CLINTON’S HEALTH PLAN : Around the World : The President’s Health Proposal Borrows Bits and Pieces From Other Nations.

Germany

THE PATIENT EXPERIENCE: Go to any doctor, get care or referral to specialist, pay nothing and never see a bill. (There is a $3 co-payment for prescription drugs.)

INSURANCE: No choice. Most Germans are assigned their insurer--called a “sickness fund”--according to locality or job. Insurers can reject no one.

WhAT’S COVERED: Everything medical or dental. Some funds even cover a two-week stay at a span every two years or daily visits by a midwife to new mothers.

HOW YOU PAY: Compulsory premium is 13% of wages, half paid by employee through withholding from you paycheck, half paid by your employer. Applies for all workers, whether full-or part-time or self-employed.

IF YOU LOSE YOUR JOB: Unemployment office pays all or some of premium for you. By law, sickness fund must cover entire family for life.

OPTIONS FOR THE WEALTHY: Those earning $50,000-plus can duck compulsory insurance, buy private insurance instead (8% of Germans do) to ensure single rooms, top doctors at hospitals.

HOW IT ALL WORKS: Premiums are pooled by the government, which funds the insurers, who pay doctors prescribed amounts for each procedure. Standard doctors fees are negotiated annually by powerful doctors association and insurers to comply with government-set cap on health spending. Government also controls purchase of high-tech machines.

HISTORY: In the 1850s, the government passed mandatory wage withholding to pay for creation of nation’s first sickness funds--the birth of social security concept. Started with low-wage workers, added other workers and dependents decade by decade. Coverage became universal in 1971.

CURRENT PROBLEMS: Rising costs, triggered by unnecessary treatments--for standard birth, mother stays in hospital for 10 days--and extending the system into former East Germany. Also, lack of food labeling, fluoridated water.

CURRENT SIMILARITIES WITH U.S.: Mostly private doctors. High number of insurers (1,200).

DIFFERENCES FROM U.S.: A 140-year history of compulsory insurance. Fee-setting medical association that all doctors must join. Culture in which legal mandates work. (U.S. had mandatory auto insurance, which millions ignore.)

JAPAN

THE PATIENT EXPERIENCE: Walk into any clinic or hospital with insurance card. Wait in line to get care, bed, or medication. Pay between 10% and 30% or your bill up front; insurance pays the rest.

INSURANCE: No choice. Everyone has it either through job (from one of 1,800 employee insurance societies) or through backup national health insurance (NHI). No one is rejected.

WHAT’S COVERED: Most things medical and dental, including long-term care, medications and, in case of catastrophe, out-of-pocket expenses above $500 a month. Uncovered: checkups for people under 40.

HOW YOU PAY: Premium for job-based insurance is 8% of wages, half withheld, half paid by employer. NHI premium is often government subsidized. All Japanese pay a 2.6% income tax to fund national system.

IF YOU LOSE YOUR JOB: Your insurance continues for up to two years; then you’re switched either to your new job’s plan or to NHI.

OPTIONS FOR THE WEALTHY: Not much. They can obtain private rooms at top hospitals and appointments with top surgeons (paying $1,000 to $3,000 for these perks is a longtime cultural practice).

HOW IT ALL WORKS: All doctor bills are paid by government-tied clearing houses which are then reimbursed by patient’s insurer. Periodic negotiations between doctors group, public interest groups and insurers lock in rigid doctors fees.

HISTORY: Government in 1927 required insurance for plant workers. By 1961, compulsory insurance expanded to all workers and dependents. To cover everyone else, in 1961 the government rammed through the national system against vast opposition.

CURRENT PROBLEMS: Doctors are paid per visit and fill their own prescriptions, leading to quick examinations (average visit; five minutes) and overmedication (Japanese take 50% more drugs than Americans). Three in five men smoke.

CURRENT SIMILARITIES WITH U.S.: Mostly work-based insurance. Mostly private doctors. Complex financing scheme.

DIFFERENCES FROM U.S.: Strong, centralized government. Cultural cohesion. One tenth as many lawyers per capita. Only 238 new AIDS cases nationwide. Unified doctors group. Acceptance of impersonal doctor-patient relationship. Culture in which legal mandates work.

CANADA

THE PATIENT EXPERIENCE: Call any physician for appointment, show medical card, get care, never see bill, and pay no deductibles or co-payments. It’s illegal to pay for most services.

INSURANCE: No choice but provincial plan.

WHAT’S COVERED: Everything but routine adult dental care, cosmetic surgery and hospital room amenities.

