clearly seen in the 41% statistic for patients under the NHS – compared to less than 8% for both

Germany and the UK.

Patients fare best under the German system – the fundamental flaws of the US system and

the problem with waiting lists and the NHS are exposed by the extensive patient questionnaires

collected by the Huntington fund.

15

5.2 - Doctors

Doctor Complaint/Status Germany

(in %)

United Kingdom

(in %)

United States

(in %)

Either been given incorrect results for a

diagnostic or lab test or experienced delays in

being notified about abnormal test results in

past 2 years

9 11 23

Medical records/test results did not reach MD

office in time for appointment, in past 2 years 11 16 23

Unnecessary duplication of medical tests in past

2 years 13 5 21

Physicians think their patients often have

difficulty paying out-of-pocket costs 35 14 42

Percent of primary care physicians’ practices

routinely using multi-disciplinary teams 41 81 29

As can be seen, a lack of communication and order between private/public health insurers

as well as hospitals/clinics results in 23% of American doctors complaining about being handed

incorrect lab results – compared with their German and UK counterparts with only 9 and 11%

respectively. This lack of communication also results in 23% of American doctors not receiving

medical records/test results on time.

Additionally, the litigious nature of American society and the absence of protection against

lawsuits inherent in universal health care systems has 21% of American doctors experiencing an

unnecessary duplication of medical tests – one fifth of tests are an indefensible waste of resources.

As in the patient section, the American health care system appears broken, with American

doctors most likely to think that their patients are unable to afford medical care, and only 29% of

American doctors routinely using multidisciplinary teams.

16

5.3 - Economy

Statistic Germany

(in %)

United Kingdom

(in %)

United States

(in %)

Did not get recommended test, treatment, or

follow-up because of cost in the past year (for

below average income individuals)

17 5 44

Did not get recommended test, treatment, or

follow-up because of cost in the past year (for

above average income individuals)

10 2 17

Had medical problem but did not visit doctor

because of cost in the past year (for below

average income individuals)

20 5 44

Had medical problem but did not visit doctor

because of cost in the past year (for above

average income individuals)

12 6 19

Visited ED for a condition that could have been

treated by a regular doctor, had he/she been

available

6 12 26

Infant Mortality (per 1000 live births) 4.2 5.2 7.0

There is a spectrum of opinions on the economic benefits/costs of the different health care

systems – only uniform with respect to the non-continuation of the US status quo. The amount of

US$ in healthcare spent per citizen as a total percentage of the GNP, the average lifespan, and child

mortality figures all indicate that50, despite spending more than double the amount of money per

citizen, the American health system is neither cost efficient nor universal.

American individuals, if they are poor, are much more likely to avoid treatment due to cost

concerns than their European counterparts. The effect ill health has on the general working class

cannot be accurately gauged in monetary terms – the amount of lost productivity due to sick days,

bankruptcies resulting from medical bills etc. is enough to make a compelling case for universal

coverage. Additionally, the money and time spent on treating an ailment at a later, more advanced

stage, is undoubtedly much higher than the cost of preventing it from occurring in the first place or

beginning treatment earlier – making the use of the ED for conditions that could have been treated

50

See Appendices B-D

17

by GPs a further waste of resources. The duplication of tests as well as communication breakdowns

further illustrates the wastefulness intrinsic in the American health care system.

Something is wrong in the United States when twice the money results in non-universal and

worse health care.

18

6.0 - Conclusion The provision of a healthcare system that provides universal coverage while maintaining the

highest standards of care and quality is – to put it mildly - a delicate task, Balancing costs with levels

of coverage and treatment standards while trying to placate the various competing interest groups

(pharmaceutical lobbyists, patients’ associations, taxpayer groups etc.) is an impossible undertaking.

No perfect system has yet been devised which, in terms of healthcare, can present everyone,

everywhere with everything all the time.

Nonetheless, the German system has received the most praise in academic and practitioner

journals both for the quality and accessibility of its healthcare. Whether it can maintain its present

ranking is questionable, being under increasing pressure due to the demographic changes of a

rapidly aging population.

In any case, letting profit be the main motive for the provision of health insurance is, in

addition to being unethical, inefficient51 and indefensible given the universal healthcare provided by

most OECD countries.

As put so poignantly by the award winning American journalist Joe Conason:

“why [does the US] spend so much more on healthcare, per capita, than other developed countries? Why do we achieve worse outcomes on several important measures than countries that spend far less? Why do we spend up to twice as much per person as countries that provide universal coverage while leaving as many as 50 million Americans without insurance?

