W.H.O. Overall Rank: No. 10
Infant Mortality: 3.2 deaths per 1,000 births
Life Expectancy: 82.1 years
Health Costs Per Person: $2,249/year
System Overview: The Japanese buy insurance through their employers and pay 30 percent of any doctor bill as a co-pay, but any and all medical bills are capped at the equivalent to $650 a month. And there are tons of choices — some 3,500 different not-for-profit insurance plans to choose from. As some have proposed for us here in the United States, everyone is required by law to own insurance; if you don’t choose a plan, they will pick one for you and send you a bill. A nationally standardized fee schedule, negotiated biannually, ruthlessly curtails costs — which has translated to Japan spending just 8 percent of its gross domestic product on health care; by comparison, the United States spends 17 percent of GDP on health care.
Key Innovation: Facing tight government cost controls, Japanese docs asked Hitachi and Toshiba to develop a cheaper MRI machine — which they did, allowing Japanese clinics to purchase a bare-bones MRI for one-tenth as much as those available in the United States.
Fun Fact: The Japanese are voracious health care consumers, going to see a doctor, on average, 14.5 times per year — that’s three times as often as Americans.
Downside: Japan’s miserly ways have put a major squeeze on hospitals and doctors. Clinics have such tight profit margins they even charge patients to park.
Lesson: Near-draconian cost controls have not ruined health care; in fact, wait times are short, even for specialists. And by all objective measures, the Japanese are among the healthiest people in the world.
W.H.O. Overall Rank: No. 18
Infant Mortality: 4.8 deaths per 1,000 births
Life Expectancy: 79.0 years
Health Costs Per Person: $2,317/year
System Overview: Under the British National Health Service, there are no insurance premiums to pay, no co-pays — no nothing. Private insurance is available, but less than 10 percent of Britons buy any. The NHS is the largest employer in all of Europe, owning some 2,000 hospitals. All this is paid for by a sales tax that runs as high as 17.5 percent. Costs are controlled by the nation’s general practitioners — who are in private business for themselves and decide who does (and does not) get which treatments.
Key Innovation: The National Institute for Health and Clinical Excellence (NICE) decides which tests, treatments and procedures make sense to fund. It’s a controversial job, to be sure, and officials try to do their job as transparently as possible. Similar decisions are made in the United States, but behind closed doors by for-profit insurance companies. Brits are mostly content with NICE’s edicts because the money saved by such decisions goes to cure somebody else. In the United States, money saved by curtailing coverage goes to a corporation’s bottom line.
Fun Fact: The NHS is so eternally popular that even former Prime Minister Margaret Thatcher, who wanted to privatize everything that moved, stayed far, far away from even appearing to touch the NHS.
Downside: The steep sales tax that pays for it all adds to everyone’s expenses, whether they’re healthy or not.
Lesson: While this may be what some politicians call “socialized” medicine, it is almost exactly the same system used by the U.S. Department of Veterans Affairs. It’s a single-payer system that the U.S. is already using.
W.H.O. Overall Rank: No. 112
Infant Mortality: 55.0 deaths per 1,000 births
Life Expectancy: 69.9 years
Health Costs Per Person: unknown
System Overview: Health care in India can be best described as a nonsystem, as is the case in most poor countries in the world. As India is a developing nation, it has at least some medical infrastructure, but it’s an out-of-pocket system — sick people either pay for treatment or stay sick and potentially die. Mortality rates across the board are much higher in out-of-pocket systems, and in India, millions have died from diseases that are easily treatable and don’t kill anyone in the developed world. Still, if you can afford treatment, ayurvedic medicine has been the system of choice for four millennia in India. Author T.R. Reid found its blend of herbal medicine and massage to be the treatment that made his bum shoulder feel the best of any health care system he studied during his world tour.
Key Innovation: It’s not an innovation at all, but India’s near-official health care method is ayurveda. Ayurvedic healers must be accredited by the government; America has learned about the system through popular health writer Deepak Chopra.
Fun Fact: Many Indian doctors will want to taste your urine prior to offering a diagnosis. And that can only come after a specialist studies your star chart to see if you are, in fact, ready to be healed.
Downside: It’s all downside if you are among the 750 million Indians who live in the rural parts of the nation; most of them are left to see either a traditional doctor with no actual medical training or no doctor at all.
Lesson: Out-of-pocket health care is the clearest example of a health care system that discriminates on the basis of wealth. Not providing health coverage to your citizens results in a lot of needless suffering and death.