HOW YOU PAY: Just pay your income taxes.

IF YOU LOSE YOUR JOB: Nothing changes.

OPTIONS FOR THE WEALTHY: Not much. They can buy private insurance for uncovered items. Also, some Canadians cross border for special treatment or procedures.

HOW IT ALL WORKS: Each province sets its own overall health budget; negotiates standard, locked-in fees it will pay doctors; then pays all medical bills out of taxes. Administrative costs are low--doctors and hospitals need minimal billing, record-keeping, or accounting. Provinces control high-tech equipment, rationing use when necessary.

HISTORY: In mid-1940s, new provincial government in Saskatchewan took over insuring everyone, and residents and hospitals liked the change. By the 1960s all 10 provinces had followed suit, leading doctors to strike for 23 days. Ironically, after backing down, doctors found their incomes rose rapidly under the new system.

CURRENT PROBLEMS: Rising costs due to aging of society. Waits for some surgeries, though never in an emergency. Shortage of doctors in remote northern regions. Unnecessarily long hospital stays because of incentives built into government payment.

CURRENT SIMILARITIES WITH U.S.: Mostly private doctors. Province-run (in the U.S., state-run) health systems.

DIFFERENCES FROM U.S.: Elimination of health insurance industry. (It covered 61% of Canadians in 1965, none by 1970.) Cultural agreement that upper-class people aren’t entitled to more or better care than everyone else. Record of efficient government management.

BRITAIN

THE PATIENT EXPERIENCE: Patient visits doctor, who will treat or refer to hospital/specialist. No charge at any stage. You do pay toward dental treatment, eye tests and a fee of about $6 for prescriptions, except for poorest group, which receives free of charge.

INSURANCE: You are free to choose any type of coverage in the private sector, but your National Health Service coverage comes directly from taxation.

WHAT’S COVERED: Just about everything, but with delays for non-urgent operations such as hip joints and cataracts.

HOW YOU PAY: The money for National Health Service (NHS) comes directly from your income tax, deducted from wages and put into the NHS pool of money.

IF YOU LOSE YOUR JOB: Nothing changes.

OPTIONS FOR THE WEALTHY: There is a private sector. You can be insured for private health care, or just pay for what you need when the occasion arises. There are 33 private insurers.

HOW IT ALL WORKS: The hospitals and general practitioners are answerable to the Regional Health Authority, unless hospitals have chosen to fund themselves. The Regional Health Authorities are then answerable to a board of governors in charge of day-to-day management of the service, who are answerable to the Department of Health Policy Board. That board is headed by the Cabinet health secretary.

HISTORY: In 1948 the National Health Service was set up by the Labor government. A report by Labor Health Minister Aneurin Bevan proclaimed that there should be free health care for all, regardless of social or economic standing. Doctors were doubtful but they were given many concessions by the government. They were employed under a self-employed contractor status, and were given power and a say in how things were run. The NHS has always been funded by general taxation.

CURRENT PROBLEMS: Increasing costs, due to high technology and an aging population, forced new reforms begun two years ago allowing hospitals to operate independently. The transition has caused bugs and criticism.

CURRENT SIMILARITIES WITH U.S.: Many private doctors and hospitals that operate similarly to American private, insurance-backed medicine.

DIFFERENCES FROM U.S.: The private sector is not the main source of health care in Britain. Free treatment is available to all. Only an estimated 10% of the British population have a private health insurance plan.

Percent of population uninsured at some point in a year: Germany: 1 Japan: 1 Canada: 1 Britain: 1 U.S.: 26

Per capita spending on health, 1990: Germany: $1,287 Japan: $1,035 Canada: $1,795 Britain: $920 U.S.: $2,566

Percent of GNP spent on health, 1991: Germany: 8.5 Japan: 6.5 Canada: 10 Britain: 5.4% U.S.: 13.4

Annual doctor visits per capita: Germany: 11.5 Japan: 12.8 Canada: 6.6 Britain: 6 U.S.: 5.3

Open-heart surgeries per million people per year: Germany: 0.7 Japan: NA Canada: 1.2 Britain: 0.5 U.S.: 3.3

MRI machines per million people: Germany: 0.9 Japan: NA Canada: 0.5 Britain: 2 U.S.: 3.7

Infant mortality per thousand: Germany: 7.6 Japan: 4.8 Canada: 7.2 Britain: 6.6 U.S.: 10

Percent saying system needs to be fundamentally changed, rebuilt: Germany: 48 Japan: 53 Canada: 43 Britain: NA U.S.: 89

NA: Not available