Preventive Health Care in Six Countries: Models for Reform? C

Preventive Health Care in Six Countries: Models for Reform? C. Patrick Chaulk, M.D., M.P.H.

International systems are frequently In this article, I examine the health care offered as models for health care reform. This systems of six industrialized countries study, focusing on preventive services for chil (Canada, Sweden, France, Germany, Japan, dren and pregnant women in six industrial and the United Kingdom), compare their ized countries, finds that a broad range of basic structures and financing arrange preventive services can be provided through ments, and describe how these systems health care systems with divergent financing address certain preventive health care and cost containment, utilizing multiple needs of children and pregnant women as entry points into the health care system, and part of a focus on primary care. Despite empioying targeted programs for high-risk wide variations in financing mechanisms, patients. Despite variability in form and levels of health care spending, and cost financing, health outcomes are not compro containment strategies among these six mised, suggesting that health care reformers systems, each provides comprehensive in this country need not be restricted to any services to all children and pregnant single model to strengthen preventive health women. Additionally, access and outcome care for children and pregnant women. measures such as insurance coverage, pre natal care, high-risk pregnancy outreach, INTRODUCTION home visiting, immunization, universal periodic screening for children, infant mor International models have attracted tality, and low birth weight are better than increasing attention from health care those of the United States. The variations reformers in this coWltry. Numerous com in program structure and financing sug parisons have been made with respect to gest that effective health care programs for overall health care systems (U.S. General this population need not be restricted to Accounting Office, 1991a; Iglehar~ 1991a, any single organizational structure; this 1991b, 1988a, 1988b), financing and cost should offer flexibility to health care containment mechanisms (U.S, General Accounting Office, 1991b), and levels of reformers in this country seeking models for expanding preventive services. health care spending (Schieber, Poullier, and Greenwald, 1991). However, little has been METIIODS written about the comparative differences or similarities of specific services within these Selected health status and health care sys systems, such as preventive health services tem characteristics of six industrialized directed at children or pregnant women nations described in the 1991 Organization (Williams and Miller, 1991; Starfield, 1991; for Economic Cooperation and Development U.S. General Accounting Office, 1993c). (OECD) Health Data ffie (Schieber, Poullier, and Greenwald, 1993) were analyzed and The author is with The Johns Hopkins School of Hygiene and Public Health. The opinions expressed in this article are those of supplemented with information from several the author and do not necessarily reflect the opinions of The sources that describe services for children Johns Hopkins School ofHygieneand Public Health or the Health Care Financing Administration. and pregnant women. The OECD data

HEALTII CARE FINANCING REVIEW/Summer 1994/Volume 15. Number4 7 characteristics analyzed included per capita single-payer centralized systems (Canada, gross domestic product (GDP) and percent United Kingdom) and decentralized sys of GDP spent on health care, public spend tems (Sweden). Other countries rely ing as a percent of health care spending, on quasi-public, employer-based sickness and number of physicians per capita. Other funds with variable coverage through pub characteristics derived from supplementary lic insurance (Germany, Japan, France). sources include percent of physicians in pri Private health insurance plays only a mary care and, for children and pregnant minor, supplementary role in all the for women, measures of health status (infant eign countries. By contrast, in the United mortality rates, percent of low-birth-weight States, the health care system is very infants, maternal mortality rates, and per decentralized and based predominantly on cent of births delivered by cesarean a system of private health insurance. Public section), preventive services (rates of programs generally serve the elderly and pediatric inununization, presence of universal certain categorical groups of poor women periodic preventive screening, home visita and children. None of these countries, tion services, high-risk pregnancy out except the United States, contains any sig reach, duration of maternity leave, and level nificant percentage of uninsured children of maternity financial support), and access or women of childbearing age. to care (percent of women of childbearing In 1991, per capita spending and percent age and children without health insurance). of GDP spent on health care were all sub However, methodological problems exist stantially less than in the United States with most comparative international stud (Figure 1). The country with the next-high ies. Health outcomes, for example, are est spending per capita on health care was determined by a variety of sociocultural Canada. The United States spent roughly factors that lack sufficient descriptive data. 50 percent more per capita on health care In addition, taxonomy often complicates than Canada, and some 175 percent more international comparisons. Recent analysis than the United Kingdom. The percent of of international infant mortality rates finds GDP spent on health care reflects a similar less disparity between the United States pattern (fable 1). The United States spent and other industrialized countries when 13.2 percent of its GDP on health in 1991, adjusting for definitional differences compared with 6.6-10.0 percent for the six applied to infant mortality (Ilu eta!., 1992). other countries. Although only 42 percent Despite these limitations, relative, rather of health care spending in the United than absolute, differences are useful in States is publicly funded, well over 70 per understanding international health care cent is publicly funded in the six countries. systems and their services. Partially because of the substantial pub lic funding of health care, all six countries HEALTH CARE SYSTEMS implement significant national cost-control measures (Chaulk and Bialek, 1993), The six countries described reflect a including systemwide global budgets wide diversity in organizational structure (Canada, United Kingdom) (U.S. General for the delivery of health care, in cost con Accounting Office, 199la), expenditure tar tainment and financing mechanisms. The gets or global budgets for hospitals and/ or organizational structure and decision office-based physicians (France, Sweden, making process are represented by Germany) (Rodwin eta!., 1990; U.S. General

