Many critics consider this system to be a fragmented or patchwork system because of the inconsistencies with delivery that create gaps in coverage for citizens Healthcare Systems - Four Basic Models, n. It is estimated that about 8.
The Commonwealth fund, n. Due to the fact that the U. S operates on a multi-payer system, coverage is sporadic and varies. This is evident by the roughly According to the U. While there are many safety net and low-income programs, this patchwork network still leaves many gaps in coverage, leaving people without direct access to affordable care.
The ACA sets requirements for essential services that must be covered under health plans offered in the markets. These services are: ambulatory patient services, emergency services, hospitalization, maternity, mental health, prescription drugs, rehabilitative services, laboratory services, preventative services, and pediatric care including dental and vision.
As mentioned above, each state determines the breadth of services covered through regulation. Safety nets in the U. S healthcare system are comprised of Federally-Qualified Health Centers FQHCs , Medicaid coverage, public hospitals, and local health clinics using cost-sharing, sliding-scale, or subsidies as a fee structure.
S healthcare system is financed through a mix of public and private spending, known as a multi-payer system See Appendix 4. Medicare is financed through a mix of general federal revenues, payroll taxes, and premiums.
In addition, premium subsidies are offered through federal tax credits. Medicaid is administered through the state and is tax-funded. In the U. Employers who offer health insurance qualify for tax The Commonwealth fund, n. As discussed in the previous sections, two countries with similar health care systems England and Taiwan and one country with a different health care system were selected because their health care systems provide universal coverage while the US was selected because its health care system is the exact opposite.
Collectively, the differences and similarities will lead into the last section of this report where insights, patterns and recommendations to improve the systems will be discussed.
First, a single-payer system is effective in controlling cost; this was a major policy goal of the government as health spending in Taiwan was growing rapidly. Second, a single-payer system is equitable: coverage is universal and all insured are treated equally regardless of ability to pay or preexisting conditions. Third, a single payer system is administratively simple and easy for the public to understand. The NHI has achieved all three policy goals. Reinhardt also suggested that Taiwan retain its predominantly private delivery system.
As long as financing and payment were within the purview of government, a mixed delivery system of private and public providers could work well within a single-payer framework. Compared to Taiwan, the creation of the NHS was the product of decades of hard work and motivation from various people who felt the current healthcare system was insufficient and needed to be revolutionized.
Calls for health care reform started in the s, but was not effectuated until the London County Council took over the responsibility for about hospitals, medical schools and other institutions in after the abolition of the Metropolitan Asylums Board Brain, n.
World War II led to the creation of the Emergency Hospital Service to care for the wounded, making these services dependent on the government Brain, n. By , the Ministry of Health was in the process of agreeing to a post-war health policy with the aim to service the entire general public Brain, n. A year later, comprehensive health and rehabilitation services was supported by the House of Commons and the Cabinet eventually endorsed the guidelines for the NHS which included how it would be funded from general taxation and not national insurance Brain, n.
Everyone was also entitled to treatment including visitors to the country and it would be provided free at the point of delivery. England uses a tax-based method of funding while Taiwan using an insurance premium method. An area of contention for Taiwan is its political issues with raising premiums to meet new rising cost.
It is speculated that at its current rate, the Taiwanese government will have to increase its supplemental funding, which could create a burden on the economy. Based on the principles of decentralization, England uses a bottom-up and top-down approach to funding. Taiwan uses a top-down approach in regards to funding and policy making power, with a mix of both in administration of the national healthcare program.
Funding power and policy making power is centralized at the top with the Legislative Yuan having the final sign off on premium budgets. Administrative power, however, is shared with national and localities by way of sub divisions. In Taiwan, providers are largely private and generally free to compete with one another. The Taiwanese system providers earn their income through patient visits, prescriptions, and procedures.
In addition, they provide additional services like cosmetic surgery, laser treatment, etc. This expands their income net and allows them to operate in a more competitive manner.
In England, GPs are contracted by the government and their salaries are negotiated by the association who represents them and the government. GPs earn income through a mixture of capitation and reimbursed directly by the government every month mostly seamless process because the data being input are the patients they are serving. If there are additional services, this is the only data that needs to be input manually into the system.
Most services are free of charge at point of use and when there are out-of-pocket expenses, it is relatively inexpensive and many groups are eligible for exemptions.
