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© 2003 American Public Health Association
PUBLIC HEALTH MATTERS |
The author is with the Mailman School of Public Health, Columbia University, New York, NY.
Correspondence: Requests for reprints should be sent to Lawrence D. Brown, Professor of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 W 168th St, New York, NY 10032 (e-mail: ldb3{at}columbia.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCOVERAGEFUNDINGCOSTSPROVIDERSINTEGRATIONMARKETSANALYSISSUPPLYSATISFACTIONLEADERSHIPReferences |
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The Rekindling Reform initiative examined the health systems of 4 countries: Canada, France, Germany, and Great Britain (United Kingdom). From the 4 country reports published in this issue of the American Journal of Public Health, 10 crosscutting themes emerge: (1) coverage, (2) funding, (3) costs, (4) providers, (5) integration, (6) markets, (7) analysis, (8) supply, (9) satisfaction, and (10) leadership. Lessons for the United States are presented under each point.
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INTRODUCTION |
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The 4 articles in this issue of the Journal that explore universal-coverage health care systems in (1) Canada, (2) France, (3) Germany, and (4) Great Britain (United Kingdom) are a sophisticated package of generalization, variation, and implication that defies easy synthesis and summation. Nonetheless, this rich cross-national variation yields 10 general themes.
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COVERAGE |
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All 4 nations entitle almost all their citizens to health coverage. Health care is not enough; their images of solidarity, community, and equity insist that how care is obtained, not merely that it be somehow obtainable, matters greatly. Respect for human dignity demands that no one refrain from seeking medical care from fear of the consequences of doing so, and that no one suffer financial adversity as a result of having sought care. The moral foundations of universal coverage are as simple as that.
Although these nations all cover medically necessary and appropriate services, they also debate the limits of publicly defined coverage. In Canada, for example, home health care and drugs lie outside the public system. In France, dental and eye care tend to be covered by supplementary insurance. As medical innovation advances, discussion intensifies about how to define baskets of benefits that distinguish the responsibilities of the national community from those that individuals and families ought to bear personally. Although these deliberations steadily gain prominence and publicity, so far they proceed mainly at the margins of comprehensive systems that show little inclination to cut back covered services. The core values of these systems—solidarity, community, equity, dignity—remain intact and surprisingly little disturbed by rising costs and by gloomy forecasts that aging, technology, and the rest are rendering their systems unaffordable.
The moral and cultural foundations of universal coverage are missing in the United States, as the continuing presence of 40 million uninsured would seem to intimate. Circumstances are not propitious: 85% of the population has medical coverage, much of it funded by private employers; the 15% who lack insurance are not organized, cohesive, or politically active; sizable redistributive shifts by national design are not the political system’s strongest suit; and the right-of-center precincts in which that system has lingered for the past 35 years do nothing to ease the struggle. Equally important, Americans "know" that safety net providers care for people who lack coverage—a powerful inhibition to public action in a nation whose welfare state programs aim less at broad-ranging security in health and other policy spheres than at post factum compensation for those who fall through private-sector cracks. Reformist appeals based on human dignity (to which health security is fundamental) resonate very little here. September 11 and rescued miners aside, solidarity finds little place in the national political lexicon. Likewise, in the United States, community is not a spur to national action but rather an alternative to—and an excuse for—declining to pursue it. The brightest and best strategies to build a normative case for universal coverage have failed so far, and no one seems to know how to change these values, which are, by definition, fairly durable.
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FUNDING |
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In all 4 systems the national government sets a statutory framework for financing universal coverage. (In Canada the provinces must meet centrally defined conditions for participation in central/provincial fund-sharing arrangements.) How they raise these monies differs substantially, however: Great Britain’s National Health Service draws mainly on general revenues; 70% of Canada’s health bill comes from national and provincial general revenues; Germany relies primarily on work-based social insurance contributions; and—the most dramatic evolutionary development in this quartet—France increasingly supports its social insurance regime with general revenues that tap a broad range of wealth. None of these approaches is plainly superior to the others; they all "work," and they all carry their burden of political and economic stress. France and Germany also have various degrees and types of cost sharing by patients.