The salience of those questions has grown over the past several decades ... other democratic states around the world [long ago] … realized that if healthcare is a public good and a human right, the domination of private interests must be curtailed.”52

For all healthcare systems, the future of public health lies partly in the promotion of

preventive steps so as to avoid conditions which require treatment altogether. A recent estimate

traced 25% of a company’s healthcare costs to entirely avoidable ailments53 while the non-profit

charity Cancer Research UK found over half of cancer cases to be down to unhealthy lifestyles rather

than genetic predispositions54. Governments should learn from private healthcare initiatives – a

51

http://www.minnpost.com/healthblog/2009/08/27/11168/more_evidence_for_us_overuse_of_ct_scans_and_other_medical_imaging 52

http://www.salon.com/opinion/conason/2009/03/09/healthcare/ 53

http://www.e-pfg.com/newsletter/benefits-consulting/summer2007/cost-of-preventable-diseases.html 54

http://info.cancerresearchuk.org/cancerstats/causes/lifestyle/

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study found that “employers who invest in worksite health promotion programs can see a return of

$3-$6 for every dollar invested over a 2-5 year period”55.

It is hoped that future technological advances in the medical field will provide earlier

methods of detection, better treatments and ultimately a more cost-efficient system. Finally,

governments should always be willing to introduce reforms – whenever needed – to meet the

changing health needs of their citizens. A cautious optimism should be had as health care enters the

21st century.

55

http://www.e-pfg.com/newsletter/benefits-consulting/summer2007/cost-of-preventable-diseases.html

20

Bibliography The following works were used:

Herzlinger, Regina DBA. Who Killed Health Care? America’s $2 Trillion Medical Problem – And The

Consumer-Driven Cure. New York, McGraw Hill 2007.

Wurman, Richard, DFA. Understanding Healthcare. Newport, Quad Graphics 2004.

Dr. Rer. Pol Preusker, Uwe. Das Deutsche Gesundheitssystem verstehen – Strukturen und

Funktionen im Wandel. Stadtbergen, Druckhaus Köppl und Schönfelder 2008.

Jonas et al. An Introduction to the U.S. Health Care System – Sixth Edition. New York, Springer

Publishing Company 2007.

Harrison, Stephen PhD, and McDonald, Ruth PhD. The Politics of Healthcare in Britain. London, Sage

Publications 2008.

Nagel, Eckhard MD, DPhil. Das Gesundheitswesen in Deutschland – Struktur, Leistungen,

Weiterentwicklung. (4th Edition) Köln/Cologne, Deutscher Ärzte-Verlag GmbH 2007.

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Appendix A: Healthcare as a human right At this point, an attempt to define healthcare will be made in order to provide parameters to this

paper. Finding a comprehensive definition proves impossible, with the British Medical Association,

the American Medical Association and the Deutscher Facharztverband defining healthcare only

fleetingly in articles. Even the Merriam-Webster dictionary fails to provide an adequate definition.

Thus, healthcare will be taken to encompass ‘government efforts aimed at maintaining a healthy

populace through the use provision of a basic, universal access to medical care and proactive

campaigns”. Government programs targeting obesity or smoking are thus included under this

definition.

Article 25(1) – Universal Declaration of Human Rights (UDHR): “everyone has the right to a standard

of living adequate for the health and well-being of himself and of his family, including food, clothing,

housing and medical care”.

As was the case after the first ‘war to end all wars, as well as after the end of the Second World War,

the devastated civilian populations and horrified leaders sought to usher in a new age of man –

where “all human beings are born free and equal in dignity and rights.” Fundamental to all the other

rights guaranteed in the ‘most translated document in the world’ is good health. The freedom to

marry and raise a family are of little use if due to ill health the individual in question is not able to

exercise/enjoy these freedoms.

The World Health Organisation itself posits that "the enjoyment of the highest attainable standard

of health is one of the fundamental rights of every human being” – making the non-coverage of

individuals in poverty or pre-existing conditions an unconscionable act. Considering the right to

health and healthcare beyond the mere absence of disease or infirmity is guaranteed in several

human rights treaties, to which the US, UK and Germany are – to differing degrees - parties to.

Similarly, the ABA (American Bar Association) - in The Various Human Rights in Healthcare - states

that the UDHR Article does “endorse the existence of human rights to healthcare in the sense that

there is some true minimum of healthcare below which intolerable circumstances occur, i.e.,

circumstances in which the society must be considered significantly broken if it does not respond.”

Written during the Clinton Administration’s push towards universal healthcare, the ABA paper

concludes that “the larger question of health and healthcare *remains] to be defined for the society

as a whole.”

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Considering healthcare as a fundamental, if not the fundamental human right, the provision of a

basic level of healthcare on a universal basis will be assumed to be indispensable and the evaluation

of countries’ health care systems will depart from this proposition.

Appendix B: UK Healthcare System Operating on a strictly public basis – i.e. offering healthcare on a free and accessible basis – the UK

National Health Service (NHS) illustrates beautifully the typical/generic public healthcare system.

