Europeans Share Their Healthcare Experience, Part 4: Switzerland and Belgium (..and Italy Part 3))

To bring some diverse experience into the discussion on health care reform here in the USA, I've asked my friends in Europe to share how health care works in their lives. In this final of four entries, here are comments from my friends in Switzerland and Belgium (and Italy Part 3):

In Switzerland, everyone has health insurance provided either through an employer (by payroll deduction) or by paying privately to a health insurance company. A family with two children has an annual premium of about 8,000 CHF (about $7,300). For every doctor's bill, the insured person pays 10 percent. If a person becomes unemployed, then the goverment pays the premium based upon 80 percent of the average wage earned by that person over the past five years. The health insurance company reimburses the insured person, who then pays the doctor or hospital. There is talk of reforming this system because it has been misused.

Switzerland can no longer afford the luxury we've had in the past. We have over 1,000 hospitals — that's too many for Switzerland. All the hospitals want the newest technology, scanners, MRIs, etc. Health care lobbying, corrupt politicians, an aging population, and billions in revenue makes changing the system almost impossible. So I pay and pay, this year 15 percent more than last year!

We have the system you are dreaming about, but our wishes and demands are so high that it gets unaffordable. Careless socialist politicians denied the missuse of our social security insurance and allowed hugh deficits. Now we have to stop and turn things around. When it comes to health care, no society can afford everything, top quality, any time, for everybody. Switzerland will now deal with that reality.

In Belgium we pay €20 (about $28) to see a general practitioner at his or her office. We are reimbursed 85 percent of this amount. Surgery is paid directly between the hospital and the social security system. A visit to the dentist is free once a year. Glasses are almost all at our expense.

One of the disadvantages of our system is a lack of responsibility. Patients have the right to change doctors without any reason given and then have the same exams done over. Doctors tend to charge for examinations which they did not do, or to do operations which are not needed. Retirement pensions are getting strained, because we live longer.

It seems that people in Belgium get their prescriptions almost always when their company is restructuring. That can be a problem. Half of the prescription is paid by your company and half by the state.

But as a whole, it is a good system, as we also pay for those who have no money at all.

The system in Italy is faaaaar from being perfect, but the idea behind it is the right one: Everybody has the right to have health care — it's really one of those things that makes a democracy, a real democracy.

In Italy, I pay for the national health care system through taxes. The rate depends how much you make per year (there are income brackets to determine how much you are going to pay). Recently, the government decided to ask for a payment for examinations or medicines (we call it a “ticket,” in America you call it a “co-pay”). There are some categories — such as retired people with low income, people with chronic diseases, and the unemployed — who don't have to pay.

What I really dislike about the system is the long lines to get appointments for any kind of tests (from basic to more complex). It depends on the region, but it's a problem all over the country.

Italy is a country of paradoxes. We have, on one side, excellent doctors with incredible training, and, on the other side, we have “scandals” involving important Italian hospitals in which the hygienic conditions are poor and dangerous. The other problem is that Italy has an “aging” population. We have fewer people working to support the retired population, which is living longer and longer. Because of that, health care costs to our society as a whole have gone way up, while tax revenue has not.

Overall, I'm satisfied with the system, but it must be said that I'm in good health. When my father had cancer and later died from it, I have to say that we were so lucky to meet such fantastic people (doctors, nurses, and volunteers) that it made this traumatic experience less severe. Moneywise, we didn't have to pay a penny for all the treatments he went through.

The Italian health system has the usual diversity of standards from north to south. In my tour guiding over the years, I have assured dubious tourists in Sicily that the hospital we were in was perfectly competent (whilst hoping they did not notice the crunch of the cockroach I had just stealthily stood on). But I have also been hospitalized in an institution in the Italian Alps where I was given a private room with balcony and mountain view, four-star meals with my choice of dishes, and treated with medical equipment worth thousands — all on national health. In the end, I would rather have national health care than be without it.

In Italy, you have to know how to work the system. A few years ago, I was spending a fortune at a private optician in Milan, who kept trying to convince me to have laser surgery costing thousands of euros per eye. I didn't have much confidence in him, so I did the Italian thing — I talked to everyone I knew until I found a friend of a friend who knew a brilliant Russian optician working nearby. A couple of phone calls and a couple of days later, I found myself in the Russian's office where, in half an hour, I was given excellent, unbiased, and free advice about laser surgery and a prescription for contacts and glasses. When in Rome...

I know critics will say that there is less inefficiency in a private system. Would the critics of nationalized medicine advocate the privatization of other government departments such as the ministry of defense? Might that not lead to a series of business-driven wars being fought...ooops! Call me naive, but I would rather support a country which spends more money on inefficiently curing its citizens rather than on inefficiently destroying its perceived enemies.

I have dual citizenship and have lived abroad for 13 years. I have experienced health care systems in the US and Italy. For me, one particular misconception about the US system is the notion of choice. It seems to be a topic that elicits such strong emotions. In the US, we are led to believe that buying into a private insurance plan means that as consumers we have more choices. In reality, the choice of care is never ours, and not even left to our doctors to decide. More often than not, it is insurance companies that decide when, where, and for how long we can receive treatment.