8 HEAL1H CARE FINANCING REVIEW/Summer 1994/Volume 15, Number4 Figure 1 Per C&plta HeaHh Spandlng lor Selected Industrialized Countries: 1991

"'''';~,;; Per Capita Health Spending

Percent by Which U.S. Spending • United States $2,868 ~~!;! Exceeds Other Countries canada $1,915 50 percent

Gennany $1,659 73 percent

France $1,650 74 percent

Sweden $1,443 99 percent

Japan $1,307 119 percent

United Kingdom $1,043 175 percent

NOTE: Spending Is In u.s. dollars. SOURCE: (Schieber, Poullier, and Greenwald, 1993).

Accounting Office, 1991b, 1993b), provider the other countries, which have predomi fee schedules (Germany, Japan, Sweden, nantly primary care physicians (53-63 per France) (lkegami, 1990; Brenner and Rublee, cent) (Chaulk and Bialek, 1993; Rodwin et 1992) or capitated fees (United Kingdom) al., 1990; Fielding and Pierre-Jean, 1993; (Ham, 1988), prolnbitions on balance billing McAuley, 1992). (Japan, Sweden), and limitations on medical malpractice (Canada, Japan) (Coyte, Dewees, PRENATAL CARE AND MATERNAL and Trebilock, 1991; Employee Benefits DISABIUIY Research Institute, 1990a). By contrast, cost contaimnent in the United States is less com In all six countries, prenatal care is com prehensive and generally limited to hospital prehensive, accessible, and either free and provider fees under certain public pro or accompanied by .financial assistance. grams such as Medicare and Medicaid, Pregnant women are not excluded from patient cost sharing, and varying managed prenatal care based on insurance status or care arrangements. income. Public prenatal clinics often coor In terms of physician supply, four of the dinate maternity services and prenatal care six countries have 2.2-3.1 physicians per for women (Goodwin, 1990). capita, and the other two (Japan, United For example, in Japan, prenatal care is Kingdom) have roughly 1.5 physicians per not a routine health insurance benefit. capita This compares with 2.3 per capita in Instead, comprehensive maternity services the United States. However, the specialty are provided through public programs; distribution of physicians is strikingly dif however, complications occurring during ferent between the United States and the pregnancy are covered by health insurance. other countries. In the United States, only Japan's focus on prenatal care and chil about 33 percent of all physicians declare dren's health began following World War II themselves to be primary care physicians as part of its national reconstruction effort. (Politzer et al., 1991). This contrasts with By the late 1950s, national guidelines led to

HEALTH CARE FINANCING REVIEW/Summer 1994/Volume 15, Number 4 9 :; Table 1 Characteristics of Health care Systems of Seven Industrialized Countries, by Type of Characteristic and Country

