TABLE OF CONTENTS
Introduction
1. An Overview of the American Health System
2. Canada – The National Health Insurance Model
3. Israel – The Kupat Cholim Plan
Conclusion
Bibliography
Appendix A
INTRODUCTION
The Organization for Economic Cooperation and Development (OECD), in its study Health at a Glance, 2009, showed that the cost of health care in the United States is the highest among 10 developed countries, as a percentage of the GDP (Gross Domestic Product). In 2007, the United States spent 16.0% of his GDP in health care (OECD 163) (Appendix A). As Reid says, “The one area where the United States unquestionable leads the world is in spending” (Reid 9).
The United Sates performs below the wealthiest countries in levels of cost-benefits, quality of health and choice of health care. In Reid’s words, America’s health care system is “expensive, ineffective and unjust” (Reid 9). In 2000, a study by the World Health Organization (WHO) ranked the United States as the 37th out of 191 countries regarding the quality of national health care system. In this study, Canada ranked 30th and Israel as the 28th.
In this study, I analyze and compare the health care systems in those three countries: the United States, Canada and Israel, aiming to see which country has the best health care system and which lessons can be applied from them.
1. AN OVERVIEW OF THE AMERICAN SYSTEM
Health care in the United States is basically a private service. Health care facilities are largely owned and operated by private sector businesses. According to Rosenthal in “Health Care’s Road to Ruin”, “All other developed countries rely on a large degree of direct government intervention, negotiation or rate-setting to achieve lower-priced medical treatment for all citizens. That is not politically acceptable here.” The United States is the only country in the developed world that has resisted a government-run health care system.
About 64% of health spending in the United States is paid for by the government, funded via programs such as Medicare, Medicaid, the Children's Health Insurance Program, and the Veterans Health Administration. People under 65 years of age acquire insurance via an employer, by purchasing health insurance on their own, or are uninsured.
On July, 2011, the Organization for Economic Cooperation and Development (OECD) made a comparative study between US Health System and 12 other industrialized nations. The study showed that the United States continue to spend more in health care than the other countries, however the United States has lower number of hospital beds and physicians, Americans visit less the doctors and hospitals, and the price of prescription drugs and diagnostic imaging is higher than most countries. Health care performance in the United States is variable. It ranks highly on cancer survival and poorly on admission for chronic diseases and diabetes complications.
The researcher, David Squires, cites some factors previously related to the high cost of health care in the USA. They would include administrative complexity, an aging population, the practice of “defensive medicine” to avoid litigation, chronic diseases, health care supplies and the high cost of technologically advanced equipment and products, among others. Nevertheless, the study shows that they are not the key factors. They suggest other reasons, like higher prices, a fragmented care delivery and a poor physician coordinated process.
Squires concludes that “the US health system is not delivering superior results despite being more expensive, indicating opportunities for cross-national learning to improve health system performance”.
A study published in the American Journal of Public Health demonstrated that the United States spends more money on health care than any other country in the world, however Americans die sooner and suffer more diseases than people living in other countries.
The study compared people living in Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Switzerland, the Netherlands, and the United Kingdom using data between the 1990s and 2008
The results showed the health disadvantage of American healthcare system in nine health domains:
- “Adverse birth outcomes—the highest infant mortality rate among high income countries;
- Injuries and homicides—a leading cause of death in children, adolescents, and young adults;
- Adolescent pregnancy and sexually transmitted infections—the highest rate of pregnancies among high income countries;
- HIV and AIDS—the highest incidence of AIDS and the second highest prevalence of HIV infection;
- Drug-related mortality—more lives lost to alcohol and drugs than in any other nation, even when excluding drunk driving deaths;
- Obesity and diabetes—the highest rates of obesity and diabetes among high income nations;
- Heart disease—the second highest rate among 17 peer nations;
- Chronic lung disease—higher mortality than in the United Kingdom and other European countries; and
- Disability—one of the highest prevalence rates of activity limitations among older adults.”
The authors conclude that the best solution for the American health care system would be a single payer health care system, aimed to provide universal and affordable health care to all citizens.
