Experts Find Global Lessons for U.S. Healthcare

Universal care is an achievable goal, but it requires an understanding of the political landscape, panelists said Wednesday at the Oregon Health Forum.


The United States has a lot to learn from how other industrialized nations provide healthcare to their citizens – but it will take incremental change and a willingness to act before this country can achieve widespread coverage, two experts in health policy aid Wednesday morning at the Oregon Health Forum.

About a hundred people showed up at Portland’s Multnomah Athletic Club to hear Kieke Okma, PhD, visiting professor at Catholic University in Leuven, Belgium, and Theodore R. Marmor, PhD, professor emeritus at Yale and author of “Politics, Health, and Health Care,” as the two experts shared the results of their research and first-hand experiences.

Greg Van Pelt, president of the Oregon Healthcare Leadership Council and former CEO of Providence Health and Services Oregon, moderated the discussion, which was titled “Should Employers Pay for Health Insurance? Lessons from Other Countries.”

Okma spoke first, outlining several prominent approaches other countries have taken to insuring their citizens. Marmor followed with insights into how the U.S. might learn from the rest of the world.

“These folks are as expert as it comes when as to how other countries have faced these challenges,” Van Pelt said. “We are perfectly designed to get the results we are achieving in healthcare today – high cost and average quality. How do we think differently?”

Thinking “differently” about providing healthcare can be traced back to the 1880s under German Chancellor Otto Von Bismark, Okma said. Concerned by the growing power of the labor movement, conservative Bismark saw offering social insurance as a preemptive strike against labor, she said.

“It was a broad range of income protection schemes for industrial workers – a subset of the population,” with programs such as workers compensation and access to hospitals provided in order to protect family income, Okma said.

“Social insurance has nothing to do with socialism. It’s an important point because it has muddled our discussion”

“Bismark invented the notion of social insurance. … Social insurance has nothing to do with socialism,” she said. “These schemes were not handled by the state. Bismark looked at what had happened already. In the 19th century, you had ‘mutual sickness funds.” They were local, regional and sometimes vocational groups.” Members would pay a small fee each week, and in return received income protection for their families in case of illness or death.

Germany first mandated that certain classes of workers be granted social insurance through their jobs. Gradually, this expanded to cover the entire populace – but the country continues to offer distinct plans rather than single-payer care.

“That model became the leading example across the world,” Okma said. “People came from Japan, from Latin America. … Germany exported the model to other countries, in bits and pieces, across the world. It took 50 years.”

A second approach to health-care-for all, meanwhile, emerged in Great Britain around the time of the Second World War.

During World War II, the so-called upstairs-downstairs class divide was challenged when people from a range of socioeconomic backgrounds crowded bomb shelters side by side in British cities, and sent their children to the countryside for safety. Against that backdrop, the British government commissioned a report that recommended socializing and nationalizing hospitals and healthcare, to extend care to all, Okma said.

“The idea was very popular,” she said. “The war itself created this window of opportunity for the first time in Britain.”

In the late 1940s, the approach that worked during the war was cemented into law.

A third approach to national insurance emerged in Canada in the mid-20th Century, when the federal government offered to fund a significant share of health costs in provinces that adopted coverage for all their residents. Every province opted in, but each is free to handle its coverage approach separately.

“Canadian provinces act as insurers,” she said. “They discuss with hospitals and doctors each year how they will allocate money. The total pool is this big, you doctors decide how to allocate, but this is how big the pool is.”

Though these approaches have worked well for the nations that innovated them, and have been adopted with much success in some parts of Europe and Asia, they are not a guaranteed route to universal care, Okma cautioned.

“If you look at some of the nations in Africa or Latin America who are trying to implement this model, they are facing the problem that if you do not have the history or the administrative understanding, it’s very difficult to implement,” she said.

An experiment in the Ivory Coast seemed to take off with wide support in its first few years, then collapsed spectacularly when it ran out of funds after growing too fast without building accountability and longevity into its plans. Now Ghana is trying something similar, but growing more slowly and incorporating broader oversight in an effort to learn from Ivory Coast’s missteps.

Marmor followed Okma’s presentation by focusing on the political reality the U.S. now faces.

He noted the value of looking to other countries for inspiration and to help policymakers here understand what is truly possible.

German insurance companies, for example, have been known to send people recovering from heart attacks to a month in a spa – which would seem unheard of in the U.S. Yet Germany spends a fraction of what the United States does on healthcare.

“Nobody has proposed a 30-day spa for Medicaid, but it can stretch your mind to consider this,” Marmor said.

Looking to other countries also offers an opportunity to compare and contrast, he said.

Canada’s move to national healthcare largely took place in the 1950s and 1960s. Before that transition fully took hold, Canada and the U.S. both spent comparable amounts, per capita, on medical care – about 4.5 percent of gross domestic product in both countries in 1945, about 7.1 percent of GDP in 1971.

“Since then, there’s been a huge differentiation,” he said.

Today, U.S. healthcare spending is about 18 percent of GDP, compared to 11.5 percent in Canada.

“Canadians learned that cost control has to be costly to somebody or it isn’t control,” Marmor said. “What does that mean in practice? It means that in order for costs to be different than they would have otherwise been, somebody has to earn less than they would have otherwise.”

The U.S. has been unwilling to learn that lesson, he said, noting that discussions of healthcare and health reform in this country have often revolved more around marketing than meaning.

He cited accountable care organizations that have risen as a result of the Affordable Care Act, and health management organizations that were popular previously. “What do these two categories share? What they share is that you don’t know whether they maintain your health or are accountable – the words they use to describe their organization. They are both examples of persuasive definitions that are trying to settle the matter by definition.”

ACOs, HMOs – “What do these two categories share? What they share is that you don’t know whether they maintain your health or are accountable, the words they use to describe the organization. They are both examples of persuasive definitions that are trying to settle the matter by definition,” Marmor said.

“Integrated delivery systems – how many of you have heard advocates for disintegrated delivery systems?” he continued. “Think about it. If there’s no antonym, you are being fooled. … To call something an accountable care organization is to not be sure the right care goes to the right person at the right time -- that’s marketing.”

Reach Courtney Sherwood at [email protected].

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