Number of Percent of Percent Percent Physicians Physicians Percent of System Structure and Characteristics of Publicly per 1,000 in Primary Population Cost-Containment Country GOP Funded PQpuiation Can> Uninsured Organization Funding Melhods United Sta1es 13.2 42 2.3 34 17 Decentralized Private more than public Fees set for public ooly Conada 10.0 75 2.2 '53 <1 Decentralized Single-payer public Global budgets and fees Germany 8.5 72 3.1 54 <1 Centralized Private sickness funds Fees set France 9.1 75 2.7 57 <1 Centralized Private sickness funds Fees set Sweden 8.6 90 2.9 NA <1 Decentralized Single-payer public Global budgets Japan 6.8 73 1.6 NA <1 Centralized Mixed public and private Fees set United Kingdom 6.6 87 1.4 63 <1 Centralized Single-payer public Global budgets

'Canadian figure reflects only lamlly physicians aod pe

" •J Table2 Maternal Access to Care and Benefits, and Health Status Measures for Seven Industrialized Countries, by Country Percent of Women 14-44 High-Risk National Mandatory Years of Age Pregnancy Home Maternal Maternity Without Outreach Visiting M-Hy Leave Mandatory Maternity Country Insurance Program Program Rate in WeekS Financial Supi>Qrt United States 16.2 No No 12 None canada <1 Yeo Limited •5 25 Equals short-term disability Germany <1 Yes Limited 5 14 Separate maternity benefit plus grant France <1 Yes y, 9 16 Separate maternity benefit Sweden <1 Yes Yeo 5 22.5 Equals short-term disability Japan <1 Yeo YO$ 11 14 Equals short-term disability plus grant United Kingdom <1 y, Yes • 18 Separate maternity benefit SOURCES: (AboUZahr and Royston. 1991); (Select Committee on Children, Youth, and Families, 1990); (Ef'll)loyee Benefits Research Institute, 1990b); (Family and Medical Leave Law, 1993). the establishment of maternal and child labor and delivery remain the province health clinics throughout the country. By primarily of physicians. 1965, when these guidelines were enacted Many of the six countries use outreach as the Maternal and Child Health Law, programs for high-risk pregnant women and there were more than 400 such clinics for postpartum care. Home visiting nurses nationwide. During this period of systemic usually provide this service (Sweden, France, focus on maternal services, Japan experi Germany) (Blonde!, Pusch, and Schmid~ enced a progressive lowering of its infant 1986; Ierodiaconou, 1986). although commu mortality rate per 1,000 live births from 60.1 nity midwives and nurses provide postpar in 1950 to 30.1 in 1960, 13.1 in 1970, 7.5 in tum evaluation to women following delivery 1980, and finally 4.6 in 1990 (Mother's and (United Kingdom, Japan) (Williams and Children's Health Organization, 1992). Miller, 1991; Chaulk and Bialek, 1993). These In the six counlries, non-physicians pro programs may conlribute to the lower infant vide varying amounts of prenatal care, mortality rates (4.59-8.42 per 1,000 live although they do so to a greater extent than births) and fewer low-birth-weight infants do non-physicians in the United States. For (4-7 percent) in these counlries than in the example, in some countries prenatal care is United States (9.8 and 7 percen~ respectively) provided predominantly by midwives (National Commission to Prevent Infant (Sweden, United Kingdom) with obstelri Mortality, 1992). cians and family physicians providing spe 1n addition to lower infant mortality rates, cialty care (Kohler and Jakobsson, 1987; four of the six counlries have maternal mor Blonde!, Pusch, and Schmidt, 1986). In tality rates below those of the United States France, prenatal care is shared more (AbouZahr and Royston, 1991) (Table 2). equally by midwives and physicians Cesarean-section deliveries of infants, gen (mostly obstelricians). However, in Japan, erally indicative of pregnancy complications, although physicians share the provision of occur far less frequently in these counlries prenatal care with midwives (of which there than in the United States (Notzon, 1990). were 22,918 in 1990) (Mother's and In all six countries, pregnancy benefits Children's Health Organization, 1992), (referred to as maternal disability benefits)