The good news for the United States is that in essence any major funding approach will serve. The bad news is that no such approach seems close to commanding consensus, and feuding over the merits of funding strategies aggravates the chronic righteous strife among proponents of reform that (given the imposing strength of the opposition) has heavily damaged reform prospects. One contingent contends that a "single payer" (general revenue—based) system is best. Another believes that the success of Social Security and Medicare validates a social insurance strategy. Whereas no other nation believes that universal coverage can be won and sustained without candid debate about taxes, a prominent American reform camp wants to build on the private employer contributions that buy most US health insurance today. (Indeed the Clinton administration’s reform plan of 1993 would have mandated such employer "premiums" precisely in order to avoid uttering the dreaded "t word.") Meanwhile, the widespread conviction that done right, universal coverage should require no new monies (tax-derived or other) beclouds the US reform debate. The system is said to be replete with waste that can be intelligently squeezed to yield abundant funds to rechannel resources from excessive use and payments to providers and toward coverage for the uninsured. (This too was a premise of the Clinton plan.)
This pastiche of theory and ideology lays down myriad stumbling blocks that reformers must somehow surmount. A workable coalition probably presupposes avoiding fierce redistributive battles over how and where to squeeze and redirect wasteful spending within the status quo, dismissal of employer mandates (and the battles with business they trigger), the political courage to discuss tax increases that (probably) mingle social insurance payments with general revenues, and, not least important, willingness among ardent advocates of diverse financing strategies to rally behind whatever seems to stand some chance of passing. Meanwhile, cost controls can be taken up after the universal deed is done—a prospect that will of course be plain to stakeholders who oppose reform and will take up their political cudgels accordingly.
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COSTS |
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Although the 4 nations spend a smaller share of their national resources on health care than the United States does, cost containment has long been a preoccupation in each and all. (Great Britain is arguably a case apart. There, reorganization and better management of the National Health Service have—until recently—been successfully offered as alternatives to the infusions of cash the Blair government was eventually moved to promise.) The 4 nations pay their physicians less and provide fewer specialized and highly technical services than the United States does, and all expect that structured negotiations between payers and providers will hold the line on costs.
These staples of cost containment seem increasingly insufficient to counter the fundamental challenges all nations face—growing and aging populations, technological progress, inflation, wage pressures, and rising popular expectations1—and so in their sundry fashions, the 4 countries try to cap health spending. In Great Britain and Canada, the public health care budget is itself a ceiling. In France, since 1996 Parliament has legislated a national spending target annually. Germany has tried to link health spending increases to the growth of workers’ wages. Only in Great Britain have these public constraints generated highly controversial waiting lists, and these, says Light,2 are mainly limited to elective referrals to specialists. Waiting lists occasionally appear in Canada, but Deber1 argues that these vary with place and procedure and are a minor, albeit well-publicized, concern. "Rationing" is a nonissue in France and Germany. Containing costs is never easy, but the 4 nations have done it—indeed, in the British case perhaps too well.
Rising health costs are of course a huge headache in the United States, and the likelihood that universal coverage would push them higher and faster is a weighty political burden on reform. Unlike the 4 nations, the United States has rejected all talk of publicly set limits on health spending. Insurers, providers, business interests, and other opponents of reform loudly equate all such aggregate constraints with "rationing," and the equation has dependably terrified public opinion. In 1993, Bill Clinton proposed to harmonize cost control with universal coverage by means of managed competition among health plans, backstopped by caps on health insurance premiums, should market forces fail to hold them down. The Clinton plan was rejected, leaving cost containment to unmanaged competition among health plans, which (to many reformers’ surprise) proceeded to "work" in the second half of the 1990s as cost increases slowed dramatically. Health spending moved rapidly upward thereafter, however, leaving purchasers and policymakers wondering what to do for an encore.
This strategic tabula rasa may leave the United States uncommonly receptive to learning from abroad. On the other hand, public budgets and caps, which continue to connote rationing and remain abhorrent to influential stakeholders, do not seem to be gaining a constituency. Adopting them would entail elimination of some politically potent sources of waste that market forces tolerate or aggravate, namely (to borrow from Deber’s list): marketing costs, efforts at selective enrollment, stockholders’ profits, executives’ exorbitant salaries, lobbying expenses, and less widely diffused technology. And if such waste were gone, the fundamental things—growing and aging populations and such—would apply here, as in other nations, as time goes by.
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PROVIDERS |
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Conflict between policymakers (in both health and financial ministries) and providers over terms and levels of payment is a persistent fact of political life in all 4 nations. Within public budgets and fiscal caps, providers negotiate with the state, the sickness funds (health insurance institutions), or both. In Great Britain and Canada, physicians’ organizations and individual hospitals bargain directly with government agencies. In Germany, associations of sickness-fund physicians and individual hospitals negotiate with sickness funds within a framework of public rules. In France, unions of physicians bargain separately with the sickness funds as the state moves back and forth between the sidelines and the battlefield. In each of the 4, payers squeeze, providers protest (and sometimes strike), payers relent, costs increase, payers squeeze, and so it goes. Although budgetmakers invariably spend more than they prefer, providers in all 4 nations earn considerably less than their more specialized US counterparts.