W.H.O. Overall Rank: No. 1
Infant Mortality: 4.2 deaths per 1,000 births
Life Expectancy: 81.0 years
Health Costs Per Person: $3,048/year
System Overview: Similar to the United States in that doctors are private businessmen and -women; some hospitals are for-profit, others are not; most citizens get their health insurance through their employers. Everyone is required to own health insurance; if you are unemployed, the government provides it. The big difference is that the 14 insurance companies and multiple supplemental insurance plans are non-profits that can’t deny claims; the government sets their reimbursement rates. While administrative expenses incurred by American insurance companies add up to 20 percent to health costs, in France those expenses account for less than 5 percent of overall costs.
Key Innovation: The Carte Vitale — a green credit card with a memory chip in it; inside are all your medical records, so you can bring them from doctor to doctor. If you lose your card, anyone can drop it in any mailbox and it will be returned (80 percent of lost cards are eventually returned). Thanks to the Carte Vitale, doctors’ offices in France are noticeably uncluttered by mountains of paperwork and patient files.
Fun Fact: In every waiting room in every clinic in France, you will find a list of exactly how much every procedure will cost, down to the 1/100th of a euro.
Downside: Doctors in France are unionized and often negotiations happen — like many things in France — via strikes. Doctors make less money in France than they do in the U.S.
Lesson: Insurance companies free of government regulations add a lot of cost into a system — costs that France has eliminated.
W.H.O. Overall Rank: No. 30
Infant Mortality: 4.8 deaths per 1,000 births
Life Expectancy: 81.2 years
Health Costs/Person: $2,998/year
System Overview: In Canada, there are 13 different insurance funds that pay your medical bills — one for each province and territory. Everyone is covered, with the bill picked up by tax revenues paid by all citizens. Canada has even tried, unsuccessfully, to ban its citizens from owning private insurance. For urgent care, everyone — rich and poor — quickly gets help; if your medical condition is not urgent, there are enormous wait times — as long as two years for a non-emergency surgery. Still, National Health Insurance is Canada’s most popular social program.
Key Innovation: The exact same pills we buy in the United States can be bought in Canada for a lot less. That’s because all the provinces and territories team up to negotiate bulk prices with drug makers.
Fun Fact: The term “Medicare” was coined by Tommy Douglas, the architect of Canada’s health care system. His plan started in Saskatchewan in 1947 and quickly spread to all of Canada — and across the world, as both South Korea and Taiwan have copied Canada’s system. In 2004, Douglas was chosen in a Canadian Broadcasting Corporation poll as the greatest Canadian ever.
Downside: Wait times for non-emergency treatment are the big complaint, and the reason is that Canada is “underdoctored,” with a big doctor shortage. But it makes for a more affordable system, with overall costs about half what they are in the United States.
Lesson: Canada did not wait on a big federal solution; an innovative approach took hold in one province, then everybody wanted it and it became the law of the entire nation.
W.H.O. Overall Rank: No. 37
Infant Mortality: 6.3 deaths per 1,000 births
Life Expectancy: 78.1 years
Health Costs/Person: $5,711/year
System Overview: In the United States, we really have four systems. If you’re over 65, Medicare kicks in — a single-payer system, like in France.If you’re poor, you can qualify for Medicaid. If you are working and decide to buy health insurance through your employer, you are part of the nation’s private insurance pool — like in Japan (but without any rules). If you are unemployed or can’t get health insurance through your employer, you’re in the out-of-pocket system like India’s — an unfortunate place where tens of millions Americans now find themselves.
Key Innovation: The system in the U.S. is unique in that it allows private insurance companies to extract profits from the health care system with no regulation on the kind of coverage they must provide.
Fun Fact: Since Theodore Roosevelt, a half-dozen Presidents have promised health care reform. Bill Clinton’s campaign promise on the issue went down in flames in 1994 — the same year that both Taiwan and Switzerland adopted brand-new health care systems that have covered all their citizens.
Downside: The United States has created a de facto rich/poor system where, some estimates say, 44,000 Americans die each year because they don’t have health insurance. It’s the kind of system that nearly every other democracy has rejected.
Lesson: A for-profit system with no regulations adds up to the most expensive system in the world — and it still leaves tens of millions without health insurance. And all the cost has not brought great results; Canadians, for example, live three years longer than Americans.
SOURCES FOR SYSTEMS AT A GLANCE: The Healing of America, by T.R. Reid (The Penguin Press, 2009); The World Health Organization, World Health Report, 2000 (ranking of overall health care efficiency among 190 nations); United Nations statistics, 2006 (for infant mortality rates); CIA World Factbook, 2009 (for overall life expectancy at birth); Organisation for Economic Co-operation and Development, 2003 (for annual health expenditures per person).