Only additional, non-necessary services some vision, dental, etc. Taiwan does not require registration to see a physician as they employ an innovative mechanism using a cloud system that allows citizens to store their basic and most recent medical information so that they can see any provider. It also allows for seamless claims management. Whereas England requires registration to see a physician who are typically the first point in contact for patients. This difference is economic - England funds their providers directly through negotiated contracts whereas Taiwanese providers have more opportunities to earn additional income and compete with one another.
Both national healthcare systems draw public funding, but the Taiwanese system incorporates market principles from the private sector by allowing providers to operate privately not government contractors and increase their revenue by offering other services.
It can also be argued that because England requires patients to register with a physician, thus eliminating provider competition and stagnating overall pay. One could argue that a health system that fails to address quality of care, regardless of coverage, fails as a system.
Despite the current versions of their health care systems starting at drastically different times, the s for England and s for the US, and the scope covered by the government, the reasoning behind their establishments is essentially the same. Before the NHS Act was enacted in , health care in England was incredibly expensive and only provided services to the working population, virtually excluding most, if not all women and children. As for the US, in , the year before the ACA was fully implemented, over 44 million non-elderly Americans did not have health insurance largely due to private insurance plans being unaffordable.
British and American elected officials created reformed their health care systems because the number of uninsured were disproportionately larger than the insured population. In the US and England, health legislation and general health policies are handled on the federal level. In England, legislative power for health legislation is with the Parliament and DHSC supervises and manages the overall health care system. While the scope and population coverage is different, health legislation is centralized.
In both countries, physicians providing primary care are paid through a mixture of negotiated capitation. These provide payment using a mixture of capitation to cover essential services representing about 60 percent of income , optional fee-for-service payments for additional services e. Capitation is adjusted for age and gender, local levels of morbidity and mortality, the number of patients in nursing and residential homes, patient list turnover, and a market-forces factor for staff costs as compared with those of other practices.
Performance bonuses are given mainly on evidence-based clinical interventions and care coordination for chronic illnesses. In the US, physicians are paid through a combination of methods as well, including negotiated fees private insurance , capitation private insurance , and administratively set fees public insurance The Commonwealth Fund, n. Physicians can also be given financial incentives, made available by some private insurers and public programs like Medicare, based on various quality and cost performance criteria.
In regards to health care, both Taiwan and the U. S exhibit characteristics of deconcentration Chaturvedi, with accountability at the federal levels. Politically, in both systems healthcare decisions are made at the federal levels between the executive and legislative branches called Yuans in Taiwan.
While the U. S provides power to the states for regulation, the ACA is mandated at the top. Giving little power to localities in the decision making. Administratively, in the U.
S, the CMS administers Medicare and Medicaid and sets the basic coverage requirements for states to follow. Both systems have short wait times, but for vastly different reasons. Whereas in the Taiwanese system, the lack of gatekeepers allow patients to quickly accesses providers and specialist at any time.
However, the quality of care suffers in the Taiwanese system due to short doctor visits and high volume of patients; in the U. In Taiwan, the payment system is formulated in global budget and based on care determined by the LegislativeYuan. NHI does not take enough money from premium payments to cover healthcare provided, which means the government has to provide additional funds to supplement.
The problem is political - any premium increase would have to be approved by the Legislative Yuan and they are typically at odds with the Executive Yuan. S, the issue is cost containment. In the end, the U. S still pays exponentially higher for healthcare compared to other nations, like Taiwan.
The following sections provide recommendations for improving the health care systems of each country:. However, wait times continue to be much longer with the worst performance occurring in January when only The limited number of physicians in the NHS is likely to be one of the reasons for the prolonged wait times. The easiest solution would be to hire more physicians, but the NHS would conduct a comprehensive analysis of the situation to understand the underlying problem.
They may find that physicians from abroad who are looking to become GPs in the UK are struggling to obtain employment licenses, or the profession is simply not as attractive in the UK because it does not pay as well as other developed countries Donnelley, Regardless, the NHS must conduct the necessary analyses to understand the problem and then develop strategies to increase the number of physicians. The availability of more physicians will likely lead to a decrease in wait times.