HEALTH CARE FINANCING REVIEW/Summer 1994/Volum~ !S. Number4 It are comprehensive, financially generous, under Federal law until 1993. During the and extend for relatively long periods 102nd Congress, the Family and Medical of time (Employee Benefits Research Leave Act (1993) was passed, requiring busi Institute, 1990b). To encourage early pre nesses with more than 50 employees to give natal care, pregnant women are offered 12 weeks unpaid leave for family illness or financial incentives, such as stipends and maternity reasons. In contrast, maternal dis maternity bonuses or grants, to seek early ability in the other six indusbialized coun prenatal care and help defray medical tries has been an established benefit, with expenses associated with pregnancy protected leave ranging from 14 weeks (Germany, Japan) (lerodiaconou, 1986). (Germany, Japan) to 25 weeks (Canada). For high-risk women and women with pre Fmancial support under maternal disability natal complications, visiting nurses routine is also more generous than in the United ly perform prenatal evaluations and screen States, which does not guarantee cash ing and ensure that women obtain full pre maternity benefits. During each pregnancy, natal services (France, Germany, United all six countries provide periodic payments Kingdom, Sweden) (Williams and Miller, based on existing disability benefit programs 1991; Blonde!, Pusch, and Schmidt, 1986; (Canada, Japan, Sweden) or under distinct Ierodiaconou, 1986; Miller, 1988). Visiting cash maternity-disability-benefit plans nurses also provide periodic postpartum (France, Germany, United Kingdom). Japan visits (United Kingdom) (Williams and also provides pregnant women with a Miller, 1991). maternity grant sufficient to cover most Other incentives, such as materna] and maternity-related expenses (Employee child health handbooks and prenatal care Benefits Research Institute, 1990a). certificates, entitle pregnant women to a variety of benefits, including free prenatal CHILDREN'S HEALTH visits, pharmaceuticals, and home-visiting services when the patient is confined to bed. In the six industrialized countries, the These certificates are usually presented to approach to children's health reflects a com women on their first prenatal visit (U.S. mon theme: accessible, comprehensive, General Accounting Office, 1991a). Family preventive services beginning at birth and planning services and free pharmaceuticals extending into preschool and school health are otherwise provided in public prenatal programs. The multiplicity of locations for clinics (United Kingdom) (Goodwin, 1990). preventive care is one key feature of this These targeted incentives encourage early approach (Miller, 1990). Japan, for example, and periodic prenatal care and routine infant where pediatricians constitute some 4.8 per examinations (U.S. General Accounting cent of all physicians, relies on a system of Office, 1991b). Because of the accessibility more than 850 public health centers and 590 to services and the absence of financial bar maternal and child health centers to provide riers, prenatal care appears to be readily a wide range of preventive services to used in all six foreign countries (BlondeL newborns, infants, and older children Pusch, and Schmidt, 1986). Oapan Research Institute on Child Welfare, In these countries, maternal benefits are Inc., 1990). Services include: (1) screening treated much like disability benefits. for metabolic diseases, hypothyroidism, However, in the United States, maternity and hepatitis B, and neuroblastoma; (2) provid parental leave were not statutorily protected ing all routine childhood vaccinations; (3)

