Four healthcare systems divided by the English language

Izvor: http://www.guardian.co.uk/healthcare-network/2011/jun/07/healthcare-systemsaustralia-medicare-canada-saskatchewan Australia, Canada and Ireland have universal healthcare systems, although run on different lines to Britain's NHS. And then there is the USA

Image: Guardian.co.uk using images from iStockphoto As David Cameron makes personal pledges on the future of the NHS, after fierce opposition to the government's NHS reform plans, the coalition would do well to examine other countries' experiences of running a public, universal health service. European countries, explored in a previous article, tend to use a mix of public and private provision, with safety nets for those who can't afford the latter. Australia and Canada have comprehensive coverage, but it is provided in different ways to Britain's, with use of insurers, public and private. Canada's universal scheme, which used to be similar to the UK NHS, was almost downed in the 1970s by GPs looking at their colleagues' wealth south of the border possibly showing what a health service with greater input from GPs might look like. Ireland has its own NHS, but its system seems complex by comparison to Britain's. Meanwhile, it is difficult to see the plus points in the US healthcare model, which President Obama is working steadily to change though he may be losing the battle.

Australia While British and Irish visitors to Australia get access to the government-run Medicare scheme on a reciprocal basis, the system is quite different to the NHS. Medicare is controlled by the Australian government's Department for Health and Ageing (DHA). But each state is responsible for public hospitals under the Medicare scheme, which dates from 1984 (the same year Canada's system was implemented). Blood transfusion services are provided by the Red Cross and dentistry, optometry and ambulance services are outside Medicare. There is a separate government-run pharmaceutical benefits scheme that subsidises prescription medication and allied treatment, but patients are expected to pay the excess at the point of dispensing. Medicare is financed by a 1.5% income tax levy, plus an additional 1% levy on higher rate taxpayers who do not take out private insurance. The government encourages all citizens to take out private healthcare to top up the Medicare co-payment system - which offers 100% subsidies (in other words, free) treatment for in-patient stays, 85% for specialist services and 75% for GP treatments. Patients are expected to pay at the point of care for the 'excess' unless they have insurance or exemption. However, there is also a low earners card allowing totally free government-funded healthcare. Private insurance is complex, with citizens choosing between a mutual or the government-run Medibank service. There are incentives for young working people to sign up for private insurance, with premiums being government subsidised on a mean-tested rebate basis of between 30 and 40%. However, citizens over 30 are premium surcharged on private insurance at the rate of 2% per year, up to a cap of 20%. Private insurance also operates on a community basis, with premiums not wholly based on age or previous medical history. Canada With its Commonwealth links, Canada has paralleled the UK in developing universal health coverage. In 1944, the province of Saskatchewan introduced universal hospital insurance, four years before Britain introduced the NHS. In 1956, the federal government offered an open-ended 50-50 cost sharing arrangement between itself and the provinces, and within two years all provinces had introduced universal hospital coverage. In 1962, despite medical strikes against the plan, Saskatchewan introduced full universal medical coverage. By 1965, the federal government had launched a national programme with 50-50 cost sharing, with national implementation in place by 1971. But the scheme started to fall apart by the late 1970s, with many GPs - reportedly eyeing the wealth of their US colleagues - opting out of the state programme. This resulted in a complete

revamp in 1984 to a Medicare scheme, implemented along the lines of the Australian scheme of the same name. However, unlike Australia virtually all Canadian healthcare is delivered free at the point of care. Most services are provided privately under the Canada Health Act, which lays down strict standards and administrative simplicity. This simplicity involves a GP-centric organisation - a single payer system which bears more than a passing resemblance to the planned GP commissioning model for England - with no billing involvement for the patient. Most hospitals are publicly-funded, though each unit operates on an independent basis, a factor which is acknowledged as potentially increasing overall healthcare costs. Each citizen is issued a health card, which acts as their passport to healthcare, in a similar fashion to many European countries including France. Dentistry and optometry are not always covered it depends on the province but if not, people are usually insured through employerfunded schemes. Prescription medicines are chargeable, but subject to very strict price controls. Republic of Ireland Considering its shared land border with the UK, the Republic of Ireland has a strikingly dissimilar healthcare system and structure to Britain's NHS. The new Irish NHS (as it is known) was launched at the start of 2005, as a result of the Health Act 2004, and is controlled by the Health Service Executive (HSE). While state-subsidised healthcare is universal, it is subsidised in two tiers. Waged citizens earning below a certain threshold, currently about 200 euros a week (177), are entitled to a medical card from the HSE. This allows the holder to receive many health services, including GP visits, free of charge. Generally, a dependent spouse or partner and/or children are also entitled to receive free services, and British citizens with a free Ehic card receive the same benefits as an HSE medical card holder. Funding for healthcare in Ireland is made through a Universal Social Charge, normally deducted from wages at 2% for the first 10,000 euros a year, 4% on the next 6,000 euros and 7% above that. Hospital stays cost 100 euros per night, capped at 1,000 euros each year, with A&E visits charged at 100 to 120 euros a time, although GP referrals to emergency departments are normally given rebates of between 25% and 50%. Maternity care is free, up to the point where baby reaches six months of age. GP visits are subsidised, but chargeable at the point of care, typically 60 euros per visit. There is a GP visit card system, with income limits of around 300 euro a week, and which offers free GP treatment. Prescriptions are 50% subsidised, subject to a complex means-tested (sliding scale) monthly cap per family.

Most Irish hospitals are HSE-run, although there are some voluntary units with hybrid state/charitable funding. As in the UK, there is a booming private healthcare market with a number of private hospitals - mostly because insured patients are usually reimbursed with HSE co-payment (excess) fees. Outside of cities, most GP/hospital out-patient services are offered by health centres, which have a much greater importance than in the UK. United States of America While most American hospitals are privately-run, around 70% are non-profit or charitable. There are many federal, state, county and city-run hospital campuses. There are many speciality statewide hospitals, such as 'surgicentres' and hospices for the terminally ill. Many maternity services are government-run, and there is increasing use of nurse practitioners this appears to be due to cost savings, although patient reaction to nurse practitioners is also highly favourable. Co-ordination in US hospitals is very limited for commercial reasons. Fierce competition helps to keep prices down in city areas, with self-pay fixed-price healthcare deals common. The situation with US healthcare insurance is famously messy. Approaching 85% of citizens have health insurance in other words, 15% do not. However, around half of this 15% are covered by government programmes for the elderly, disabled people, children, military veterans and some poor people in special needs categories. But even with insurance, many citizens have to pay $1,000 (610) or even $5,000 excesses. Government programmes are many and varied, depending on individual state. Although the elderly and disabled are generally covered under the national Medicare scheme, with low income citizens are covered by the parallel Medicaid plan. Other programmes include state Children's Health Insurance Program (CHIP) and Tricare for military personnel (outside of military bases). Most insurance schemes require pre-approval for treatment, as do most government programs. Even then, a hefty deposit is often required. Repeated claims can often result in hikes in excesses or even expulsion from insurance schemes. A 2001 study in five US states revealed that medical debt contributed to 46% of bankruptcies, and by 2007 this had reached 62%. The USA has highest infant mortality rate amongst industrialised nations, according to the World Health Organisation, and life expectancy is 42nd in the world, after Chile and Cuba.