The US medical profession is more lucrative and entrepreneurial than is the case elsewhere. To American providers, collective negotiations with public payers, which imply more than tacit consent to a state-run social enterprise called (or headed toward) national health insurance, have long been anathema. The United States has coped politically by evolving a bifurcated pattern of payer and provider relations. The main public program, Medicare, shifted from a payment system that mimicked the private sector (retrospective payment of actual hospital costs and usual and customary physician charges) to prospective payment models, steered by commissions in which providers have a voice, and by Congress, which they lobby directly. In the private sector, purchasers have hoped to discipline providers by shopping among and signing on with managed care plans that presumably contract selectively with "efficient" providers and apply organizational reviews and constraints that enforce efficiencies.
The future of these disparate arrangements is a key question for health reform. Would a public system of prospective payment prevail, and could it coexist with the current private managed care model? Must reform mean the end of unmanaged competition among health plans and a belated biting of the bullet on managed competition, and if so, what version of it? As with financing, there appears to be no one right way, but workable reform will have to hold the line on provider payments, and doing so will mean constructing new bargaining machinery with which providers agree to "live," however grudgingly. Today, US providers are more inclined to wish a plague on the payment practices of both Medicare and managed care than they are to think constructively about better ways to negotiate collectively with payers. Most American physicians and hospitals continue to view health insurance as an economic, not a social, enterprise and organize and strategize accordingly.
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INTEGRATION |
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These 4 nations all voice dissatisfaction with the organization of their delivery systems; they all deplore "fragmentation" and aspire to "integration." International literature and their own observations teach that overuse of services is substantial and that, to coin a phrase, care ought to be better managed. Having long allowed physicians and hospitals to practice medicine largely as they pleased—a norm crucial to the quid pro quo in which providers accepted regulation of their payments—these countries now seek efficiencies in production that supposedly accompany organizational innovation. Great Britain’s tools of choice, for example, were fundholding among general practitioners and hospital trusts, now giving way to primary care trusts. Indeed, writes Light,2 the government now plans to "unite specialty care with primary care, unite primary care with community health care, and unite all three with social services," yielding "comprehensive, integrated services that are community based." The French are experimenting with "networks of coordinated care," notes Rodwin.3 These countries view reorganization (or redisorganization, in health economist Alan Maynard’s term) soberly, as "reforms" worth testing as possible sources of better value for money within fundamentally sound systems.
The United States, the esteemed source of much of the theory and practice of the services integration other nations seek to emulate, may be ahead of the international curve but faces integrative challenges of its own. Both here and abroad, proponents of reform sometimes divide over whether the achievement of universal coverage is a necessary and sufficient policy objective, over whether to insist that such coverage be encased in a properly designed delivery system. Americans must decide how far to tie reform to managed care, the driver of US-style integration, and increasingly an 800-lb gorilla politically. Will the new system seek to redeem a fee-forservice system, follow Medicare’s dubious lead into some variant of choice between a fee-for-service system and managed care, or assume that managed care will be mainstream and fee-for-service payment an exception? Beyond decisions about how far to push managed care lie others on what to do about managed competition, an issue that has vexed US health policy since the 1970s. Is integration—in this case the proliferation of managed care organizations—a natural institutional receipt for better efficiency and quality? Or do these objectives presuppose competition among integrated entities? Can this competition stay loosely managed, as now, or would universal coverage trigger anew the many disputes about managed competition that sunk the Clinton plan a few years ago? Ironically, other nations are better equipped to address integration incrementally than the United States is: here it invites a host of radical questions.
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MARKETS |
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American reformers who admire the rest of the West for its refusal to treat health care as a commodity to be bought and sold in the marketplace tend to view the growing foreign fascination with market forces in health care as a trip down the garden path. This fascination is unmistakable in all 4 nations, however, as evidenced by Great Britain’s internal markets, Germany’s regulated competition, France’s networks, and Canada’s Community Care Access Centres. All the same, foreign attachment to health care markets tends to be clear-eyed and decidedly nonevangelical, is far from taking national health insurance systems by storm, and may already be waning (judging by Light’s account2 of Great Britain, the most market-friendly of the 4). Other nations recognize that competition is difficult, at least in a real world populated by real institutions. Besides breaking important political compacts (for example, that any national health insurance physician may treat any national health insurance patient, a settled norm that pretty much precludes closed panel plans and selective contracting by payers), competition requires heroic analytic feats, which carry no small price tag: better management information systems, copious consumer information, subtle measures of quality, methods to adjust payments by risk of enrollees, and more. None of these countries views competition as a panacea, and none fantasizes that market forces can supplant the solid regulatory machinery now in place. All 4 worry that even well-designed competition could undercut solidarity, community, and equity, and each wonders candidly whether the market game is worth the social candle.
