Monday, December 20, 2010

The Big Four

The nations of the world have coalesced around four approaches to delivering health care:
  • The Beveridge Model, wherein the government owns and operates health care. Cuba, England, Hong Kong, Italy, Spain, and the four Scandinavian countries all provide health care via the this model, which is named for the British reformer who designed the parameters of Britain's welfare state. Beveridge Model systems are characterized by their commitment to public health and primary care, as well as efficiency. Also known as single payer, the Beveridge Model is the embodiment of socialized medicine
  • The Bismarck Model, wherein all residents of a country are required to have health insurance and insurance companies are required to sell it to them. France, Germany, and Switzerland and most countries of western Europe operate under this model (as does Japan), named for the German chancellor who designed it in the 19th Century. Insurance can be profit, non-profit, or both (depending on the country); individual or employer driven. In any case, the insurance and health systems of Bismarck countries are tightly regulated. Bismarck Model nations often have advanced systems of health information technology.
  • The National Health Insurance Model, wherein each resident pays into a government run insurance program that compensates private-sector providers. As the sole insurer, the government has a powerful negotiating role with providers and pharmaceuticals. Canada, Taiwan, and South Korea provide national health insurance.
  • The Out-of-Pocket Model, wherein access to health care depends on the individual ability to pay. All undeveloped, non-industrialized countries must resort to this approach, as they have neither the resources nor the infrastructure to adopt the Beveridge, Bismarck, or NHI models.
As you can tell, the United States has a bit of all four. VA health care is government-owned and -operated (Beveridge); most Americans get insurance through employment and will soon have it mandated (Bismarck); most Americans pay into Medicare (NHI); and the uninsured and underinsured look to their own devices (Out-of-Pocket).

HealthMatters will examine each of the first three models, covering their implementations in different countries and pointing out the tradeoffs that each country makes.


  1. What the U.S. nor so-called Obama-care does not have, are any of the parts that make each of these other models work as far as they do work.

    It does not does not include tight regulation and / or oversight. It lacks non-profit and government competitive plans.

    What it has that none of the others do is mandatory payment to the insurance corporations that broke our health system in the first place without any guarantee that they must deliver care and / or payment.

  2. Right. The insurance-based models in other countries work as well as they do because

    1. Health care access is unified under a single model instead of fragmented.
    2. Insurance regulation is centralized instead of dispersed to 50 different places.
    3. Insurance companies are answerable to a single body instead of unlinked entities (state insurance commissions, businesses large and small, and hospital systems).

    In addition to the problems created by our approach to insurance, we suffer from the absence of a national health policy. This constrains efforts to deal with chronic disease (75% of health care costs center on five conditions), contain the obesity epidemic, develop coordinated public health measures, emphasize preventive health care, and educate the public on the necessity of population health.

    Right now, we spend between 15-18% of our GDP on health care. Some argue that that number would drop like a stone if a third of it were redirected to public health. On the other hand, I've heard one public health expert say that while that is theoretically correct, the American public health infrastructure is so anemic that it couldn't effectively absorb that kind of money, at least right away.