2. CANADA – THE NATIONAL HEALTH INSURANCE MODEL
The Canadian health system is a government-financed program, built on a thirteen-payer system. The ten provinces and three territories have their own Medicare plan, with their own structure and rules. In some provinces the health care delivered is completely covered, others require a co-payment from the patient. However the system is coordinated and integrated by the federal government, based on five principles: public administration, comprehensiveness, universality, portability and accessibility.
Most medical bills are covered by the national health insurance plan; however two out of three working Canadians have private health insurance as well, to pay for health costs not covered by the Medicare plan, like dental care, prescriptions, private hospital rooms, childbirth, among others. Under this system, citizens receive preventive care and medical treatment from physicians, hospitals, dentists, and also prescription drugs. Canada has one of the highest life-expectancy in the world, about 80 years, and lowest infant mortality rates.
On the bad side, there are two main things clouding the excellence of the Canadian health care system: the waiting list and physician shortage. The government is trying to bring in more physicians in order to reduce the waiting list. The good accomplishment for physician’s work in Canada is that the province provides malpractice insurance for them; all medical records are digital; the province pays all the fees monthly; and the tuition cost for a medical degree is about half of the same cost at a public university in the United States, leaving Canadian medical doctors with less debt when starting their careers.
I asked a friend, Thais, who lives in Canada, to share her experience with the Canadian health service. She said she is completely happy with the health system there. Everything is paid by the government health plan. She and her family hold the health card and can use the doctor and hospitals freely for almost everything. The government also pays a percentage of the prescription drugs.
She said sometimes they have to wait to see a doctor, and if they need a specialist, the wait line may take months. But when they get the appointment, the medical service and treatment are excellent. She delivered a baby girl who was born with a heart defect, and they got easy access to a pediatric cardiologist; also all the diagnostic exams, the surgery and the Intensive Care Unit time were paid by the government plan, providing them with the best cardiologic surgeon of her city, a center of medical excellence per se.
She concludes that the difference between Canada and the United States is that in the USA they would need a great health insurance plan to get everything they needed and they would pay a huge amount of money for the treatment they got. Thais says, “In Canada there is no difference between social classes. Everyone, rich or poor, is treated in the same way, waits the same amount of time and has the same rights regarding health care”.
3. ISRAEL – THE KUPAT CHOLIM PLAN
Israel has universal health care and participation in a medical insurance plan is compulsory. In Israel, health care is considered a fundamental right, and all Israeli citizens are entitled to basic health care.
Israel provides universal insurance coverage, guaranteed by the 1995 National Health Insurance Law (NHIL). All Israeli residents can choose any of the four non-profit, non-governmental health plans, the kupat cholim (sickness funds, in Hebrew). They provide a core package that covers hospitalization and doctors’ appointments. There is a co-payment for some prescription drugs and a comprehensive list of procedures available to everybody in the system, like in vitro fertilization, liver transplants, Aids treatment, and others, without a long waiting line. The government pays the health plans based on the number of members and their age distribution.
Half of the emergency care beds are operated by the Ministry of Health, a third is provided by Clalit, the largest health plan, and the rest is operated by for-profit and nonprofit organizations. However the government regulates the payers, providers, the purchase process, health care professionals, the pharmaceutical companies and public health.
The Ministry of Health monitors the health care quality through the Quality Assurance Unit and the Department of Health Services Research. The licenses applied to hospitals are valid for one to three years, based on the results of the latest inspection. The Ministry of Health develops quality-monitoring tools regarding topics as hospital infections, coronary bypass operations, ICU care, transplants, among others.
Israel’s National Blood Bank is directed by the Magen David Adon, the national ambulance service. The health plans use Electronic Medical Records connected to a central database and to the health professionals, and linked to a website providing “personal health record”, accessed by the patients; and they are presently using a biometric identification in order to replace the magnetic card system.
Israel spends about 8.4% of the GNP on health, compared to the 16% spent by the United States. They have more access to health care and more efficiency. They cover everyone at half the cost. Israel has a lower mortality rate and a higher life expectancy than the United States. Polls show that 80 percent of Israelis are satisfied with their health care system. The main problems of Israel’s health system are the shortage of doctors and nurses, especially in rural areas, and the increasing cost of health delivery.