12 HEALTII CARE FINANCING REVIEW/S1llllnter 1994/Volume 15. Number4 conducting hearing, vtston, and speech screening program involved counseling on screening; and (4) providing special serv oral hygiene, diet, and fluoride supple ices for low-birth-weight children with dis ments, and was associated with a decline in abilities and children with chronic condi the percent of children with dental caries tions (approximately 95,000), including (from 65 percent in 1973 to 30 percent in malignant neoplasms, diabetes mellitus, 1983) (Kohler and Jakobsson, 1991). and birth defects Uapan International Most pediatric care in the United Cooperative Agency, 1990). Public health Kingdom is provided through general prac nurses also make home visits to provide pre titioners who, under the British National ventive services to high-risk children. Health Service, receive annual bonuses for As part of an extensive school program achieving high immunization rates among in France for preschool children, a health their pediatric patients. Parents may obtain care team, including a physician, nurse, preventive services for their children from child psychologist, and social worker, pro their general practitioner or from 1 of more vides language and psychomotor skills than 3,000 community clinics. Utilization of assessment, hearing and vision screening, well-child examinations is estimated to be and physical examinations (U.S. House of greater than 95 percent for infants under 1 Representatives, 1990). These children year of age and approximately 70 percent also may receive preventive care from pub for children 1-5 years of age (Williams and lic maternal and child health centers or Miller, 1991). In addition, the Home from a private provider. When a medical Visiting Service (HVS) provides preventive problem is identified, the child is referred services and health promotion at home to to the patient's physician for further evalu high-risk children or children without ation and treatment. When children enter ready access to a physician. the elementary school system, a health The HVS, which dates back to the late care team continues to provide periodic 1800s, has generally focused on maternal evaluation and screening of students. and child health, drawing upon the skills of School health services are coordinated registered nurses who frequently have with other school services to address additional training in public health. HVS health education and counseling issues nurses provide screening, counseling, and such as nutrition. health education services in order to Sweden employs a system of child health identify existing or potential problems. centers throughout the country that per These nurses provide regular home visits forms health and developmental assess to newborns and preventive counseling on ments for infants and children. These cen breastfeeding, injury prevention, child ters also provide free immunizations for hood immunizations, and health care. HVS preschool children and conduct vision, services for children usually include one hearing, and speech screening (Kohler and prenatal visit and five visits from birth to 5 Jakobsson, 1991). School health programs years of age. Although all British citizens provide continued screening and assess are eligible for HVS services, frequent ment and also provide health education limitations on resources have focused directed at alcohol and tobacco use services on children, especially high-risk (Kohler and jakobsson, 1987). Sweden children, or children in certain catchment instituted an aggressive dental health areas (U.S. General Accounting Office, program for children in the 1970s. This 1990). Studies evaluating the efficacy of the

HEALTH CARE FINANCING REVIEW/Summer 1994/Volume t5, t'lumber4 13 -~ Table 3 Children's Access to Health Care and Benefits, and Health Status Measures for Seven Industrialized Countries, by Country

