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PUBLIC HEALTH: US VS. SWISS HEALTH CARE SYSTEMS

The following points are made by Uwe E. Reinhardt (J. Am. Med. Assoc. 2004 292:1227):

1) Health services researchers around the globe have known for decades that the US, with a comparatively young population, spends much more on health care than do other nations(1,2). As US annual health spending continues to exceed that in comparable nations by ever wider margins, and as US health policymakers begin to run out of ideas for how to constrain that growth, interest in the performance of health systems abroad has increased in recent years. One need not import another country's political system or social ethic to learn from the techniques they use to seek cost-effective health care. Cost-effective health care delivers the maximum attainable benefit for a given sacrifice of resources or, alternatively viewed, minimizes the sacrifice in resources for a given level of benefits. While economic circumstance and a preferred social ethic may lead some nations to spend more on health care to achieve higher levels of benefits than others, in principle, all nations should strive for cost-effective health care at whatever level of health spending they have chosen.

2) Americans who are not in favor of government-run health insurance may find the German, Dutch, and Swiss health systems of special interest. None of these nations relies on government-run health insurance as in the model of the Canadian provincial health insurance plans or the US Medicare and Medicaid/State Children's Health Insurance Program programs. All 3 have flirted in recent years with elements of price-based consumer choice, albeit within a framework of strictly regulated competition.

3) The Swiss, for example, have experimented with consumer choice in the market for health insurance. Herzlinger and Parsa-Parsi(3) examine that system in detail and conclude that it delivers a superior, more cost-effective, and more equitable performance than does the US system. They believe that "the positive results achieved by the Swiss system may be attributed to its consumer control, price transparency of the insurance plans, risk adjustment of insurers, and solidarity."

4) It is difficult to argue with the assertion by Herzlinger and Parsa-Parsi(3) that relative to the US health system, the Swiss system delivers an overall superior performance. Much the same can be claimed by many other foreign health systems because, in cross-national comparisons, the higher US health spending has not translated into consistently superior quality of care(4) or in greater satisfaction among patients,(5) physicians, and hospital executives. Furthermore, the US has consistently ranked relatively low on most traditional health status indicators, such as life expectancy and infant mortality. These population-based health status indicators are driven by numerous socioeconomic variables besides health care and cannot be used as a reliable indicator of health system performance in cross-national studies. Even so, it is troublesome that on the metric of potential life years lost per 100 000 population (due to premature death that could have been avoided through timely and appropriate health care, public health measures, and less risky behavior), the US was estimated by the Organization for Economic Cooperation and Development (OECD) to have lost 5120 lives per 100 000 in 2000, while the comparable numbers were 3888 in the United Kingdom, 3806 in Germany, 3571 in Canada, and 3400 in Switzerland.(2)

5) The superior performance of the Swiss health system is not necessarily attributable to the role of consumer choice in that system. One can just as plausibly ascribe that performance to the pervasive government regulation that guides the Swiss health system. In fact, the Swiss health system in its current form reminds one of nothing so much as the Clinton health security plan, which also called for market-driven consumer choice within a framework of government regulation.

6) What is most impressive about the Swiss health system is the role tight government regulation plays throughout the entire system. One can plausibly argue that this regulation is chiefly responsible for both the high quality and (relative to the US) low cost of Swiss health care. Absent that regulation, the Swiss health system probably would metamorphose into something resembling the much less regulated, high-cost US system, which is both more inefficient and more inequitable than the Swiss system.

