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«Forthcoming in Culyer, Anthony (ed.) Encyclopedia of Health Economics, Elsevier Press., Inc. 2014.       Comparisons of Health Insurance Systems ...»

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Forthcoming in Culyer, Anthony (ed.) Encyclopedia of Health Economics, Elsevier Press., Inc. 2014.




Comparisons of Health Insurance Systems in Developed Countries

Randall P. Ellis, Tianxu Chen, and Calvin E. Luscombe

Boston University, Department of Economics

270 Bay State Road; Boston MA 02215 USA

ellisrp@bu.edu, tianxu@bu.edu, calvinl@bu.edu

Synopsis: Health insurance systems in developed countries vary in many dimensions. We develop a

framework for discussing these dimensions and then use this framework to compare the health insurance systems of Canada, Germany, Japan, Singapore and the US. These countries span a wide array of dimensions, including who in the system bears risk, what choices are allowed, how much health spending burdens are redistributed, sources of revenue, cost saving strategies, and use of specialized and secondary insurance.

Keywords: Insurance, risk adjustment, secondary insurance, health savings accounts, cost sharing, Canada, Germany, Japan, US, Singapore 1      Introduction There is an enormous literature evaluating and comparing health insurance systems around the world, which this article attempts to synthesize while emphasizing systems in developed countries. Our approach is to provide an overview of the dimensions along which health insurance systems differ and provide immediate comparisons of various countries in tabular form. To organize our analysis, we focus our discussion on coverage for the largest segment of the population in all developed countries: workers under age 65 earning a salary or wage, which we call the primary insurance system. We later touch on the features of special programs to cover the elderly, the poor or uninsured, and those with expensive, chronic conditions. We do this not because these groups are less important, but rather because special programs are often used to generate revenue and provide services to these groups, and including these programs in our discussion would add considerable complexity. For the same reason, we also focus on primary insurance coverage of conventional medical care providers – office-based physicians, hospital-based specialists, general hospitals, and pharmacies – knowing that there are many specialized insurance programs for long term care, specialty hospitals, informal providers, and certain uncovered specialties.

A key feature of our analysis is that we focus on providing a broad framework for evaluating different systems rather than immediately comparing specific countries. We initially distinguish between the alternative contractual relationships used in different insurance settings and the choices available to each agent or decision maker. We then provide an overview of thealternative dimensions in which health care systems are commonly compared, which include the breadth of coverage, revenue generation, revenue redistribution across health plans, cost control strategies, and specialized and secondary insurance, Throughout the chapter, we use the health insurance systems of Canada, Germany, Japan, Singapore, and the US. As shown in Table 1, insurance systems in these five countries span much of the diversity exhibited by health insurance systems around the globe. These countries include both the most expensive system (US) and the least expensive (Singapore), single payer as well as multiple insurer, government sponsored and employer sponsored insurance. Unlike many comparisons, we try to emphasize the general nature of the institutions used to provide care rather than the specifics of the institutional arrangements.

More unified discussion of each country is reserved until after we characterize the dimensions in which health care systems can be compared.

–  –  –

The topics in this chapter relate to almost every other chapter in this Encyclopedia, but are particularly relevant for the topics of health insurance, risk adjustment, equity, demand-side incentives, and provider payment.

Agents and Choices Agents As summarized in Table 2, it is useful to distinguish six classes of agents in all health insurance markets.

Consumers are agents who receive health care services, but in some systems they may have other choices to make. Providers actually provide information, goods and services to consumers and receive payments;

we focus on providers covered by insurance contracts. Health plans are agents who contract with and pay providers, also known in some countries as sickness funds. The sponsor in a health system serves as an intermediary between consumers and health plans, allowing for consumer contributions for insurance to differ from the ex ante expected cost of health care across consumers. In most countries the sponsor is a government agency, although in the US and Japan the sponsor for most employed workers is their employer. The key role of the sponsor in most countries is to ensure that the insurance contribution by a consumer with high expected costs (such as someone old, chronically ill, or with a large family) is not many times larger than the contribution of a consumer with low expected costs. Despite the enormous complexity of diverse intermediaries in many health insurance systems, consumers, providers, health plans and sponsors can be viewed as the fundamental agents in every health care market.

