MEDICAL-CARE SYSTEMS OUTSIDE THE UNITED STATES
In most of Western Europe there are state-run health-insurance systems based on work-related taxation of employers and employees as well as some general-revenue contributions provided by the government; coverage is universal and mandatory. Almost all medical-care services are included and paid for in this way. In some countries the ministry of social affairs or a related agency is responsible for overseeing regional systems (Germany and Canada); in others the ministry of labor administers the
program directly (Norway), with the ministry of
health taking responsibility for education, planning, and setting
MEDICAL practice standards.
In Britain, instead of a health insurance program, a guarantee of service and not just guaranteed payment is provided by the government-supported medical-care program, the
National Health Service. Costs are met almost entirely out of
general revenues, and the entire population is covered. Physicians and hospitals remain independent negotiators and are not
government employees, but the system is under parliamentary control for budgeting and setting of standards.
Canada has developed a national medical-care insurance program that is administered by the provinces. The federal government provides about 50% of the operating capital from general revenues, and the provincial governments provide the rest through a variety of means: a general state tax, joint employer-employee contributions, a special tax on state resources, or some combination of these. As in Britain, physicians are private practitioners, not government employees, and hospitals are private institutions.
In all the national health-care programs, physicians negotiate their incomes with the governmental payment authority or with administrators reimbursed by the government, while hospitals are generally reimbursed by way of an annual budget provided by legislative action. These are general statements, because since the early 1980s, economic and political factors outside the United States, as well as in it, have had significant effects on governmental structure and the institutions served. Western Europe and Canada spend less proportionately than the United States, but they too have suffered the consequences of cost inflation, coupled with a decline in national income and rising unemployment, which have necessitated instituting constraints on budgets. Many different approaches have been tried to conserve resources and reduce costs by limiting some access, restricting availability of technology, and capping professional reimbursements.
Eastern European countries, under the Soviet umbrella after World War II, operated national health programs directly controlled by government agencies. Physicians were government employees, and hospitals and clinics were government institutions. The usual bureaucratic problems plagued these socialist-style health systems, but since the collapse of communism and command economies and the liberation of the Eastern European countries from Soviet domination, the previous centralized organizations for health
CARE have undergone some modification. However, the health systems in these countries have been cruelly buffeted by the economic crises attending the transition to market economies.
The greater medical-care cost inflation in the United States has stimulated proposals for drastic changes, and many of the recommendations for reform have been derived from the European and Canadian experiences, but without much success. First of all, Americans apparently do not believe other countries' experiences are relevant to the U.S. scene; and second, while the more comprehensive population coverage offered by a national program is attractive, European countries and Canada seem to be having the same kind of, if not as explosive, cost-containment difficulties as the United States.
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