Guest: Health care models — America’s options


The U.S. receives a lower quality of health care at an exorbitant price

Disparity, high costs and prohibitive complexity are long-standing trademarks of American health care. The federal government sought to address these issues with the 2010 Affordable Care Act. This legislation uneasily straddled the divide between universal health care and America’s previous health care system. While the Centers for Disease Control and Prevention reports that upwards of 20 million more Americans have received coverage under the ACA, health care premiums are on the rise, states have resisted federal impositions and some insurance companies are pulling out of ACA’s trademark “exchanges.” Americans need and deserve better.

Ideally, a health care system serves the most amount of people with the highest quality of service for the lowest cost. Which system achieves the best value? Let’s explore four basic forms of health care worldwide.

Under the single payer Beveridge Model, first used in the United Kingdom, the government taxes citizens to operate the health system and provide care. Each citizen is treated alike, though some companies may offer employees additional private insurance, which provides perks, such as skipping waiting lists and choosing specialists. Appointments and treatments are free at the point of service, and the cost of prescription medicines is capped to ensure accessibility. Because the government foots the bill for health care costs, this model requires high levels of taxation. The wait times for non-emergency secondary care can be long. Additionally, the government analyzes the cost-effectiveness of certain treatments before paying for them, meaning that some newer or more expensive treatments are rarely covered under this model.

In the German-born Bismarck Model, payers and providers are both private. Citizens must enroll in one of many not-for-profit “sickness funds” (insurers), guaranteeing them universal coverage. Through income tax, workers pay close to half of the cost of belonging to an insurer, and employers pay the remainder, while the government covers welfare-recipients. The government regulates the price of medical services and fees, and appointments usually incur a small co-pay (<$20). Citizens may choose to use private insurance to access perks. With no deductibles and no network limitations, patients can see practitioners as they choose, but this freedom makes it difficult for doctors to prevent redundant procedures or consultations. Specialists are also paid more than GPs and are paid per procedure performed, incentivizing specialization and quantity of procedures.

Some have debated the merits of the single-payer National Health Insurance Model as an option for the U.S. This Canadian model collects premiums from citizens and pays health care bills, providing health care coverage through the federal government, with services rendered by private providers. In this way, the National Health Insurance Model delivers nationally funded care with freedom of choice. Costs can be kept low by the government’s negotiating power, but as with the Beveridge model, wait times can be long.

Finally, there is the Out-of-Pocket Model. In the absence of organized health care, people must pay 100 percent of their health care costs without the assistance of the government or the safety net of insurance. This model can lead to bankruptcy, a life of discomfort or a death sentence. Citizens of all developing nations are subjected to this model.

An American’s health care model varies depending on their circumstances. An unemployed person without insurance uses the out-of-pocket model. However, Americans on Medicare receive health care that more closely resembles a National Health Insurance model. Veterans receive Beveridge-style health care, while working Americans with insurance receive coverage like that in a Bismarckian country. No other country has this muddled mix. Even on one system, health care is confusing to navigate. Our system needs to be streamlined.

Perhaps we could overlook this confusion if all Americans received inexpensive, high quality health care equitably. But among “developed countries,” the U.S. achieves some of the lowest marks in health care, all for the highest cost. The Commonwealth Fund — a private American health research institute — found that the US ranked last among “access,” “equity” and “health care outcomes” among 10 peer high-income countries and came in last overall.

Nonetheless, the U.S. spent $9,403 per capita on health each year — $1,500 more than the next-most expensive country on the list (Switzerland at $7,919), over twice as much as the UK ($3,935) and $4,000 more per capita than the Netherlands ($5,385) — three countries with far superior healthcare system performance, according to a 2016 report by the Organization for Economic Cooperation and Development and data from the World Health Organization. Although the ACA may be a step in the right direction, Americans still receive overall lower-quality care for an exorbitant price.

The ACA’s critics and proponents alike realize that the current model is unsustainable. When considering alternatives, some politicians criticize the bureaucracy, wait times and centralization of universal health care. Others are taken with the model’s health equity, impressive health outcomes and low cost. With recent health care proposals and the administration’s efforts to destabilize our existing markets, Americans face these choices and must soon decide where their health care priorities lie.

The taxation and government centralization intrinsic to both the Beveridge and National Health Insurance models are too high to receive much American support. The Bismarck Model is more familiar to Americans. Adapting the Bismarck model for a 21st-century America is the most realistic way to provide care to all Americans. Insurers and health care providers would still be private, and a share of insurance costs would still fall to employers. However, unemployed adults would have coverage through the government, and healthcare costs would be subject to government regulation. The Bismarck model offers Americans a chance to achieve universal, high-quality health care at potentially nearly half the current cost per capita. The U.S. must allow Americans access to a system of health care that costs less, provides care equitably and delivers outcomes on par with its international peers. If Republicans really want to put “America First,” shouldn’t that be their goal?


Brynna Thigpen graduated from UC Davis in 2017 with a B.S. in psychology and currently serves as an advocate with the University of California’s Global Health Institute’s Advocacy Initiative.

Written by: Brynna Thigpen