Here in Italy, everyone has access to a government-run system that is funded through taxes, with some private alternatives for those who want to or can afford to go beyond our public service. Health care decisions are not made by someone worried about making a profit. Even the language we use to discuss health care in America (patients are “consumers”) echoes the fact that in the US we rely on a system meant to generate profits — whereas in Italy health care is viewed as every person's right.

It seems impossible to me that a country as wealthy as the US cannot find a way to guarantee access to health care for everyone. There are so many ways to cut costs, including eliminating all of the frills. In the US, when you walk into a hospital or doctor's office, you are greeted by a nice reception area with art on the walls, plants, matching chairs, etc. In Italy the paint may be peeling off the walls, and the chairs in the waiting room may not be the most comfortable — but the care you get is good and thorough.

And here are earlier posts on the same theme.

Europeans Share Their Health Care Experience, Part 1: Scandinavia

To bring some diverse experience into the discussion on health care reform here in the USA, I’ve asked my friends in Europe to share how health care works in their lives. In this four-part series, we’ll start with the most highly taxed and socialistic part of Europe: Scandinavia.

From Hakan in Sweden:

In Sweden, we have free choice in health care. It means that patients can choose a hospital anywhere in the country.

In 2005, the cost of the health and medical care sector amounted to 8.4 percent of GDP (in the US, it was over 15 percent). This amount includes the cost of pharmaceutical products, dental care, eyeglasses, and patient fees paid by households.

We employ a “high-cost protection scheme” that means that no patient ever needs to pay more than a total of 900 SEK (about $125) over a 12-month period. For pharmaceutical costs, no patient has to pay more than SEK 1,800 (about $250) over a 12-month period for prescription drugs. This way, no citizen will be put into poverty because of health problems.

The fee for visiting a doctor or hospital varies from 100-300 SEK (about $14-32), but once you have paid 900 SEK in a 12-month period, the rest of the care is totally free — no matter what kind of treatment you need. Private-care providers are also “clients” of the government. A patient can choose a private doctor or hospital, pay the small fee, and the government pays the difference.

The health and medical services have an obligation to strengthen the situation of the patient, for example, by providing individually tailored information, freedom to choose between treatment options, and the right to a second opinion in cases of life-threatening or other particularly serious diseases or injuries.

Having lived here all my life and raised my family here in Stockholm, I honestly do not see anything bad with our health care system.

From Richard in Demark:

I have lived and worked in Denmark for 24 years and have had numerous encounters with the health care system. In all cases I was satisfied or impressed with the quality of service and the low cost (apart from the tax system — more about that later).

The health care system in Denmark is free to all who live here. Even visiting tourists will be treated free of charge in case of an emergency. A non-Danish friend of mine who sprained her ankle during a recent visit was X-rayed, bandaged, treated by a doctor, and even given a pair of crutches to use — and was not charged anything. She was only asked to return the crutches when she left Denmark.

The quality of Danish health care — which is not run on a profit motive — is very good, though there is a waiting time for some non-life-threatening operations like a hip replacement. But everyone will eventually get the operation they need. Hospitals are free, doctor visits are free, and medicine is highly subsidized so that those who need a lot of medicine get it at a greatly reduced charge. Dentistry is subsidized.

This is paid for through our tax system, which — at 52 percent — is perhaps the highest in the world. None of the 10 political parties in Denmark has ever wanted to change that, because they know that they would not get any votes. The vast majority of Danes are agreeable to pay these high taxes; they know that they get about 50 percent of the money back each year in a vast array of benefits. Seven out of 10 Danes are willing to pay even more taxes, if necessary, to maintain the health care system we expect.

Danes have the mature and realistic understanding that you cannot give everyone a quality health care system, good schools, and the elements that help to make for a good quality of life, without paying for it. Freedom does not mean not paying taxes. For us, freedom is paying taxes. By taking care of each other, and the weaker elements in our society, we all have a better quality of life with very low crime rates, few prisons, and a sense of security that it is not “me against the world.” That is part of what it means to be Danish.

From Hanne and Trond in Norway:

In Norway, everyone has, in principle, equal rights to health care. Norwegian hospitals are “free” for patients (being financed with taxes) and everyone is entitled to treatment, irrespective of income and insurance. However, many things are not always working well here.

When hospitalized, no one asks for insurance coverage. You can stay for as long as it takes without having to worry about costs. At the hospital, every part of the treatment is free, indefinitely. At home, people with chronic illnesses get medicine and necessary medical equipment almost for free, save for a limited, annual base payment.

But some parts of the system don’t function well. Depending on the illness, you could wait a long time for necessary hospital treatment (typically non-emergency surgery). For instance, you have to go through your family doctor in order to be referred to a specialist. When the family doctors have way too many patients and limited opening hours (and limited telephone hours!), this is often an obstacle. Of course, any emergency treatment is exempt from “queuing.”