Founded in 1948 as a result of the National Health Service Act 1946, the NHS is funded by tax

revenues as well as minor contributions by national insurance companies. Having used an allocated

budget of 161.9 billion US$ 56for the 2008-09 period – an average of 2992$ per person57 - the NHS

consumes 8.4% of the national budget. British citizens or residents using the service are not charged

for services provided and are given free necessary medication/pharmaceuticals as well as

reimbursed for travel expenses to and from the hospital. This high level of accessibility leaves the

average UK citizen with a life expectancy of 79.1 years and an infant mortality rate of 4.8 deaths per

1000 live births58. Nonetheless, 11% of the UK population opt for private health insurance and if one

is dissatisfied with the NHS service, private clinics are available.

Appendix C: US Healthcare System The US system can be seen as the antithesis of the NHS. The traditional American values of

independence, self-reliance, unbridled capitalism and a trust in invisible market forces has led to the

US government providing a minimal level of coverage to some and no coverage at all to others.

While the US-run Medicare program targets senior citizens aged above 65 and not having the means

to take out private insurance, Medicaid targets low income and disabled individuals. These programs

still require some degree of participation from the receivers – with coverage costing 45$ a month for

Medicaid (a substantial amount for an impoverished individual). Other programs such as the SCHIP

and the US Department of Veteran Affairs offer low cost or free care to children or veterans

respectively. Apart from these government sponsored health insurance programmes, individuals can

choose to pay for health insurance from private insurance companies themselves or be covered as

part of their work benefits by way of their employer paying their premiums for them. Those not

falling under either category are then left without any healthcare access and although hospitals will

not refuse to cover them in an emergency, these individuals are not covered for any non-emergency

treatment. This category comprises 45.7 million Americans – nearly three quarters of the population

56

http://webarchive.nationalarchives.gov.uk/+/http://www.hm-treasury.gov.uk/media/7/3/bud08_chapterc.pdf 57

http://news.bbc.co.uk/1/hi/health/8201711.stm 58

http://news.bbc.co.uk/1/hi/health/8201711.stm

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of the UK! The downside of the US healthcare system is reflected clearly in the average lifespan for

the US citizen (78.1 years), the ‘high’ infant mortality (6.7 deaths per 1000 live births) despite an

average of 7290 US$! being spent on every citizen – making out 16% of the national budget in

costs59.

Appendix D: German Healthcare System The German system represents a combination of the US and UK system – having both a basic,

universal standard of healthcare as well as large-scale private insurance companies. Assuring

universal coverage is a basic level of healthcare insurance (a.k.a. ‘sickness fund’ or Gesetzliche

Krankenversicherung) requiring statutory contributions from employers and employees based on a

percentage of income (usually around 13-14%60). These sickness funds cover around 90% of the

population and provide extensive coverage including ambulatory services. In a nutshell, the public

healthcare is “financed by individuals on the basis of their ability to pay, but *is meant to+ be

available to all who need it on roughly equal terms” – with no disparity between poor and wealthy

individuals (as in the USA) plaguing the system. The national option is practically compulsory for

individuals earning less than 3975€ per month for over three years61 as private insurance is costly

and may cause privately insured individuals to neglect other expenses or take out loans in order to

avoid defaulting on payments (as switching back from private to statutory health insurance is a

difficult and time-consuming process).

Nonetheless, about 10% of the German population chooses to go private – paying insurance

premiums independent of their income (i.e. a middle-class family may pay a much greater

percentage of their income than an investment banker for the same coverage) to private insurance

companies. With a free market ensuring competition between insurance providers, costs are kept

down while levels of coverage are kept high. Taking out private insurance is an option and private

insurance companies are heavily regulated. Unlike private insurance companies in the US, German

insurance companies cannot: deny coverage once legitimate claims have been submitted; cancel

contracts due to a temporary default in premium payments; and need to keep at least 10% of

premiums aside to keep coverage costs stables on an individual’s retirement.

Consuming 10.7% of the GNP and spending an average of $3420 per citizen62, the public

sickness funds provide a high level of care with patients, thanks to a minimally bureaucratic process,

being able to freely choose facilities, avoid the GP gateway used in the UK and receive same-day

59

http://news.bbc.co.uk/1/hi/health/8201711.stm 60

http://www.civitas.org.uk/pubs/bb3Germany.php 61

http://www.dw-world.de/dw/article/0,,2335651,00.html 62

http://spreadsheets.google.com/pub?key=pqVgDLeO6WJ1Epmhi4w3rXg

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appointments. The average German enjoys a lifespan of approximately 79.1 years and has an infant

mortality rate of 4.03 deaths per 1000 births63 – lower than the UK or the USA. The income provided

by privately insured individuals boost doctors’ salaries and hospitals’ budgets – with the same

facilities often used by both privately and statutorily insured individuals – resulting in a more

equitable distribution of healthcare technology and treatments. Having a much higher percentage of

individuals over 65 than either the UK or the US (those aged 65 and over are expected to constitute

over a third of Germany’s population by 201064), chronic care and the ailments that come with

increasing age make the provision of high quality healthcare an important issue among German

politicians.

63

http://www.indexmundi.com/germany/infant_mortality_rate.html 64

p.49 http://www.demographic-research.org/Volumes/Vol16/2/16-2.pdf