Although the United States has embraced markets and competition as health care "solutions" with a passion puzzling abroad, it hesitates too. For years, 1 school of market reformers has predicted that competition among managed care plans per se will make the system more efficient, whereas another has contended that such competition must be managed (by and within a sophisticated and extensive framework of public rules) lest it lapse into such market failures as selection of preferred risks, underservice, and geographic segmentation of markets, all of which would damage the public interest. The slow growth of health costs in a strong economy in the latter 1990s cushioned the horns of the dilemma. Today costs rise faster, the economy grows more slowly, and the prospect of incorporating 40 million uninsured into a new reformed system brings competitive disputes to center stage again. Would a new round of reform put managed competition over the political goal line at last? Dare reformers view reform as the great escape from an imprisoning competitive mindset? Must they accept it as part of the strategic furniture they must perforce rearrange? Having gone to market so often, the United States may no longer be capable of a swift, clean U-turn, but if we cannot live without competition, how will reformers live with it?
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ANALYSIS |
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The 4 countries show a strong and growing curiosity about how analytic tools—evidence-based medicine, technology assessment, report cards, and cost-effectiveness analysis, for example—can help policymakers to assess the performance of their health systems and suggest means to improve them. New agencies such as the National Institute for Clinical Excellence in Great Britain and the ANAES (Agence nationale d’accréditation et d’evaluation) in France promote and conduct such evaluative studies. Although foreign policymakers have suitably modest expectations for these tools, their influence might advance by several different routes—for example, improved performance as measured by analytic criteria could become a condition for increased pay to providers, and continued documentation of overuse of services within these systems might fuel budget makers’ determination to manage care—that is, providers—more assertively.
In the United States, the birthplace of many of these tools, expectations are high, but stubborn professional resistance to implementation of practice guidelines and kindred constraints and the befuddlement of most private and some public purchasers over what to do with analytic findings often leave the evaluative enterprise all dressed up with no place to go. In this arena, the United States and the 4 nations may well converge. As cost pressures build, so too will the impulse to find diagnoses and recommendations in neutral expertise and objective evidence. Analytic findings and advice will throw down the gauntlet to providers, who will respond both by seeking to shoot the messenger and by redoubling their efforts to document, define, and perhaps even reconsider their practice patterns. Policymakers will reply that the providers offer too little, too late, and the deployment of analytic weapons in the unending political conflicts will escalate.
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SUPPLY |
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The 4 nations all use public authority and planning to control the number and distribution of hospitals and physicians. Contrary to conventional wisdom, such constraints do not necessarily make the system "smaller" or harder to access. Rodwin’s Table 2,3 for example, shows that on most measures of resources and utilization—for instance, active physicians per thousand population; total inpatient hospital beds, physician visits, and hospital days per capita; admission rates to and lengths of stay in hospitals—France surpasses the United States. These limits do make the systems less specialist driven and technology intensive, however, which seems to be how they register savings for the nations in question.
Notwithstanding such programs as certificates of need, the United States relies mainly on a combination of market forces and professional preferences to decide what levels of supply are adequate. The market itself must challenge the hoary conviction that "health is a community affair," meaning in practice a highly entrepreneurial affair in which local providers behave as if more is better, often with the acquiescence of boosterish local business leaders. Hospitals and physicians want bigger and better facilities, the latest and best equipment, deeper market penetration, and more accessible satellite sites, as do the communities they serve. Managed care plans that contract too narrowly risk losing customers. Health "planning," which connotes rationing, waiting lists, and beneficial services foregone has largely vanished from the American radar screen. Perhaps, however, the cost pressures accompanying universal coverage will so obviously overmatch the disciplinary powers of market forces that US policymakers will rethink their options on this controversial count.
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SATISFACTION |
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In all 4 nations, citizens record high (though not unreserved or uncritical) satisfaction with their health care systems. No one views national health insurance as a big mistake and wants to start over. The vices of the US system—40 million uninsured people, an additional (and sizable) number with inadequate coverage, wide disparities in access and quality—are thought to overwhelm such modest and distinctive virtues as more extensive integration of services and more advanced analytic capacity. The foreign systems’ costs are routinely and rhetorically said to be in "crisis." The systems themselves are not.