In response to the High Court ruling, new regulations were enacted in October, which allow authorities to only access communications data while investigating serious crimes, and require the approval of an independent commission to obtain such data Freedom in the World , The premium structure in Taiwan, while affordable, will not scale with population growth rates and will have long-term effects on the country's economic infrastructure.
As mentioned in the financing section, from to , the expenditures exceeded the revenues generated, which forced the Ministry of Health to raise the premium rate from 4. It is recommended that the Ministry of Health MOH work with the Legislative Yuan to raise the non-payroll income and lottery tax rather than the premium rate. Tobacco tax is currently under fire for being too high and the DPP is considering lowering the tax and funding long-term care from another source Yu et al.
Thus, in the interim, it is suggested that non-payroll income be taxed at a higher rate. Each tier would have a different tax rate, which would increase the amount of taxes collected, thus having the ability offset the amount being supplemented from the general fund. By avoiding the tobacco tax, and focusing on taxing supplemental income areas, it is assumed that the Legislative Yuan and policy makers would face minimal push back. To help support this initiative, policy makers and health advocates could argue the economic and social benefits to developing a long-term care program.
As the literature and population opinion suggest, the most immediate need for this health system is to increase the quality of care. Currently, the country uses three strategies to address the issue payment incentives, transparency, and claims review , but none of them address the root cause, gatekeeping. The two other systems in this analysis use referral or networks as a method to contain overcrowded providers. Taiwan system allows patients to see a specialist as easily as they see a provider.
Due to the high-volume of patients, providers on average spend five minutes or less with patients, leading to the low quality of care. It is recommended that the MOH implement a referral system and coordinate with localities to determine if networks of care could be enforced. In addition, the cloud-based system could be leveraged to help with coordination between localities and patients.
While this seems to be the most sustainable solution, it would present economic issues for providers. The government should work at all levels to centralize funding. In particular, the federal government should increase funding to rural and community clinics that serve underserved populations so they can be better equity at filling the gaps of covered until a better, more universal solution is available. Implementation of this system may allow patients to easily change their physicians and specialists as needed and provide hospitals with their medical records seamlessly in emergency situations.
This may also be used as an easy way to verify health coverage and make electronic payments. Further, implementing this program early on may make the transition to universal health care much easier if the US decides to move in this direction. This will also allow states to have autonomy while providing comprehensive care to the citizens. Once a proven framework has been determined, the federal government can mandate basic requirements, similar to the ACA, for states to follow while leaving most of the power at the state-level in regards to regulation, level and extent of services provided, and the role of private insurance companies.
Chaturvedi, A. Comparing democratic systems [Powerpoint presentation]. Arora, S. The English Health Care System. Cheng, T. The Taiwan Health Care System. The Commonwealth Fund. S Health Care System. Update your browser to view this website correctly. Update my browser now. Introduction Access to comprehensive health care services is important in maintaining health, preventing disease and achieving health equity for the most vulnerable of populations.
Democratic Landscape Evaluating the democratic context of each country is critical to understanding the similarities and differences in their health care systems. Who is Covered? What is Covered?
Health Delivery System Table 1. Table 1. England Health Delivery System Primary Care Outpatient Specialist Care Mental Health Services Registration required for GPs, not for walk-in centers GPs are contracted and paid via mixture of capitation to cover essential services, optional fee-for-service payments for additional services, and optional performance-related schemes.
NHI System The NHI initiative integrated medical programs from existing insurance systems with the goal of improving efficiency and social justice by increasing coverage. Health Delivery System Table 2. Table 2. Mental health services are fully covered Coverage includes: Private clinics or outpatient mental health departments Day care for mentally ill patients requiring supervision Hospitals After-Hours Care Long-Term Care Hospitals are contracted with the NHIA with three-year renewal periods.
No formal Long-term Care Program Integrated home care program provides care to elderly and disabled people. United States Unlike England and Taiwan, the US does not have a uniform health care system, does not provide universal health care coverage, and only recently enacted legislation mandating health care coverage for almost everyone.
Multi-Payer Health System The ACA has established a shared responsibility between government, employers, and individuals to ensure all Americans have access to quality health insurance. Health Delivery System Table 3. Table US Health Delivery System Primary Care Outpatient Specialist Care Mental Health Services Patients generally can choose any doctor within the network of providers There is no gatekeeper to primary care physicians this varies for managed care plans Physicians are paid through a mixture of negotiated, capitation of patients , and publically set fees.
