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KQµårk 死神 On March - 4 - 2011

As some people know my biggest issue is healthcare for personal reasons. I just want to share with people the journey I went through learning about healthcare systems to try to figure out what real improvement would look like. Most of my initial perceptions of what a healthcare system needs has been flipped on it’s head with one respect. I discovered that how many people were covered by some kind of healthcare insurance far outweigh what form that insurance was in when it comes to lowering costs and providing better healthcare.  I also realized no matter how much we did on the healthcare insurance side of the equation ultimately how we change our outlays to providers will by critical to achieving lower costs.

Main Things I Learned and My Take

  • Healthcare systems around the world that work come in all kinds of flavors and colours but they are all universal. Blanket statements like European healthcare is all single payer and not for profit could not be further from the truth.
  • We have great healthcare in this country for people who get healthcare. But accessibility to that healthcare and the costs help make us one of the unhealthiest people in the western world.
  • For our healthcare system to be better and less costly the insurance component that fuels it must be as Universally paid into as possible. What percentage of those components are public, private are truly secondary.
  • Healthcare systems around the world that fit the countries culture are most effective.
  • The hidden gems inside the ACA include; the option that states can use non-profit private insurers in the exchanges, now healthcare insurers have to pay 80% of their premiums toward claims and the trials the government will be able to run with Medicare to solve the fee-for-service problem.
  • Not for profit insurance works to lower costs whether it’s a private system administering it like Germany or a publicly administered system like France.
  • Killing provisions in the ACA that would prevent near universal insurance coverage just undermines the efficacy of all the other legislation in ACA.
  • Fee-for-service payouts with Medicare needs to be adjusted for the long term stability of that program.  The fee-for-service model most private insurance use as well is one of the reasons more medical students opt for becoming medical specialists rather than primary care physicians.   It also is one of the reasons why providers order much more medical tests than other systems around the world alone with fear of medical malpractice.
  • Giving states more flexibility in implementing and managing their healthcare systems could be the best way to fit the current healthcare law into a state’s or region’s culture.   My guess is you would have much better systems in progressive states and race to the bottom systems in conservative states.
  • Universal, universal did I say universal?  Making the system as universal as possible is the key step to make a more affordable system with better outcomes.

Short Summaries of a Few Universal Healthcare Systems Around the World


The Netherlands – I start with their system because it breaks the mold from what Americans think about European healthcare systems. The Netherlands is now almost entirely private. They have adopted a regulated competition model. Yes they make you buy healthcare insurance from private industry that makes a profit.  They public healthcare to cover the poor and elderly like we do.

The way it works is private healthcare must all offer a basic level of healthcare insurance that is regulated by the government. Costs of these policies are regulated to some extent but insures can compete mostly by lowering their internal costs. If you want additional coverage you can buy it but for about half of all Dutch people they get it through their employer.

The Netherlands spends just 9% of GDP on health care compared to 16% in the US, breaking down to about 3,100USD per capita compared to 6,700 USD per capita in the US and their healthcare system is consistently ranked much higher than ours.

France – The French have the gold standard healthcare system but that gold standard. No other system around the world quite shows how the culture of the country and the culture of the healthcare system defines how it works more than France. The whole culture of healthcare is vastly different in France compared to the US.   French healthcare does not even start in the doctors office it really starts in their educational system. All college and medical school is paid for by the government. The system is based on a public system but still the vast majority of French still opt to buy supplemental private coverage.

By almost every measurement the French healthcare system is one of the top 5 in the world.

England – England is one of the few western countries that has true socialized medicine. It’s system is most consistently the lowest cost healthcare system in the western world for this reason. The main problem with any nationalized system like England’s NHS is that it’s often underfunded since it’s only funded by tax revenue.  So in effect the effectiveness of the system is more dependent on the current pols in power.  This is true in all healthcare systems to some extent but nationalized medicine by it’s very nature is more vulnerable to current politics.  The access and availability to specialists is a major concern in England because it is run like a government HMO where all decisions much go through your GP. Do not miss understand me it’s a good system especially for workers but they have more problems than some hybrid systems.

Obviously access is second to none but very much Americans would accept the limitations of the UK system when it comes to wait times and especially freedom of choice.

Germany – Germans have had universal healthcare longer than any country in the world with the first system starting in the late 19th century.  Employers and individual pay into “sickness funds” that are run by private non-profit insurers and independent of government.   Similar to the co-ops some congress people proposed and part of the ACA within the exchanges.  However many people buy supplemental private insurance.   Again the German system is less costly and has better outcomes than our system.