As for the cost, the hospitals operate with a combined budget of approximately NOK 75 billion ($13 billion). Our health care is not free — we pay for it in our taxes: Our corporations pay a flat tax rate of 28 percent on their profits. Wage income is taxed under a progressive structure, from almost zero (very low, part-time wages) to a maximum marginal tax rate of 54 percent. The average “industrial worker” has a tax rate of 30 to 35 percent.

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Europeans Share Their Healthcare Experience, Part 2: Great Britain

To bring some diverse experience into the discussion on health care reform here in the USA, I’ve asked my friends in Europe to share how health care works in their lives. In this second of four entries, here are comments from my British friends:

From Martin in Wales:

The National Health Service (NHS) in Wales is essentially the same as the English NHS founded over 60 years ago. Today, the main difference between the services in England and Wales is that in Wales (as in Scotland) we pay nothing for medications. Our Welsh Assembly decided that no matter the cost of the drugs, the duration of the illness, or the wealth of the patient, no charge is made for prescription drugs.

This fulfils of the one of founding principles of the NHS — like justice, health care is “blind.” You are treated no matter who you are or what your financial means are. None would pretend that the NHS is perfect: New and expensive drugs are used to combat diseases in an increasingly aging population, which puts financial strains on our system. However, knowing that the NHS will try always to treat you to the best of its ability is something valued highly by most Welsh people.

Treatment under the NHS is free, but the cost is huge. We pay for it in our taxes. In the US, people pay insurance companies for their health care, whereas in Britain, we pay the government. You may think this makes the two systems the same, that it’s only a matter of who you pay. I don’t think so. Don’t forget that the NHS is “blind” and its blindness is its true virtue. Insurance companies insure the individual for a profit, while the NHS delivers care, free to all.

From Tom in England:

The United Kingdom National Health Service (NHS) was 60 years old last year and continues to provide “free” health care from cradle to grave. The NHS is state-funded. It is paid for by employers and employees making a contribution direct from earnings. Care and treatment is free to citizens. Drugs are about $10 per prescription. The NHS system enables completely free access and care for people who can’t pay taxes: the poor, unemployed, and elderly.

When things go wrong with the NHS, it’s given massive prominence by a media looking to sell newspapers and pump up TV ratings. However, for the majority of the English — those not made fools by hysterical media coverage — it is quite popular. We like the NHS because it takes away the worry about what would happen if your health fails, if there’s an accident, or if you just need help as you get older. It’s not perfect. No health care system is. But there are millions of people who would testify that they’d be dead without it.

The creation of our free service came after World War II, when there was a desire to spread health care to all citizens. The demographics have changed since then, however. A population that lives longer requires more costly care. Every society needs to deal honestly with this reality. Life-saving treatments have been developed that cost more. And so, in 2009, the NHS is one of the biggest topics of political debate — it’s called by some a “sacred cow.” The bottom line is that none of the major political parties will try to remove it — and certainly not when they are facing a general election in 2010. I think most of us would call our NHS a 60-year-old success story, regardless of today’s financial challenges.

“Treatment under the NHS is free, but the cost is huge.”

Throughout these anecdotal comments there are some common themes. Perhaps the most alarming non-sequitur that runs through these comments is that health care is free but because of that it costs a fortune (in taxes). That is so ignorant on its face that it helps us understand why so many Europeans have such idiotic views of the US — many Europeans (not all, of course) are not logical and are oblivious to obvious realities. Euro health care systems cost a fortune.

The poor quality of facilities in Italy mean that sanitary conditions are not as good as an average US hospital. The fact that 80% of Euros like their health care should be alarming because that is considered a low level of satisfaction by most standards. A look at the studies of customer satisfaction will reveal that 80% is not especially high. It is also important to understand the psychological nature of illness. You can’t get a sense of how people view a health care system if you survey healthy people—recall is more favorable than attitudes at the time of an event such as treatment at a clinic.

I don’t see mention of the less obvious but serious costs such as loss to employment. Employers are reluctant to hire people because of the tax costs—hence, young Euros at the peak of their youth are unemployed and the productivity is lost to their societies while they cost working people in terms of support and benefits.

The consequences of paying for people who don’t have the means to pay include increasing the proportion of the population that doesn’t have the means to pay. That is a certain consequence of such an incentive system but it is difficult to measure—it is certain, however. Just look at how welfare for single mothers, based on number of children, promotes having more children.

Note how the Italian poster mentions gaming the system. That is how people work complex systems. The US system will get gamed by everyone and that is especially true in the beginning when the system is not yet tuned to reduce the loopholes and gaming. It will drain peoples’ time and energy gaming the system but everyone will have to play games.

Note the comment about long lines and despite that the commenter doesn’t seem to connect those lines to the quality of the health care system.

The commenter who compares her US and Euro health care misses an important point. The US system is hindered by govt regulation; her criticisms of the US system and lack of choice can be traced to govt rules. It is an argument for less, not more, govt interference.

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