References (abridged):

1. Reinhardt UE, Hussey PS, Anderson GF. US health care spending in an international context. Health Aff (Millwood). 2004;23:10-25

2. Organisation for Economic Cooperation and Development. OECD Health Data 2004. Paris, France: Organisation for Economic Cooperation and Development; 2004

3. Herzlinger RE, Parsa-Parsi R. Consumer-driven health care: lessons from Switzerland. JAMA. 2004;292:1213-1220

4. Hussey PS, Anderson GF, Osborn R, et al. How does the quality of care compare in five countries? Health Aff (Millwood). 2004;23:89-99

5. Blendon RJ, Kim M, Benson JM. The public versus the World Health Organization on health system performance. Health Aff (Millwood). 2001;20:10-20

J. Am. Med. Assoc. http://www.jama.com

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HEALTH CARE AND RURAL AMERICA

The following points are made by S.J. Blumenthal and J. Kagen (J. Am. Med. Assoc. 2002 287:109):

1) Poverty, a major risk factor for poor health outcomes, is more prevalent in inner-city and rural areas than in suburban areas. In 1999, 14.3 percent of rural Americans lived in poverty compared to 11.2 percent of urban Americans. Irrespective of where they live, persons with lower incomes and less education are more likely to report unmet health needs, less likely to have health insurance coverage, and less likely to receive preventive health care. When combined, these variables raise the risk of death across all demographic populations.

2) Many of the ills associated with poverty, including lower total household income and a higher number of uninsured residents, are magnified in rural areas. In addition, rural communities have fewer hospital beds, physicians, nurses, and specialists per capita as compared to urban residents, as well as increased transportation barriers to access health care.

3) The highest death rates for children and young adults are found in the most rural counties, and rural residents see physicians less often and usually later in the course of an illness. People in rural America experience higher rates of chronic disease and the health-damaging behaviors associated with them. They are more likely to smoke, to lose teeth, and to experience limitations from chronic health conditions. While death rates from homicides are greater in urban areas, mortality rates from unintentional injuries and motor vehicle crashes are disproportionately more common in rural America.

J. Am. Med. Assoc. http://www.jama.com

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ON THE BRITISH NATIONAL HEALTH CARE SERVICE

The following points are made by Rudolf Klein (New Engl. J. Med. 2004 350:937):

1) Britain's National Health Service (NHS) presents a paradox. It is the only health care system in the rich world that is actively and enthusiastically committed to spending more money instead of seeking to restrain cost increases. Extra tax billions are being pumped into the service by the government at an unprecedented rate. In fiscal year 2002-2003, the budget of the NHS rose by more than 10 percent as part of a long-term fiscal strategy announced by Prime Minister Tony Blair four years ago. The aim of the increases is to bring spending on health care up to the European Union's average of 8 percent of the gross domestic product. At the same time, an ambitious process of self-transformation is under way. Founded in 1948 as a technocratic, paternalistic service, with scarce resources allocated according to medical and bureaucratic criteria of need, the NHS is now being redesigned as a consumer-oriented service.

2) Despite the additional money flowing into the system and despite the enticing vision of a service that combines health care that is universal, comprehensive, and free at the point of delivery with choice, flexibility, and responsiveness, controversy and discontent still dog the NHS. The medical profession has diagnosed itself as suffering from poor morale. The public remains skeptical. In a recent poll, 69 percent of those interviewed said they believe that the government is not improving the NHS.(1)

3) The paradox is all the more puzzling because there is considerable evidence that more money has indeed meant better services. The government's report on progress as of April 2003 claims substantial improvements.(2) Since 2001, an additional 17,000 nurses, 2000 therapists, 1200 consultants, and 400 general practitioners have been recruited. New medical schools are being launched to train more doctors. A new style of diagnosis-and-treatment centers, designed to provide quick day surgery, are being opened. Services for patients who have coronary heart disease are being modernized and expanded. Long waiting times, which have been the NHS's most notorious failing, are declining. So, for example, the number of people who had to wait for more than a year for an operation fell by 68 percent during the past year, from 29,600 to 9600.(3-5)

References (abridged):

1. Anyone see where the money's gone? Economist. May 8, 2003:27-8

2. Delivering the NHS plan -- expenditure report. London: Department of Health, April 2003

3, Getting better? A report on the NHS. London: Commission for Health Improvement, May 2003

4. Secretary of State for Health. The new NHS: modern, dependable. London: Her Majesty's Stationery Office, December 1997

5. Robinson R, Le Grand J, eds. Evaluating the NHS reforms. London: King's Fund Institute, 1993

New Engl. J. Med. http://www.nejm.org

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