If I had my choice I would eventually model the American healthcare system after the German system instead of totally public single payer because I think it fits our culture best.

Switzerland – I saved the Swiss system for last because it’s closest to the system that we are implementing now with the ACA. The Swiss system is the second highest cost system in the western world but still over 30% cheaper than ours. The Swiss much purchase healthcare insurance or employers must buy it for the employee. No doubt the Swiss has a pro-business culture and that’s why they opted for a private employer based system. Things that are best out our system are best about the Swiss system. Wait times are the shortest and you have the most freedom to see doctors of your choice.

There are allot of structural differences in healthcare systems around the world compared to the US that are caused by inadequacy of universal coverage and our fee-for-service model.  Most countries with universal healthcare have a higher ratio of primary care physicians to medical specialists, much less medical testing, less medical procedures and of course much less visits to ERs or critical care centers.

Last Word on Single Payer

My opinion is single payer, Medicare for all, would just not fit the current culture in most states and certainly not the country as a whole.   Whether people like to admit it or not you would be forcing people to give up their current healthcare insurance whether they like it or not.  My guess is this would be even more unpopular than individual mandates.  In red states the GOP would starve the system like they do with Medicaid now and create shortages as a way to fit a sick self fulfilling prophecy.   The political climate and even economic climate in this country is far different from when Medicare or even Medicaid were established.  Back then the vast majority of seniors and the poor just did not have healthcare coverage of any real kind so implementation of a new system was much easier.

Medicare shows that even the single payer model can be inefficient when you base it on fee-for-service like it is now.  Public single payer simply does not have the resources to manage payouts for the sickest individuals to providers.  One of the worthwhile components private healthcare insurers have now are case managers.  Yes Medicare can manage broad provider costs well but do poorly on an individual basis.  For single payer to work even in states that support it they would have to substantially change their payout models to providers.

Thanks to the president giving states flexibility recently in developing their universal healthcare insurance delivery systems at least the beginning of single payer models can be adopted by individual or groups of states.  Since states like California and New York are the size physically, financially and geographically as many European countries they would be excellent areas to begin expanding something akin to a public option that can evolve into a more single payer system.  From a purely social science perspective it would be a huge social experiment to see how blue states and red states develop their healthcare systems.   There are probably two big unintended consequences of a more state based system.  First the GOP would set up competition models that could lead to a race to the bottom system where healthcare coverage is nothing more than minimal catastrophic healthcare coverage.  The ACA provides many buffers that should prevent this from happening but you would still need to trust states to enforce these standards.   Second there is a chance that providers would flee to states that don’t manage their payouts to providers.  Again we see this with Medicare where fewer and fewer providers participate in that system.

I got my information from a variety of sources and can supply individual sources upon request.

Written by KQµårk 死神

My PlanetPOV contact is [email protected] Proud Dem whose favorite hobby is cat herding. The GOP is not a political party, it's a personality disorder. Cancer, Heart Failure and Bush Survivor.

36 Responses so far.

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  1. Questinia says:

    KQ, I really appreciate what you wrote in your Main Points part. Especially about regional differences and how the medical systems which best suit the culture and area seem to work the best.

    I was to go into primary care after med school. I was part of the Community Health Residency Program in Greenwich Village designed to take care of those people who fell through the safety net. This was in the early nineties. When I saw that most people who were being seen in the clinics were depressed and I realized that I was going to have to fight hard for every dollar I earned, I hightailed it outta there and continued to work in clinics treating the poor but in a specialty. I still get to use my internal medicine training which is nice and I don’t have to chase after shit, spit, blood and piss.

  2. KQuark says:

    A study I just came across.

    Single Payer and Costs

    A Harvard study concluded:

    “A .”

    Single Payer
    Country Health Exp as Share of GDP

    Canada 10.0
    Norway 8.7
    Portugal 10.2
    Spain 8.4
    Sweden 9.2
    United Kingdom 8.4

    Country Health Exp as Share of GDP

    Germany 10.6
    Japan 8.2
    Netherlands 9.3
    United States 15.3

    I think the study accidentally came to the right conclusion in a way.
    Whether single payer is more efficient is not really being measured. What’s being measured is how you can more efficiently pay providers with other payout models with a single payer or multi-payer system.


    I take studies like this with a bit of a grain of salt. Because in our “opinion” culture they often are slanted. I got this from Healthcare Economist website which is highly slanted toward business. But the raw data is interesting to see.

  3. Caru says:

    While the Dutch healthcare system is private, most, if not all, of its insurance agencies are non-profit companies.