I interviewed an Israeli friend, Marty, who also had lived in Canada, about his experience with both health care systems. His opinions are stated below:
1. “Israel does not have one large public health system. There are several different insurance companies that offer public care. Each one is very similar to the others and they are all somehow subsidized by the ministry of health.”
2. “Everybody is covered - everyone decides which company they will use for health care.”
3. “We don’t need a co-payment to see a doctor in the ER or on regular appointments. There may be a very nominal fee, but it’s trivial”.
4. “One does pay for prescription drugs but surgery and exams and tests are covered under the insurance company.”
5. “Canada is more sophisticated, more expensive and less efficient. In Canada a patient needs to get a referral from the GP to see a specialist and if it is not an emergency it can take up to 6 months. In Israel one can make an appointment with a specialist without a referral and usually can get an appointment within a fortnight. MRIs take longer but I was able to get a CT scan in about 2 weeks. Canada has public health care but monthly premiums are much more expensive. Doctors and nurses in Canada make a lot more than their counterparts in Israel”.
6. The degree of satisfaction from the Israeli people with the health care delivery: “Like everyone else we like to complain about our health care system and it has its problems (just like every other system). Coming from Canada I am very pleased overall with the system. However about a month ago I had to go to emergency at our local hospital. I had never been there before. There was a young man sitting in the waiting room with a nasty foot injury. There was blood on the floor, blood on a seat and no one cleaned it up - it was pretty disgusting and would never happen in Canada.”
CONCLUSION
I understand that the United States’ health care system can incorporate and apply the best experiences from health care systems in other countries. As a health care provider, I believe one of the greatest achievements of a universal health care system is to shift the focus from curative to preventive medicine. It saves costs and saves lives. Preventive medicine involves a multidisciplinary and a holistic approach to patient care, focusing on the quality of life of patients and their families.
From this study, we can see that no health care system is perfect, however a single-payer system is a start, where the taxes already paid by individuals and corporations are used to provide a basic health care to every citizen. A single payer system does not necessarily takes away private insurance companies, which can be used to provide a better health care to the ones who want to pay a little more for the service. It may also be used to cover cosmetic surgeries and procedures.
However, in the end I understand that healthcare is a fundamental right to every individual, as stated in the World Health Organization (WHO)’s Constitution:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.
The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States. The achievement of any State in the promotion and protection of health is of value to all.”.
BIBLIOGRAPHY
1. Chernichovsky, Dov. “Not ‘Socialized Medicine’ — An Israeli View of Health Care Reform”, The New England Journal of Medicine. October, 2011.
2. Elias, Norbert. The Society of Individuals. Continuum International, 2001.
3. McDonough, John E. “Shorter Lives and Poorer Health on the Campaign Trail”, American Journal of Public Health 106, no. 3 (March 1, 2016): pp. 395-397.
4. OECD (2011). Health at a Glance 2011: OECD Indicators. OECD Publishing.
5. Reid, T.R. The Healing of America. Penguin Books, 2010.
6. Rosen, Bruce. Healthcare in Israel for US Audiences. Jerusalem: 2011
7. Rosenthal, Elizabeth. “Health Care’s Road To Ruin”, New York Times. December, 2013.
8. Squires, David. The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations. 2011.
9. Spinoza, Benedict de. Ethics. London: Penguin Books, 1996.
10. Swirski, Barbara; Kanaaneh, Hatim and Avgar, Amy. “Health Care in Israel”, The Equality Monitor, 1998.
APPENDIX A
Total health expenditure as a share of GDP, 2007:
USA -------------------------------------------------- 16.0
France ------------------------------------------------ 11.0
Switzerland ------------------------------------------ 10.8
Germany --------------------------------------------- 10.4
Belgium ---------------------------------------------- 10.2
Canada ------------------------------------------------ 10.1
Austria ------------------------------------------------ 10.1
Portugal ----------------------------------------------- 9.9
Netherlands ------------------------------------------- 9.8
Denmark ----------------------------------------------- 9.6
(Source: The Organization for Economic Cooperation and Development (OECD), in Health at a Glance, 2009).