American public opinion voices no small dissatisfaction with the US system and considerable support for major, even fundamental, changes in it. The rub, however, is that this grousing does not yield a clear mandate for anything very different from the status quo. Despite years of intense opinion polling, policymakers remain unsure precisely what people are upset about (beyond the impossibility of enjoying ready access to fine care at minimal cost) and what they think would work better. Nor is this so odd after all: the same political leaders who quietly pushed arcane payment reforms in public programs have generally declined to launch searching public discussions of the big and touchy redistributive and regulatory issues and tradeoffs on which health reform turns. Bill Clinton’s unavailing and politically painful effort to break the pattern reaffirmed it instead. A perplexed public has therefore come to view health care reform as something like shopping for shoes: "We think we are in the mood to buy a health care reform today but not that style or fit, so keep showing us others." The technical opacity of the debate, not to mention continuing skepticism of anything "made in Washington," inhibit grassroots mobilization, citizen education, and other key concomitants of vigorous pluralist politics. No one seems to have a clue how to make well-documented dissatisfaction kindle a political fire under health reform.
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LEADERSHIP |
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The 4 countries all recognize that strong, continuing leadership by the central government is the sine qua non of affordable universal coverage. Great Britain is, of course, the home of "socialized medicine." Efforts by France’s famously powerful state to reform the health care system have multiplied in the last 2 decades, especially since the Juppe reforms of 1996. Germany’s central government is a "supervisor, enabler, facilitator, monitor,"4 and purveyor of national standards for the health system. Canada’s constitution reserves health duties for the provinces, but the central government uses its financial leverage to enforce on them 5 straightforward principles that protect solidarity and equity for Canadian citizens.
None of the 4 countries, however, supposes that health policy can be run entirely from London, Paris, Berlin, or Ottawa. Germany and Canada are federal systems and, as Altenstetter4 and Deber1 explain, a mix of constitutional, political, and informal rules and norms ensure that states and provinces participate extensively in making and running health policies that affect them. With such consultation comes conflict and delay, but federalism and universal coverage are eminently compatible.
Great Britain and France have created new regional and community bodies—the Primary Care Trusts in the former and regional hospital councils and public health conferences in the latter, for instance—that encourage deliberation and coordination closer to the proverbial grass roots. All 4 acknowledge that decentralization and devolution are goals worth pursuing, but they also understand that workable decentralization presupposes effective centralization of policy authority.
This latter proposition generally eludes US health policy. Save on rare occasions—for example, the New Deal and the Great Society—when issues of economic and social justice dominate the national agenda, fights over the alleged evils of new central powers quickly upend debate on the ends of reform, health or other. At least in the health sphere, actions may speak louder than words—Medicare, Medicaid, Children’s Health Insurance Program, and other public programs control roughly half the dollars in the health care system, after all—but political protocol requires proclaimed allegiance to an official ideology of market forces and less government even as reformers quietly and incrementally add a new piece of managed care regulation here, expansion of public coverage to another income category there. Much of this (abundant) public action originates in the states or evolves from complex sharing of initiatives, funds, and powers between the national and state governments. Fifty states are a more daunting tableau than 10 provinces, but the United States might infer from the Canadian system that universal coverage in a federal system can be managed by 5 succinct principles, not 50 volumes of the Federal Register. Unfortunately American reformers have been more inclined to admire Canada’s "single-payer" financing than its much more instructive central/provincial accommodations.
Where this self-denying activism, this stealthy state leadership, leads is anyone’s guess. Perhaps the present pattern—one step forward, one step back, and the nation counting itself lucky if the number of uninsured does not exceed 40 million—will persist. Perhaps incrementalism will proceed and the nation will awake one day to find that enough programmatic pieces are in place to sustain near universal coverage if only the money and leadership can be summoned to add a few more beneficiary categories and raise income thresholds a few more notches. Perhaps another 1932 or 1964 waits right around the corner, and "real" health reform may suddenly arrive on waves of social indignation and political innovation. At this point, however, cross-national learning disappears into the depths of national character.
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Footnotes |
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Peer Reviewed
Accepted for publication September 17, 2002.
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References |
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TOPABSTRACTINTRODUCTIONCOVERAGEFUNDINGCOSTSPROVIDERSINTEGRATIONMARKETSANALYSISSUPPLYSATISFACTIONLEADERSHIPReferences |
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1. Deber, RA. Rekindling Reform: lessons from Canada. Am J Public Health.2003;93:20–24.
2. Light, DW. Universal health care: lessons from the British experience. Am J Public Health2003;93:25–30.
3. Rodwin VG. The health care system under French National Health Insurance: lessons for health reform. Am J Public Health2003;93:31–37.
4. Altenstetter, C. Insights from health care in Germany. Am J Public Health2003;93:38–44.
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