    Futhermore, most of the insurance premium is paid by employer payroll taxes. However, the government contributes an amount that can be shifted depending on how much a specific company has to pay out. This means that insurance companies have no incentive to not insure high-risk individuals.

    I quite like this system, except I believe that it hinges on the insurance companies being non-profit. Otherwise, there would many, many problems.

    The reason I know a bit about this system is that one of the parties here in Ireland wants to implement a system based on the Dutch model, however, I do not exactly trust them to implement it in favour of the public.

    • KQuark says:

      It could be most but not all insurance companies and hospitals are not for profit. It’s really their incentive to lower overhead.

      The big difference in their system to ACA is that the insurance companies get a 45% subsidy instead of individuals getting the subsidies. They have a fixed premium for individuals which is become a big problem because insurance companies are starting to lose money. They also don’t adjust premiums for age and other risk factors.

      They also have a problem with too many opt out clauses and this is causing people to game the system.

  4. AdLib says:

    KQ, hope you’ll pardon the OT but just wanted to remind all that Vox Populi is in progress and all are welcome to join our live chat there right now. Here is the link:


  5. Artist50 says:

    KQ -- I thank you for any info on healthcare, it seems to be my biggest problem also. Too young for Medicare and no one else wants me! It’s a lonely world. However, I’ve passed my six months without so now I can apply for the PCIP. I’m just so scared they will repeal it. I had a chance for insurance with pre-existing conditions in my state but I had to do it when I had my Cobra and now I don’t qualify and it was going to cost me $14 000 a year. I just couldn’t afford it.

    Thanks for keeping us informed.

    • KQuark says:

      Please tell us if PCIP works for you. It’s actually a little cheaper than I thought. In my state it’s about $200 per/month cheaper than my COBRA was. Unfortunately when I lost my COBRA I lost half my disability income as well.

      It doesn’t keep me up at night because I don’t think ACA will be repealed but for it to work for my wife and I we need the full subsidies and exchanges to kick in.

      • Artist50 says:

        I’ll let you know -- I haven’t sent the app in yet. It’s suppose to be around $525 a month and I’m paying over $800 for meds out of pocket right now, so that sounds like a bargain.

        • KQuark says:

          Yeah that’s even a bigger difference than with my COBRA but that ended 4 years ago. I think there are two levels of insurance as well and around $500 was the minimal coverage in my state.

          • Peabody II says:

            My wife and I had to find an alternative to her COBRA after it ran out. (Her company closed down after the crash.)

            The only insurance we could get at all was through my self-employment. We pay $1600 per month for that, with a $5000 deductible… Each.

            • Artist50 says:

              Peabody you should look into this PCIP program that has stemmed out of the new healthcare system. It is for those with pre-existing conditions so you must be turned down by someone. If you don’t have that problem you can probably find regular insurance.

            • KQuark says:

              That’s what they quoted me but then I was denied for a preexisting condition.

            • escribacat says:

              Wow, that’s a lot.

  6. choicelady says:

    Oh wow KQ -- yes, the BEST overall analysis I’ve read. I am on the State Strategy Group for Single Payer in CA. In principle I love it, but I’m getting cranky (surprise!) with the folks who dis the gains we’ve just made. Now progressives are sneering at it as “Obamacare” as if there were something WRONG with it. There are weaknesses -- and paying individually to what the insurance and provider rates are remains a poor use of our federal dollars -- but overall, as escat shows, getting affordable care AT LAST has been a benefit to millions. It’s a GREAT start that would indeed be infinitely improved with a public option.

    Only once in the course of doing the policy work on CA single payer did we do a fiscal bill. Much of it was adopted -- the costs to individuals -- by the federal reform. There were huge problems with the financing, too. It required a tax on estates over a certain value (I forget what) that seriously troubled seniors.

    Only the UK has a national health system. We would do worse than emulate Canada (though the financing is totally regressive with the 17% VAT that falls heavily on the lower income people) or several other systems. What Americans fear is the Gulag -- the gray, possibly grungy, clinic where you are a number assigned to a cold and heartless doctor, probably with filed steel teeth. Stories -- true stories -- about lowest common denominator care do arise. An Irish friend had stubbed his toe badly and lifted the toe nail from its bed. He went to the Irish health service where they removed the nail -- without anethesia. Eeeeuuuwww! OK -- you know, we don’t HAVE to do that! Killing pain just cannot be bankrupting the system. But that’s what everyone fears.