Incentives are offered by both public and private insurers Employed in both private practice and hospitals Specialist generally require referral which limit patient choice Publicly insured patients have additional barriers due to the limited number of specialist who accept low-income patients due to variance in reimbursements Specialist are paid through negotiated rates, capitation, and set fees.
Provided by for-profit and nonprofit specialist Generally, insurance plans covers inpatient, outpatient, emergency, and prescription expanded via ACA Covered as a preventative service Hospitals After-Hours Care Long-Term Care Hospitals can be for-profit or non-profit Funded through per-diem charges, case payments, bundled payments additional liability Physicians are either salaried or paid on a fee-for-service basis Primary care offers limited access to this service Generally provided by emergency rooms which charge higher rates Limited urgent-care centers offer after-hours care Insurance companies provide phone consultations Provided by for-profit and nonprofit providers Medicaid provides the more robust coverage Required patients to spend assets prior to utilizing service Majority of nursing facilities are for-profit 1 The Commonwealth Fund, n.
Comparative Analysis As discussed in the previous sections, two countries with similar health care systems England and Taiwan and one country with a different health care system were selected because their health care systems provide universal coverage while the US was selected because its health care system is the exact opposite.
Method of Funding England uses a tax-based method of funding while Taiwan using an insurance premium method. Medical Providers In Taiwan, providers are largely private and generally free to compete with one another.
Health Legislation In the US and England, health legislation and general health policies are handled on the federal level. Physicians In both countries, physicians providing primary care are paid through a mixture of negotiated capitation. Short Wait Time Both systems have short wait times, but for vastly different reasons.
Financial Problems In Taiwan, the payment system is formulated in global budget and based on care determined by the LegislativeYuan. Taiwan Restructuring Premiums The premium structure in Taiwan, while affordable, will not scale with population growth rates and will have long-term effects on the country's economic infrastructure. Improve Quality of Care Using Gatekeeping Systems As the literature and population opinion suggest, the most immediate need for this health system is to increase the quality of care.
Appendices Appendix 1. In BBC. China-Taiwan Relations. Health Insurance Coverage in the United States: The birth of the NHS. Patients suffering as direct result of NHS wait-time failures. In The Guardian. Decentralization, Local Governments, and Accountability [Powerpoint presentation]. On another morning, inside a north-central Taipei primary care clinic, several patients were already sitting along the walls, hooked up to machines receiving infrared therapy for chronic pain, just a few minutes after the doors opened.
The one doctor on site looked a bit frazzled as he showed me around before his clinic filled up any further. The scenes bring to mind something I heard from trauma surgeon Li-Jian Chien, a member of the Taiwanese doctors union that formed in out of the frustrations felt in the medical profession. Chien says national health insurance with negligible cost sharing has pushed doctors to the brink. The low costs mean patients have little incentive to avoid the ER.
Lin has started doing cosmetic medicine for adults on the side because he has become so frustrated by his pediatric practice. His is not an uncommon choice, according to experts. Taiwanese hospitals and clinics are understaffed compared to the rest of the world: There are about 1. There are especially shortages of specialists in less urbanized parts of the country. The country does excel at keeping wait times short for services like cataract and hip replacement surgeries. But providers are feeling the strain.
Taiwanese doctors work about 10 more hours a week on average than those in the United States. A survey of hospital physicians found that working overtime was prevalent, and doctors who worked a lot of overtime were more likely to say they might leave the hospital where they worked.
Crowded facilities, like the NTU Hospital, are the norm. Hospitals supplement their medical payments with high-margin non-health care services — food courts, parking, and so on — to keep themselves solvent. The patients have their own grievances. Costly treatments for rare conditions are sometimes excluded. Yi Jie Li, a year-old woman with spinal atrophy and an outspoken advocate who wrote the book 7 , Days: The Most Ordinary Luxury , penned a letter to the NHIA pleading with it to cover the drug for the patients it could help.
The department replied in a letter, and the president of Taiwan called her on the phone. They said they would do their best. New medicines sometimes debut in Taiwan a full five years after they came on the market in the United States. For patients who need those medications, every day of waiting is a trial.