Percent of Infant Mortality National Percent of Universal Percent of Children Under 2 Years Children Under Rate Home Visiting low-Birth- Periodic of Age Receiving Immunization 19 Years of Age per 1,000 Program Weight Preventive Diphtheria- Measles-Mumps- Country Without Insurance Live Births Available Births Screening Pertussis-Tetanus Oral Polio Rubella United States 14.6 9.80 No 7 No 57 57 57 Canada <1 7.20 limited 6 v., 85 85 85 Germany <1 7.36 Limited 5 v., 70 85 70 France <1 7.44 National 6 y., 85 85 64 Sweden <1 5.77 National 4 y., 95 95 94 <1 4.59 National 5 v., 90 95 65-70 J-United Kingdom <1 8.42 National 7 y., 85 90 89 SOURCES; (Blonde!, Pusch, and Schmidt, 1986); {Employee Benefits Research Institute, 1993); (lerodlaconoo, 1986); (Miller, 1988); (Na!ional Commission lo Prevent Infant Mortality, 1992); (United NatiOnS International Chiklmn's EmergeflCy Fund, 1991); {U.S. General Accounting Office, 1993a); {Wdliams and Miller. 1991). HVS program suggest that it has been suc baby preventive services (Canadian Task cessful in teaching health promotion and Force on the Periodic Health Examination, disease prevention, increasing rates of 1979; Gilbert eta!., 1984; Rourke and Rourke, immunization, and reducing hospitaliza 1985). For many provinces, these well-baby tions for infants and children (Select services-screening, cmmseling, and immu Committee on Children, Youth, and nizations-are provided through community Families, 1990). health agencies using community health Germany, with roughly 6 percent of all nurses and physicians in addition to office physicians identiJied as pediatricians (com based care (Hemmelgarn et al, 1992). Some pared with roughly 7 percent in the United communities have established regionalized States), provides most pediatric care through special programs, such as for high-risk peri private, rather than public, health clinics natal care. Although health insurance bene (Williams and Miller, 1991; Federal Ministry fits may vary somewhat among Canada's for Youth, Family Affairs, Women and provinces, utilization of children's services Health, 1988). Routine newborn screening does not involve cost sharing. includes hypothyroidism, phenylketonuria, Other measures of preventive health and galactosemia (Williams and Miller, services and access to preventive care for 1991). (In the United States, only the first two infants and children include rates of child are routinely screened.) In Germany, infants hood immunization and percent of children and preschool children are entitled to a pre without health insurance (fable 3). For all determined number of free comprehensive six foreign countries, immunization rates examinations. Immunizations are adminis for children under 2 years of age are 70-95 tered free of charge. Public clinics provide percent for the diphtheria-pertussis limited preventive services, such as Immu tetanus (DPI) and oral polio vaccines. nizations, primarily to poor families or those With respect to measles vaccination, three without insurance (such as immigrant of these countries have achieved immu families) (U.S. General Accounting Office, nization rates of greater than 85 percent 1993a). Home visiting is available, but only (United Nations International Children's for exceptional circumstances. Emergency Fund, 1991). Measles immu Canada, although it has not established a nization rates are lower for children in governmental agency formally charged Germany, Japan, and France, and appear to with responsibility for maternal and child be related to timing of vaccine approval and health issues, provides comprehensive provider concerns over vaccine side effects pediatric services under its universal sys (U.S. General Accounting Office, 1993c). tem of health insurance. Many provinces This compares with estimated immuniza have developed an extensive network of tion rates over the past decade of roughly community health centers that deliver a 57 percent for this same age group in the wide range of preventive services, includ United States (U.S. General Accounting ing well-baby care, postpartum care, and Office, 1993a). However, data from the immunizations (Pless, 1990). 1992 National Health Interview Survey The Canadian Task Force on the Periodic suggest that immunization rates may be Health Examination in 1979 released the first increasing in the United States (DPT, 83.0 national recommendations for periodic percent; oral polio, 72.4 percent; and preventive services. These include recom measles, 82.5 percent), although underim mendations on the content and timing ofwell- munization continues to remain a problem

HEALTII CARE F1NANCING REVIEW/Summer 1994/Volume 15, Number4 15 for low-income children and children of 16.2 percent of all women of childbearing races other than white (Centers for age in the United States are without health Disease Control and Prevention, 1994). insurance (Employee Benefits Research By providing comprehensive services Institute, 1993), a factor that has been asso using a combination of public clinics, ciated with more frequent adverse natal out school-based programs, and private office comes in this country (Braverman et al., based care, children in these countries 1989). In the six countries, when necessary, have a broad range of entry points into the as in the case of high-risk pregnancies, pre health care system. In addition, virtually all natal care may also include outreach ser children in these six countries have health vices provided through visiting nurses. insurance. This compares with the roughly Prenatal care and childbirth involve a wide 12.9 percent of children under 19 years of range of providers, frequently including age in the United States who do not have non-physicians. For mothers working out health insurance (Employee Benefits side the home, maternity benefits are finan Research Institute, 1993). cially comparable to earned income and extend for periods well beyond the time allot SUMMARY ted in the United States. These focused and comprehensive approaches likely contribute The six foreign industrialized countries to the improved infant status and pregnancy in this study reflect a wide range of health outcomes seen in the six countries. care systems (single-payer, multipayer, With respect to children's services, all mixed private and public insurance, cen six countries provide accessible and com tralized and decentralized), differing prehensive infant and pediatric prograros financing arrangements (employer-based beginning at birth. Children receive a full sickness funds, payroll- and personal range of preventive services that have income-tax-financed), and broad cost-con been recommended in this country as din~ tainment strategies (global budgets, ically effective (U.S. Preventive Services provider fee schedules, and utilization con Task Force, 1989; U.S. Department of trols). Despite spending considerably less Health and Human Services, 1993), includ than the United States, these countries ing metabolic screening, vision, hearing have health outcomes, reflected in rates of and speech evaluation, early childhood infant and maternal mortality, low birth immunization, dental care, and preventive weigh~ and childhood immunization, that couoseling (injury prevention, tobacco and do not appear to be compromised and gen substance abuse, nutrition, and fitness). erally surpass those of the United States. Services are delivered through private To achieve these outcomes, these six providers in office-based settings, as well countries offer various models of health as through a system of public clinics that care programs for children and pregnant are later supplanted by school-based pro women. A recurrent theme among them, grams. In some countries, providers and however, is the high priority given to pre parents are given financial incentives to ventive services. Prenatal care is compre increase the number of children receiving hensive and readily accessible and does certain preventive services, such as immu· not involve financial barriers such as cost nizations. As a result, the vast majority of sharing or demonstration of insurance status infants (80-97 percent) in most of these as a prerequisite to care. By contrast, some countries Oapan, France, Germany, United