    I researched Medicare and was pretty horrified at how little it covers anymore. The out of pocket and decuctibles are high. It’s definitely better than nothing, but the RW has gutted some of its provisions over the years. One thing every system should have, and may do NOT, is a “lockbox” for the contributions. Canada’s national health funds are routinely raided as are our Medicare funds (and Social Security). We have to stop that. I and you and each of us donates a portion of income to our future medical care -- and it’s OUR money, not a slush fund. Never DID get over the headlines in the 80s that Reagan was taking $86 billion from SS.

    Anyway, thank you for SUCH a great summary. We all have to be thinking about this. In the meantime, we have a GREAT start. Let’s not let it go. Anniversary is coming up March 23 -- let’s build on what we have not cut it off at the knees.

    • KQuark says:

      Thanx CL because I know you are very knowledgeable and have boots on the ground with this issue.

      I heard rumblings that CA, OR and WA could form a regional healthcare network. After making coverage as universal as possible whether it’s administered by an NGO or is truly public as long as it’s non-profit I just don’t see the necessity I once did for public single payer or even a PO. In fact I dare say in our polarized political system having NGOs administer insurance may be more efficient if they are non-profit.

      Remember Medicare Advantage used insurers that could make a profit and that’s why it should have never been used to replace parts of Medicare.


  7. Abbyrose86 says:

    Thanks KQuark. I too am personally vested in our nations health care issues and the debates about it’s effectiveness and the way it is delivered.

    I really appreciated your analysis and it’s provided some food for thought, which I may have to share another day after I’ve given it some time to digest!

    • KQuark says:

      You have no idea abby. Healthcare is my 1st, 2nd and 3rd most important issue because of my personal health hardships. Check out my post “Hospital Stay Survivor’s Guide” about my last extended hospital stay.


      I don’t know if it’s a blessing or a curse but since I was trained as a scientist I can analyse situations even though they are dear to me with a more or less dispassionate POV.

      • Abbyrose86 says:


        I just read the piece and that was really good advice.

        My daughter is in and out of the hospital A LOT. As a result, I’ve become very astute at how to handle her situation and the hospital. (She is an epileptic).

        In addition to my daughter, I was the primary care giver for my dad, when he was alive and helped care for my mother when SHE was alive. My father had heart issues and renal issues. My mother had cancer. My ex husband was stabbed and almost killed in a robbery attempt…for five years we were in out of the hospital with his issues.

        Between ALL of them, I probably have logged as many hospital hours as an intern. I’m not joking…21 years in and out of the hospital, at least, once every 2 months. Fighting with insurance companies, staying on top of doctors and nurses, working with the staff at VARIOUS hospitals. Shoot, I got on a first name basis with many of the administrators. I WAS and still am, the patient advocate for my family.

        Your piece provided many many good tips, especially for those who aren’t hospital veterans!

        For me the health care fiasco in this nation…is a huge issue and I’m very passionate, myself as to trying to fix it.

        The things I’ve seen in my 21 years dealing with the US health care industry would make people’s toes curl.

        I would add, to your great list, not to be intimidated by the system, the people, the doctors…or anyone who is giving you care. DON’T feel you can’t question them or take issues up with higher authorities if need be.

        (I also found, they don’t like bad press OR to have substantial donors of the facility pissed off at them…so if you have contacts, of people who give donations to the hospital or have relatives/friends etc who work with the hospitals….don’t hesitate to use them IF needed).

        • KQuark says:

          Wow I hope it goes well with your daughter.

          My family has had health problems as well so I know the care giver side too. My wife’s mum died of cancer soon after we were married and that was about 15 years ago a year before I got cancer. So you can imagine how hard it’s been for my wife. She really can’t stand all the ugly politics around healthcare for that reason.

          Great point about questioning doctors and all the providers. I probably need to repackage my list and post it again at some point.

  8. Peabody II says:

    This is among the best articles I have read on the subject. I learned a lot about topics I really wanted to know more about, but didn’t have the time to research.

    Great work, KQuark!

    • KQuark says:

      I don’t want to sound like I’m touting my horn because I learned everything I know from others. But by far healthcare is the most misunderstood issue in this country I found out the hard way. I guess it’s because it’s such a complex issue that cannot be summed up in bumper sticker slogans. I would read the link I supplied under AD’s post if you want even more detail.

      I can’t really minimize how much my perception changed about what really makes universal healthcare work around the world.

      The ironic part of the political debate is that when the Dem candidates talked about healthcare without much detail they focused their messages on Universal Healthcare. In the end the Dems should have probably stuck with that messaging because as soon as the debate went into the details of healthcare the real solution to improving our healthcare system was lost in a way. The debate should have never gotten away from just offering Universal Healthcare as an end to itself.

