Everywhere I went last fall, I would often hear the same twang of pity when I told someone I’d come to their country from America to learn how their health care works.
There were three moments I will always remember, one from each of my trips to Taiwan, Australia, and the Netherlands. In Taiwan, I met a man named Wong Shin-Fa, of the Taroko people, an indigenous tribe living in the mountains on the island’s east coast.
I was walking along a township road, clearly out of place, and he was planting orchids with his mother. He stopped me and asked what I was doing there. I said I was a journalist from the US, reporting on health care. He smiled a bit and then went straight into a story, about his friend who was living in Los Angeles and broke his arm but came back to Taiwan to get it fixed because it’d be cheaper than getting it fixed in the US.
In Australia, my colleague Byrd Pinkerton and I got caught in a rainstorm while walking through a park to one of our appointments. We took shelter in a small building with a cafe and tourist information desk, and one of the employees, Mike, introduced himself. I ended up telling him why we were there; he considered it a moment and then said: Well, we’ve got some problems, but nothing as bad as yours. (Check out Everybody Covered on The Impact podcast series on Wednesday and Friday, with episodes covering Taiwan and Australia. Our project was made possible by a grant from The Commonwealth Fund.)
In the Netherlands, the researchers I met with at Radboud University had asked me to give a presentation on American health care, a quid pro quo for their presentation on the country’s after-hours care program. So I obliged. There were two moments when the audience audibly gasped: one when I explained how many people in the US are uninsured and another when I mentioned how much Americans have to spend out of pocket to meet their deductible.
Throughout my travels, I was ever mindful of my own country’s shortcomings in health care — and was constantly evaluating how what I was learning might inform our next steps in reforming it. People have often asked which system was my favorite and which one would work best in the US. Alas, that is not so simple a question to answer. But there were certainly plenty of lessons we can take to heart as our country engages in its own discussion of the future of health care.
The first necessary condition for universal health care is a collective commitment to achieving it. Every one of the countries we covered — Taiwan, Australia, the Netherlands, and the United Kingdom — has made such a commitment. In fact, every other country in the developed world has decided that health care is something everybody should have access to and that the government should play a significant role in guaranteeing it.
Except for the United States. Our two political parties are still deeply polarized on this question: 85 percent of Democratic voters think it’s the government’s responsibility to ensure everybody has health coverage, but only 27 percent of Republicans agree. (Overall, including independents, 57 percent of Americans say the government has this obligation.)
In other countries, there might be disagreement about how to achieve universal health care, but both ends of the political spectrum start from the same premise: Everybody should be covered. Even in the Netherlands, which overhauled its health insurance in 2006 under a center-right government, there was no question about universal coverage.
I came across this quote from Princeton economist Uwe Reinhardt while I was starting to report this project, and it stuck with me throughout. From his most recent book Priced Out, which was published after he died in 2017:
Canada and virtually all European and Asian developed nations have reached, decades ago, a political consensus to treat health care as a social good.
By contrast, we in the United States have never reached a politically dominant consensus on the issue.
When I told people in Taiwan or the Netherlands that millions of Americans were uninsured and people could be charged thousands of dollars for medical care, it was unfathomable to them. Their countries had agreed that such things should never be allowed to happen.
The only question for them is how to prevent it.
I saw all kinds of health systems in action: true single-payer in Taiwan, a mix of public and private insurance in Australia, private coverage for everybody in the Netherlands. Each of them surpassed the United States in two critical ways: Everybody had insurance, and costs to patients were much lower.
But each system also had its downsides.
In Taiwan, there still isn’t enough health care supply. The country does a good job of keeping wait times for surgeries down, but doctors say they’re overwhelmed. Taiwan’s doctor-to-patient and nurse-to-patient ratios are terrible compared to Europe. Specialty care in the rural parts of the country is lacking. On the whole, the medical field seems to be ambivalent about the national health insurance. And while it’s been difficult to measure whether there’s been a “brain drain” resulting from this dissatisfaction or how bad it’s been, it’s a real concern.
It could be that Taiwan is underfunding its health care system; it’s spending a smaller share of GDP than even the socialized systems in Europe. But raising taxes to more adequately fund the system or bumping up cost sharing to encourage more discretion in health care use is almost as big of a political challenge there as it would be here. Nobody wants to pay more for health care next year than they did the year before.
Australia has layered a private health care system on top of its universal public insurance program, and that gives both doctors and patients more choice about medical care. But once you have different tiers in your health care system, disparities are going to emerge. Wait times in Australia’s public hospitals are twice as long as those in private hospitals.
And because the Australian government is spending billions of dollars supporting a struggling private insurance industry for middle-class and wealthier patients, it has fewer resources to devote to disadvantaged populations, like indigenous Australians or patients living in rural areas who have less access to medical care. Public patients in public facilities face longer wait times.
The Netherlands, meanwhile, has handed over the responsibility for providing coverage to private health insurers, and that has come with costs too. The Dutch have had to impose strict regulations on health insurance, including harsh penalties for people who fail to sign up for insurance on their own.
