2015 International Profiles JANUARY 2016 JANUARY of Health Care Systems AUSTRALIA CANADA CHINA DENMARK ENGLAND FRANCE GERMANY INDIA ISRAEL ITALY JAPAN NETHERLANDS EDITED BY NEW ZEALAND NORWAY Elias Mossialos and Martin Wenzl SINGAPORE London School of Economics and Political Science SWEDEN Robin Osborn and Dana Sarnak SWITZERLAND The Commonwealth Fund UNITED STATES THE COMMONWEALTH FUND is a private foundation that promotes a high performance health care system providing better access, improved quality, and greater efficiency. The Fund’s work focuses particularly on society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. 2015 International Profiles of Health Care Systems Australia, Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, The Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, and the United States EDITED BY Elias Mossialos and Martin Wenzl London School of Economics and Political Science Robin Osborn and Dana Sarnak The Commonwealth Fund JANUARY 2016 Abstract: This publication presents overviews of the health care systems of Australia, Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, the Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, and the United States. Each overview covers health insurance, public and private financing, health system organization and governance, health care quality and coordination, disparities, efficiency and integration, use of information technology and evidence-based practice, cost containment, and recent reforms and innovations. In addition, summary tables provide data on a number of key health system characteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views. To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. 1857. CONTENTS Table 1. Health Care System Financing and Coverage in 18 Countries . 6 Table 2. Selected Health System Indicators for 17 Countries . 7 Table 3. Selected Health System Performance Indicators for 11 Countries . .8 Table 4. Provider Organization and Payment in 18 Countries . 9 The Australian Health Care System, 2015 . .11 The Canadian Health Care System, 2015 . 21 The Chinese Health Care System, 2015 . .31 The Danish Health Care System, 2015 . 39 The English Health Care System, 2015. .49 The French Health Care System, 2015 . 59 The German Health Care System, 2015 . 69 The Indian Health Care System, 2015 . 77 The Israeli Health Care System, 2015 . 87 The Italian Health Care System, 2015 . .97 The Japanese Health Care System, 2015 . 107 The Dutch Health Care System, 2015. .115 The New Zealand Health Care System, 2015. .123 The Norwegian Health Care System, 2015 . 133 The Singaporean Health Care System, 2015 . 143 The Swedish Health Care System, 2015 . 153 The Swiss Health Care System, 2015 . 161 The U.S. Health Care System, 2015 171 Table 1. Health Care System Financing and Coverage in 18 Countries HEALTH SYSTEM AND PUBLIC/PRIVATE INSURANCE ROLE BENEFIT DESIGN Private insurance role (core benefits; cost-sharing; noncovered benefits; private facilities or amenities; Government role Public system financing substitute for public insurance) Caps on cost-sharing Exemptions and low-income protection Australia Regionally administered, joint (national & state) public hospital funding; General tax revenue; earmarked income tax ~47.3% buy complementary (e.g., private hospital and dental care, Caps for pharmaceutical OOP expenditure only, Low-income and older people: Lower cost-sharing; universal public medical insurance program (Medicare) optometry) and supplementary coverage (increased choice, faster dependent on income and total OOP expendi- lower pharmaceutical OOP cap and lower OOP maxi- a access for nonemergency services, rebates for selected services) ture in the same year mum for 80% Medicare services rebate Canada Regionally administered universal public insurance program that plans Provincial/federal general tax revenue ~67% buy complementary coverage for noncovered benefits No There is no cost-sharing for publicly covered services; and funds (mainly private) provision (e.g., private rooms in hospitals, drugs, dental care, optometry) protection for low-income people from cost of prescrip- tion drugs varies by region China Supervision by health authorities (Health and Family Planning Commis- There are three main publicly financed health insurance Complementary to cover cost-sharing and gaps, No Government subsidies to low-income families for insur- sions) at the national, provincial and local levels; some direct provision types with local-area risk-pooling: urban employer-based as well as better health care quality and/or higher ance contributions and OOP; emergency assistance through public ownership of hospitals (mainly payroll taxes, for formally employed urban resi- reimbursements. No data on coverage, but growth by local governments for specific diseases and unpaid dents), urban resident basic (mainly government funded, has been rapid. emergency department or other expenses for urban nonemployed residents), and rural cooperative medical scheme (government-funded, for rural residents) National health care system. Regulation, central planning, and funding Earmarked income tax ~39% have complementary coverage (cost-sharing, noncovered No. Decreasing copayments with higher OOP Drug OOP cap for chronically ill (DKK3,775 [USD498]); Denmark a by national government; provision by regional and municipal authorities. benefits such as physiotherapy), ~26% have supplementary cover- drug spending. financial assistance for low income and terminally ill age (access to private providers) England National health service (NHS) General tax revenue (includes employment-related ~11% buy supplementary coverage for more rapid and convenient No general cap, but OOP payments almost Drug cost-sharing exemption for low-income, older insurance contributions) access (including to elective treatment in private hospitals) exclusively apply to prescription drugs and medical people, children, pregnant women and new mothers, appliances only. For drugs, prepayment certificate and some disabled/chronically ill; financial assistance with GBP29.10 [USD41.10] per three months or with transport costs available to people with low GBP104 [USD147] per year ceiling for those need- income; vision tests free for young people, older people, a ing a large number of prescription drugs. and low-income people Statutory health insurance system, with all SHI insurers incorporated into Employer/employee earmarked income and payroll tax; ~95% buy or receive government vouchers for complementary No. EUR50 [USD60] cap on deductibles for Exemption for low income, chronically ill and disabled, France a a single national exchange general tax revenue, earmarked taxes coverage (mainly cost-sharing, some noncovered benefits); consultations and services and children limited supplementary insurance Germany Statutory health insurance (SHI) system, with 124 competing SHI insurers Employer/employee earmarked payroll tax; general ~11% opt out from statutory insurance and buy substitutive Yes. 2% of household income; 1% of income for Children and adolescents <18 years of age are exempt (“sickness funds” in a national exchange); high income can opt out for tax revenue coverage. Some complementary (minor benefit exclusions from chronically ill. private coverage statutory scheme, copayments) and supplementary coverage (improved amenities). India Children and adolescents <18 years of age are exempt General tax revenue Limited role (<5% of total expenditure) providing substitutive No. Significant reliance on OOP payments Various government-financed health insurance schemes coverage for the upper class urban population (>70% of total health expenditure). for poor and vulnerable population groups to improve access to hospitalization and reduce out-of-pocket payments Not overall. Caps on OOP for drugs (chronically Israel National Health Insurance (NHI) system with four competing, nonprofit Earmarked income-related tax and general government Complementary (for benefits such as dental care, drugs, or long- Quarterly OOP caps for drugs for the chronically ill health plans. Government distributes the NHI budget among the health revenues term care) and supplementary coverage (for quicker access and ill only) and specialist visits (at household level). and age-, income-, and health status-related discounts; plans primarily through capitation. superior service) provided by two types of voluntary insurance: copayment exemptions for Holocaust survivors; age-, VHI offered by statutory health plans (HP-VHI) (~87% of adult income-, disability-, and health status-related exemptions population coverage); commercial VHI (C-VHI) (~53% coverage); on copayments for specialist consultations; reduced C-VHI tend to be more comprehensive and more expensive. health tax (3% instead of 5%) for