In some rural parts of the country, medical understaffing means less access to specialists and pediatricians. Some of the patients I met, including those who have faced the gravest diagnoses, seem acutely aware of the trade-offs demanded of them to keep a single-payer system sustainable.
Gloria Lin was diagnosed with breast cancer shortly before national health insurance took effect; today she is president of the Taiwanese Cancer Patient Association. Her group plays a part in talks between government and providers about what will be covered and for how much.
She told me that of course she wants to see every new cancer drug covered by the government plan. National health insurance achieved what the Taiwanese government hoped it would.
Everybody can afford health care. People are living longer, healthier lives. But the ever-growing cost of providing health care to everybody makes it challenging for the program to remain financially sustainable. The government keeps having to ask doctors, hospitals, and patients to make sacrifices to keep single-payer running. No elected official is running on a campaign of higher premiums and higher copays. But it helps that national health insurance has proven so popular. People want to make it work because single-payer has clearly improved Taiwanese lives.
One metric tells the tale: a rating based on medically amenable mortality, which gives a sense of how often people die of causes for which medical interventions should be available. In , Taiwan had nearly caught up with the US, topping 85; the US sat at 88, trailing its socioeconomic peers in Europe.
There is no doubt that medical care in Taiwan is better under single-payer, though it improved from a much worse status quo than the American system. Today, Americans die prematurely of heart disease and lung cancer at higher rates than the Taiwanese. People in Taiwan live a little longer in general, though there are populations that encounter early deaths from alcohol use and stroke, just as some disadvantaged groups do in the United States.
There is no comparison between the Taiwanese system of yesteryear — a 40 percent uninsured rate and the risk of financial catastrophe — and the one that exists today. In the early s, with health spending growing too quickly, the national health insurance office decided to institute the global budgets, a set pool of money that would cover all the medical services in a given year.
Hong-Jen Chang, then the NHIA director, remembers seeing his effigy being decapitated in protests by hospital supporters. The opposition was overwhelming, and he had to resign over that decision in That was also shortly after the first premium increase was approved. Po-Chang Lee told me that, after the presidential election this month, he would pitch the new government on increasing copayments so patients pay more out of pocket if they visit the doctor or hospital.
It may take more than that. The financial crunch is coming. The NHIA, which ran surpluses for a while after the last round of rate increases, is now about to see its reserves run out.
It will happen. Since the beginning, the debate in Taiwan has been about balancing the imperatives of equity and access that underpinned the national health insurance program. So he decided to start the rural care delivery program that covers Tien and her patients. On the same day she treated the Taroko woman at her clinic, Tien ventured out to visit a bedridden stroke patient in his home and showed the same warmth, offering him a cheerful thumbs-up as she went through her exam. A few doors down, a diabetes patient with gout welcomed a nurse into his house, parakeets chirping at the front door, so she could take his blood sugar readings, something she does two or three times a week.
Meanwhile, in the town hall, a pop-up Chinese medicine clinic was set up, and patients filed in to get acupuncture treatments. Chang told me a health care delivery program like this was the natural endpoint for the single-payer experiment, a necessary extension of its services to reach a vulnerable population. Without it, the work of Taiwanese health reform would always be incomplete.
The people here seem grateful. Wong Shin-Fa, a year-old Taroko man, stopped me on the side of the road in Xiulin and asked me what I was doing there. When I said I was an American reporting on health care, he told me a story. He had a Taroko friend in Los Angeles who broke his arm, he told me, with a government health worker interpreting. Rather than get it fixed in the United States, his friend decided to fly back to Taiwan and have it mended there because he said it would be cheaper.
Shin-Fa knew Tien and her shock of pink hair. Byrd Pinkerton contributed reporting to this story. Ashley Pon is an editorial photographer based in Taipei, Taiwan. The Everybody Covered project can be found at vox. This series was made possible by a grant from The Commonwealth Fund. All content is editorially independent and produced by our journalists. Our mission has never been more vital than it is in this moment: to empower through understanding.
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By choosing I Accept , you consent to our use of cookies and other tracking technologies. Reddit Pocket Flipboard Email. Huei-wen Tien has worked in Hualien County for 30 years, serving people from the indigenous Taroko tribe. Some of her patients, like a Taroko woman who came to her clinic in early October, have been seeing her for decades.
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