Patients have to pay out a 385-euro deductible every year — that’s serious money for lower-income families. Doctors in the Netherlands are more likely than those in more socialized systems to say their patients struggle to afford medical care. They are also more likely to say the administrative work they have to do is a drain on their time. Health care spending in the Netherlands has also been rising at a faster clip since the move to the mandatory private insurance system.
So the question becomes what kind of trade-off is more palatable. That’s a decision for each country to make: Taiwan wanted equity; Australia is trying to balance access and choice; the Netherlands bet on managed competition.
There is no way to avoid it: If you want universal coverage, the government is going to play a huge role. In Taiwan and Australia, that means the government runs a universal insurance program that covers everybody for most medical services.
But even in the Netherlands, which relies on private health insurers, the government oversees everything. It sets rules about what benefits have to be covered, what prices can be charged, and what cost sharing is required. It collects contributions from employers to pay the cost of covering everybody and spreads it among the insurers based on the health status of their customers.
All told, about 75 percent of the funding for health insurance in the Netherlands is still running through the national government, even if the actual insurance benefits are being administered by private companies.
The US stands alone in how much of its health spending comes from private sources — and still doesn’t have universal coverage.
Under all of these insurance schemes, the governments use much more force to keep health care prices down compared to the US.
In Taiwan, that means global budgets — an annual amount set aside every year for various sectors of the health industry (hospitals, drugs, traditional Chinese medicine, etc.).
In Australia, most doctors do what’s called bulk billing for their Medicare program: The government sets a price, and doctors generally accept it. They can choose to charge more, but it’s relatively rare. They’ve also set up a respected system for evaluating the value of drugs and what their national health insurance plan will pay for them, incorporating input from medical experts, patients, and the drug industry.
In the Netherlands, even with private insurers, the government sets limits on how much health spending can accrue in a given year and has the authority to impose budget cuts if spending exceeds that limit. Prices are also set for particular services, like after-hours primary care. Insurers do have some limited flexibility in which providers they contract with, but the government sets their health care budget for them.
We have experimented with that kind of system in the US, as Tara Golshan covered in this series in her story on Maryland. She documented how the state has tried to use a model like this, global budgets, to improve care for patients by encouraging hospitals to focus on the health of their patients instead of whether they have enough people in their beds.
But Maryland remains an exception. And as the research shows, the US spends dramatically more for many common medical services compared to other developed countries:
Something we didn’t cover as much in our stories but that came up again and again in my reporting is the challenge for long-term care for older people and those with disabilities. For most developed economies, their aging populations will present a serious challenge of both cost and care delivery. The chart below shows what countries were already paying (notice the US lags significantly both overall and in public investment) and then projects what they will be paying in 2050:
What was most interesting is that the countries’ different approaches to long-term care didn’t necessarily track with how they handle the rest of medical care. Taiwan, for example, even with its single-payer program, doesn’t include long-term care as a benefit. Yi Li Jie, a spinal atrophy patient I met, has to pay out of pocket for her caregivers; she also has to pay a substantial share of her transportation costs to get to medical appointments. Taiwan is beginning to debate how to add long-term care to its national health insurance plan, but it’s going to be expensive.
On the other end of the spectrum, the Netherlands has a universal public program to cover long-term care, even though it has private medical insurance. The country’s primary care is geared toward accommodating the needs of patients who are older or have disabilities; doctors make more home visits, and even the after-hours primary care program is set up to be able to reach older people and those with disabilities in their homes.
Of course, the needs for these populations extend beyond the basic provision of medical care. Australia recently transitioned to a new disability insurance program, which covers nonmedical supports for those folks, and beneficiaries have described it as “too complex and difficult to navigate,” as the Guardian reported.
No matter the health system, the most complex patients are going to have the most challenging needs to meet. Nobody has figured out a silver bullet for fixing that yet.
I think it’s telling that Uwe Reinhardt, invited to participate in Taiwan’s debate in the late 1980s about how to achieve universal health coverage, had a pretty simple answer to the question of which system was best for that country: single-payer. It would be the most equitable and the most efficient. But he didn’t believe it would work in the US, because of the influence wielded by private industry.
But other countries, like Australia and the Netherlands, have found a significant role for private insurance even as they strive toward the same goal. Frankly, however, private insurance seems to be more of a political compromise (and, by extension, to reflect some differences in societal values) than a preferred policy solution.
Australia had had private insurance for decades before its universal public insurance plan was introduced in the 1980s; both of its major political parties have come to accept the existence of that program. The conservatives scrapped the first public program in the ’70s, but they’ve given up trying to roll back the current one. Private insurance in Australia has given the better-off more options in their health care; that comes at the expense of some equity, but it is a compromise the country has been willing to make as it tries to balance access and choice.
