Introduction
With the 2020 US presidential election, there has been much discussion over the healthcare system. From Biden to Trump, each side of the political spectrum has different views on American healthcare and different ideas on reform. Namely, the shift from privatized healthcare to public healthcare, otherwise known as healthcare reform. There has been debate over universal healthcare, retaining the current American system, and abolishing the Affordable Healthcare Act. There have also been accusations that a for-profit healthcare system is detrimental to lower class Americans. Countries such as Canada and Australia are often used as examples of ideal public healthcare systems. However, the two are not identical, even if they are both public. Rather, they have marked differences as well which need to be examined as the United States searches for a new model.
United States
Technically, the US has a two-tier healthcare system. A two-tiered system has both a public and a private option. In the United States, this involves Medicare as the public option for those over the age of 65 and Medicaid for low-income citizens. These are funded by federal and state tax revenue. There is also the Veterans Affairs system, which is similar to the UK. The UK has a single-payer system and healthcare facilities are owned by the government. The providers are government employees. Finally, the most common option is private insurance, which covers 56% of the population. After all, the US, unlike other two-tiered systems like Australia or Germany, does not have a well-supported public option. Medicare and Medicaid have restrictions to be eligible, while public options in other countries do not. Consequently, most people carry private insurance.
Some detractors state that this system is inefficient. Admittedly, the US spends 17.6% of its Gross Domestic Product (GDP) on healthcare in contrast with Australia’s 9.1% and Canada’s 11.4% expenditure. The US also spends approximately $300 more out-of-pocket per capita on medical care. While both Canada and Australia require a specialist referral from a general practitioner or primary care physician, it differs in the United States as some private insurers permit referrals while others will cover not the visit. Others argue that allowing unnecessary specialist visits is expensive and invasive. In general, US healthcare is more expensive.
Approximately 27% of Americans report that their healthcare system needs to be completely rebuilt [1]. This is also reflected by physician opinion. In a survey of primary care physicians across the world, US doctors were the most likely to report that they spent substantial time struggling with insurance providers and billing, despite new electronic records. Nearly 60% also reported that their patients had difficulty paying for their health services [2]. To corroborate this, American adults are the most likely to have high medical costs, even with insurance. Thus, patients and physicians can confirm that patients have high healthcare costs that are not fully covered by insurance. Consequently, this becomes a burden on patients.
A symptom of this is a phenomenon known as “medical tourism”. On one hand, citizens from developing countries travel to the US to access better expertise with the latest r technology. Conversely, American citizens also travel to less developed areas where costs may be as low as 10% of prices in the US. Naturally, this occurs with elective procedures, especially cosmetic ones. Elective procedures can still be life-saving. However, they can be scheduled, allowing them to complete these procedures overseas at a lower cost. Emergent procedures must be done immediately and, as a result, cannot be done in a foreign country. So, medical tourism does not ameliorate the costs of emergent procedures [3].
Canada
Canada is a single-payer system, where the sole option is the regionally administered public insurance program. Hospitals are often, though not always, public and are considered government property. Their healthcare professionals are considered government employees. There are private practices and hospitals, but they are all compensated by the government. This government compensation is funded by province and federal revenue. There are, however, services that are not covered by the government, such as vision or dental services. Approximately 67% of the population purchases private coverage for these needs.
An accusation against this single-payer system is that the wait times are substantially longer than private healthcare systems, such as the one in the US. 41% of Canadian adults report that they have waited at least 2 months to see a specialist. In comparison, 9% of American adults report that they have waited at least 2 months to see a specialist. On the other hand, only 15% of Canadians experienced cost as a barrier to access, in comparison to the US’s 33% [1]. Consequently, the Canadian healthcare system is a trade-off between access and wait times. Canadian healthcare is more accessible to lower-income patients due to lower costs, though they must wait longer to receive this treatment than American patients.
The lack of commercialization in Canada also reflects the disposition of patients. In America, there have been assertions that this payment for care has led to patients behaving more like customizers. Patients can demand unnecessary and invasive care. In a study done on cancer patients, Canadian care was less aggressive than in the US. This may be due to the American patients desire for care even when it is futile, because they feel as if they are entitled to this care provided they will pay for it. Other than cancer treatment, some American physicians report that their patients are more demanding of certain services and substances, like opioids. They also report that using patient satisfaction metrics to measure standards of care pressures them into giving opioids and other unnecessary treatments [4]. Canadians do pursue “medical tourism” for economic reasons, though it is almost solely for cosmetic procedures and other procedures not covered by the government [3].
Australia
Australia has a two-tier healthcare system, with both public and private options. Unlike the US however, the public option is universal. There is no income or age requirement and is funded by general tax revenue and earmarked income tax. Like Canada, there are services that are not covered, such as dental or vision services. On top of that, some citizens choose to use the private option. Approximately half the population purchases coverage for uncovered services and private hospitals. Nonetheless, the government negotiates with pharmaceutical companies to lower costs [1]. The Australian government also subsidizes 80% of out-of-pocket costs if it exceeds 1,033 USD.
Similar to Canada, 60% of primary care physicians report that their patients face longer wait times to see specialists [2]. In a study conducted at the Townsville Hospital in Australia, the original health system sent referrals, then triaged them. However, this ended in long waitlists unless the condition was critical. A solution devised by Townsville Hospital was then to reduce and update referrals. A follow-up letter was sent to patients who had waited longer than 2 years, requesting that they either: 1) take no action if they felt their referral was no longer necessary or 1) visit their general practitioner (a primary care physician in the United States) to update the referral [5].
In other cases, patients were willing to pay the premium of private care in exchange for faster treatment.With the presence of a private option, once again, care is more “customer service”-focused. Approximately 60% of US and Australian physicians use patient satisfaction metrics. In Canada, this figure is only 15% [2].
Conclusion
Each healthcare system is different, with varying strengths and weaknesses. With the impending US election, it is vital that the American voters understand the nuances of each and how it affects Americans, specifically in the COVID-19 pandemic. A contraindication is that this article does not cover every healthcare system available. While healthcare is variable and every country differs in its policies these nuances are opaque to many healthcare professionals, let alone the general public. Nonetheless, people must be educated before they vote. A democracy cannot function without an educated public that knows what is best for themselves and society as a whole. These decisions affect millions of citizens and must not be taken lightly.
Aleicia Zhu, Youth Medical Journal 2020
References
[1] The Commonwealth Fund. (2012). International Profiles of Health Care Systems. The Commonwealth Fund. www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2012_nov_1645_squires_intl_profiles_hlt_care_systems_2012.pdf.
[2] Schoen, Cathy, et al. (2012). A Survey of Primary Care Doctors in Ten COuntries Shows Progress in Use of Health Information Technology, Less in Other Areas. Health Affairs, 13(12). www.healthaffairs.org/doi/full/10.1377/hlthaff.2012.0884.
[3] Horowitz, M.D., et al. (2007). Medical Tourism: Globalization of the Healthcare Marketplace. MedGenMed, 9(4), 33.
[4] Ho, T.H., et al. (2011). Trends in the Aggressiveness of End-of-Life Cancer Care in the Universal Health Care System of Ontario, Canada. Journal of Clinical Oncology, 29(12). dx.doi.org/10.1200%2FJCO.2010.31.9897.
[5] Stainkey, L.A., Seidl, I.A., Johnson, A.J. et al. (2010). The challenge of long waiting lists: how we implemented a GP referral system for non-urgent specialist’ appointments at an Australian public hospital. BMC Health Serv Res, 10, 303. doi.org/10.1186/1472-6963-10-303.
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