  9. ADONAI says:

    I read somewhere that we spend more on the “bureaucracy” of health care each year than it would take to provide everyone with free health care.

    That really tells me all I need to know. I just wish we would do that and not worry so much about how others operate. We’re the richest country on Earth. We could do so much better than everyone else.

    It always comes back to money, and despite what the “monied interests” would tell you, we have plenty. Just not when it comes to helping people. Killing them? The coffers are bottomless. Helping them? Well,we are actually broke.

    • KQuark says:

      That would not surprise me at all. Sorry I take it almost as a no brainer but most universal systems that work well use electronic medical records. Converting to electronic medical records is a big part of the ACA for that reason. It’s also why I point out that capping how much insurers can slop off in overhead and profits at 20% is such an important part of the law which actually went into effect this year.

      Following is an excellent excellent link summarizing what a universal healthcare system needs and what the ACA provides and what it does not to fix the biggest problems in the system.


  10. ghsts says:

    Excellent comparison and like the sign says it’s a roadtrip so long as were ALL going to the same place. Only wanted to add this nice link for an impressive counter to gop potty mouths.


  11. Fi says:

    Good read, as a recipient and an employee of the UK HC system, I’m here to say, yes it does have problems, anything of that size will, but the basics are,
    1. Everybody is gets to see the GP, or Specialist of their choice, of course most folk, don’t know who the Specialists are, so it is left to the GP, most often than not to choose one, but patients do have the right to change.
    2. Most important, no one goes bankrupt paying medical bills, it is a “pay as you earn” scheme, National insurance is taken out of your wages, just like tax, so everyone pays, and the more you earn, the more you pay.
    3. Personally, because I have to take Thyroxine daily, I am exempt from prescription charges, but the Scottish parliement only a few days ago, totally aboilished prescription charges, I think there probably was so many exemptions, it was not worth it.
    Being an employee of the NHS, its something I deeply believe in, HC is a human right.

    • KQuark says:

      Cheers for your input. I hope you keep us updated if they make changes to NHS.

      First and foremost say that the NHS is much better than the current US system and is up there with most universal systems. Not to mention it’s the lowest cost western system of all.

      Second no doubt healthcare is a basic human right.

  12. escribacat says:

    Thanks for this informative rundown, KQ. As you know, this is a big issue for me as well. I think I’ve mentioned several times that, after having no coverage for several years because I’m self employed and have back problems, I now have coverage in the temporary “pre-existing condition” pool created by the new legislation. It is an enormous relief to have that coverage. I am grateful!!!

    What I admire most about your rundown here is that you skipped the hyperbolic deification of one idea and demonization of another that seems to have taken over most discussions of this topic. I believe the president and democrats are trying to figure out the best way to fix our system and move forward. We don’t really know what will work best yet but we must try something — now. Hopefully, we’ll figure out what works and doesn’t work out in the process.

    • Artist50 says:

      I’m just getting ready to apply. You still have to wait 3 months for your pre-existing condition to be covered, correct? I’m 60, so barring they don’t repeal the healthcare bill I don’t know when exactly this coverage will end and if I can get covered by regular insurance before my Medicare kicks in. I have a 9 month gap. Heck, either Medicare or I could be gone by then!!!!!

      • escribacat says:

        Artist, You will be covered for everything right away. (They don’t ask what your preexisting conditions are). But you must have been uninsured for at least six months and have documentation that you were turned down for insurance within the past six months.

    • KQuark says:

      Cheers for your kind words.

      Setting up a universal healthcare system has to be a highly practical endeavor to work well. As long as your don’t have fatal flaws in the system it can be molded into a good working model. A sure fatal flaw would be a system that does not expand the risk pool enough with healthy people entering it to cover people with preexisting conditions. That’s one reason the GOP is attacking the mandate so fiercely. They know the law will not lessen the tragic trajectory we are on without it.

      Of course there is one true Republican solution already in place until the insurance exchanges are developed. McCain even campaigned on it which is the formation of high risk pools for people with preexisting conditions but only about 12,000 people are enrolled because obviously high risk pools are still too expensive even if they are subsidized somewhat by states.

      I did look up the Pre-Existing Condition Insurance Plan and while it’s still too expensive for me it’s less than a third as costly as the last insurance company that turned me down because of my preexisting condition in my home state.

      I don’t know if it will help you but here’s the link.


    • jkkFL says:

      E’cat, you said it perfectly, so I will just second your post! :)

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