It’s a different story with similar themes in the Netherlands: Its old two-tiered system was facing an existential crisis in the mid-2000s. Because a center-right government was in charge, they wanted to pursue a market-driven, managed-competition model to try to fix it. Universal coverage was still a shared goal for all the political parties, but they pursued private insurance to do it because it aligned more with the ideology of the ruling government.
Now critics say that was a mistake, that it has made health care more expensive in the Netherlands. But it was the pragmatic path available to the country at that moment.
I’ll never forget a chart Po-Chang Lee, director-general of Taiwan’s National Health Insurance Administration, showed me during our interview. He had approval ratings for the single-payer plan on big whiteboards, and he had just been showing us the enormous spike in approval among the public for the national insurance plan and its steadiness over the years.
But then he pulled out a chart showing how doctors felt about the program.
As recently as 2016, 39 percent of physicians said they were either dissatisfied or very dissatisfied with national health insurance. Another 31 percent said they were neutral. Just 30 percent said they were satisfied or very satisfied (a paltry 2.9 percent said the latter).
I encountered that ambivalence from the two doctors I met in a coffee shop in downtown Taipei. One of them said he was by nature a lefty politically, but he felt the country’s very low cost sharing — what patients have to pay out of pocket when they go to the doctor or hospital — had spoiled patients. His friend cried out at one point, “We’re not the Avengers!”
But such complaints are not unique to Taiwan or its single-payer system. The data suggests physicians the world over are often frustrated by their health systems. Even in countries like the Netherlands and Australia, which have more of a role for private insurance and therefore for doctors to have more choice in their practice and the opportunity to make more money, opinions are split.
But at the same time, providers everywhere are generally happy about the actual practice of medicine.
It’s a pipe dream to think you can build a health system with only happy doctors. But luckily, doctors seem to get into medicine not because they like their country’s health care policies but because of the experience they have treating patients.
Coverage isn’t enough. You actually have to get health care to people.
All of these systems, even with their varying approaches to insuring people, have had to add other reforms to improve medical care itself. In Taiwan, that meant setting up a rural health program that employed doctors to work in clinics at mountain outposts and make visits to indigenous communities part of their daily routine.
“That’s the essence of universal health coverage,” Hong-Jen Chang, the former NHIA director who set up the program, told me. “The principle of health [as a] human right is that everybody, regardless of geography, religion, gender, age, should have the right to access.”
In the Netherlands, it was the doctors who saw a delivery problem and came up with a way to fix it. Years ago, every individual doctor was responsible for providing after-hours care to their patients if needed. Elise Nillesen, who followed in her father’s footsteps to become a general practitioner, remembers her family had to stay home most nights when she was a child and couldn’t really take vacations.
So the doctors proposed a new model: What if they formed cooperatives so they could share the load? They would pool their patients together and each doctor would take a few shifts a month, either providing care in an after-hours clinic or doing home visits. They get paid a flat hourly rate by the private insurance plans.
The result? Today, people in the Netherlands say they have very little trouble getting after-hours care. Just one in four Dutch patients say it’s hard to get treated outside of business hours; in other developed countries, it’s closer to 50 percent or even higher.
Maybe the most sobering interview I had was before I ever left the United States, with Ellen Nolte at the London School of Hygiene and Tropical Medicine. She has evaluated health care systems on how well they prevent deaths that should be avoidable with accessible medical care.
I had asked her what I thought was a pretty basic question: How would you describe the US health system in relation to other countries? Her answer surprised me.
“One thing that always strikes me about the American system,” she said, “is effectively there are, like, 51 American systems.”
Health care in the US varies by geography, of course, depending on which state you live in. It also varies by age: The US does quite well with the over-65 population (which is covered by one public program, Medicare) but struggles with the under-65 patients (covered by a hodgepodge of private and public insurers) compared to other countries. Racial disparities run deep too: There is effectively one health system for white people and another for minorities, given the disparities in income.
“If you want to have access, if you have money, then the US probably is a good system,” Nolte said. “If you want a fairly equitable system, it’s probably not the best. It’s probably better to look at other places.”
Taiwan and Australia have about the same population as Texas, but Taiwan’s is contained to a tiny island off the coast of China and Australia is a continent. The Netherlands is one of the most densely populated countries in the world; the United States is one of the least.
Then you’ve got political differences; Uwe Reinhardt famously didn’t believe single-payer could work in the US, not because it’s not a good idea but because the government was too beholden to corporate interests. The recent failure of surprise billing legislation in the face of industry opposition is certainly a warning sign to any aspiring reformers.
So the dissatisfying answer to “so what can the US learn from these other countries’ successes?” is: It’s complicated. But my hope for this series is it would speak to the kinds of values and strategies, if less the specific policies, that are necessary to achieve universal health care.
Every health system is different. But all of them, except ours, have figured out a way to make being uninsured or going bankrupt over medical bills a thing of the past. The US can do better.
This series was made possible by a grant from The Commonwealth Fund. All content is editorially independent and produced by our journalists.