Two other types of agents deserve mention. Insurers are agents that bear risk in their expenditures. In a given system they can be identified by asking who absorbs the extra cost of care from a flu epidemic or accident. The insurer is not always a health plan since many health plans do not actually bear risk, but instead simply contract with and pay providers and pass along the expense to someone else. Insurance (or risk sharing) in a health care system can be shared by any of the four main agents in the health care system. Finally, regulators set the rules for how the health care and insurance market is organized, and Table 2: Six classes of agents in every health insurance system   Consumers: People actually receiving health care, and in some countries choosing health plans or  sponsors     Providers:  Agents actually supplying health care services, such as doctors, hospitals, and pharmacies  Health plans: Agents responsible for paying and contracting with health care providers    Sponsors: Intermediaries between consumers and health plans who are able to redistribute the ex  ante expected financial cost of health care across consumers and among health plans    Insurers: Agents who bear risk (insure), who can be any combination of the Consumers, Providers,  Health Plans or Sponsors  Regulators: Agents who set the rules for agents in the health care system 

–  –  –

this role can be played by sponsors (e.g., government), health plans, or providers (such as the American Medical Association in the US). Sometimes the functions of two or more agents are combined in the same agent. For example, some health plans own hospitals, and hence are simultaneously a health plan and a provider.

Systems of paying for health care

Fundamentally, there are four different ways of organizing payments and contracts in health care systems.

Schematic diagrams of these are shown in Figure 1. System I is a private good market, in which consumers buy health care services directly from providers. This system is still used in all countries for non-prescription drugs and many developed countries for certain specialized goods (e.g., routine dental and eye care, and elective cosmetic surgery,) but is rare for the majority of health care services. Most consumers in Singapore and uninsured consumers in the US rely on a private good market, and pay for their health care when needed, without insurance.

Figure 1: Four structures of health care payments System I: Private good markets without insurance System II: Reimbursement insurance

–  –  –

System II is a reimbursement insurance market, in which consumers pay premiums directly to an insurer in exchange for the right to submit receipts (or ‘claims’) for reimbursement by the insurer for spending on health care. Under a reimbursement insurance system the insurer need not have any contractual relationship with health care providers, although the insurer will need rules for what services are covered and how generously. As will be seen, System II, is most common for secondary insurance in developed countries, and it is also widely used for automobile and home insurance.

System III is a conventional insurance market in which the consumer pays a premium to a health plan, who in turn contracts with and pays providers. Although popular in theoretical models of insurance System III is not used for the primary insurance system in any developed country, but is sometimes used

for secondary insurance programs. Note the key difference in incentives between these two systems:

System II incents the consumer, but not the health plan, to search for low price, high quality providers, while System III does the reverse, reducing consumer incentive but enabling the health plan to negotiate over price and quality.

System IV is a sponsored insurance market in which the revenue is collected from consumers (directly or indirectly) by a sponsor who then contracts with health plans, who in turn contract with and pay providers. All developed countries that we have studied involve a sponsor, although in some developing countries the sponsor may be a health plan.


Each of the line segments shown in Figure 1 reflects a contractual relationship, in which money or services are transacted. These relationships are generally carefully regulated. Countries differ in the extent to which they restrict or allow choice in each of these contractual relationships. Although many comparisons of international insurance systems do not emphasize these choices, they vary across countries significantly. Table 3 summarizes them for the five countries that are the focus of this paper, where check marks indicate the system allows the choice, two check marks indicate it is dominant, and an epsilon (ε) signifies that the choice is allowed but rare or of minor significance.

Table 3. Health system choices allowed in five countries

–  –  –

Every developed country insurance system allows consumers to choose among multiple providers, but only a few allow providers to turn down consumers, or charge fees above the plans’ allowed fees (Singapore, US). In some countries (notably the US, and legal but rare in Germany) health plans may choose which providers they want to contract with, and providers may in turn choose the health plans they contract with (selective contracting). An especially important dimension of choice is whether the primary system has more than one health plan (Germany, Japan, US), and how choices among health plans are regulated. In countries like the US and Japan, employers implicitly choose who to sponsor when they hire workers, and hence employers play a key role in redistributing the costs of health care between young and old, healthy and sick, or small and large families. In the US consumers and their sponsors (employers) are allowed to choose not to purchase any insurance at all; some Japanese consumers ignore the mandate and do not purchase insurance, making it similar to the US. The 2010 US Affordable Care Act, will start imposing tax penalties on consumers and employers in 2014 if they do not purchase insurance, but the system will remain voluntary.

Breadth of Coverage and National Expenses Breadth of Coverage With the exception of the US, all developed countries have universal coverage for their own citizens through their primary insurance programs. As shown in the first row of Table 4, insurance coverage approaches 100% of the population in Canada, Germany, Japan, and Singapore, while only 83% of the US population has coverage. The 2010 Affordable Care Act (ACA) in the US will increase the percentage covered, but there is considerable uncertainty about how much coverage will increase.

Because these measures are often a focal point of international comparisons of health care systems, Table 4 also contrasts the dollars per capita and percent of Gross Domestic Product (GDP) spent on health care.

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