16 HEALTH CARE FINANCING REVIEW/Summer 1994/Volume\5, Nurnber4 Kingdom) receive a broad range of recom Braverman, P., Oliva, G., Grisham-Miller, M., et al.: mended preventive services (U.S. General Adverse Outcomes and Lack of Health Insurance Among Newborns in an Eight-County Area of Accounting Office, 1993c). More than 50 California, 1982-1986. New England journal of percent of preschoolers appear to receive Medicine 321:508-512, 1989. preventive care, compared with 42 percent Brenner, G., and Rublee, D.A: The 1987 Revision of or less in the United States (Short and Physician Fees in Germany. Health Affairs Lefkowitz, 1992; Newacheck and Halton, 10(3):147-156, 1992. 1988; U.S. General Accounting Office, Canadian Task Force on the Periodic Health Examination: The Periodic Health Examination. 1993c). In all six countries, virtually all chil Canadian Medical Association journal 121:1193 dren have health insurance. This compares 1254, 1979. with 14.5 percent of children under 18 Centers for Disease Control and Prevention: years of age without health insurance in Vaccination Coverage of 2-Year-Old Children the United States. United States, 1991·1992. Morbidity and Mortality The international models in this study Weekly Reporl42:985-988, 1994. provide evidence that a wide range of Chaulk, C.P., and Bialek, R.: A Seven Country Perspective of Clinical Preventive Medicine. In health care systems based on differing Matzen, R.N., and Land, R.S., eds.: Clinical financing and delivery mechanisms and Preventive Medicine. StLouis, MO. Mosby, 1993. cost-containment strategies can avoid creat Coyte, P.C., Dewees, D.N., and Trebilock, MJ.: ing significant numbers of uninsured. pro Medical Malpractice-the Canadian Experience. vide a wide range of preventive services, American journal ofPublic Health 324(2):89-93, 1991. and avoid compromising health outcomes. Employee Benefits Research Institute: International Benefits: Part 1: Health Care. EBRI Issue Brief. 1990a. ACKNOWLEDGMENTS Employee Benefits Research Institute: International Benefits: Part 3: Disability, Parental Leave, and The author wishes to thank Barbara Unemployment Benefits. EBRJ Issue Brief. 1990b. Starfield, Division of Public Health Employee Benefits Research Institute: Sources of Policy, Department of Health Policy and Health Insurance and Characteristics of the Uninsured. Analysis of the March 1992 Current Management, The Johns Hopkins School Population Survey. EBRI Issue Brief Number 133. of Hygiene and Public Health, and Washington, DC. January 1993. Maryanne P. Keenan and Andrew K Bak of Family and Medical Leave Law. Congressional the U.S. General Accounting Office for Quarterly Weekly Report February 13, 1993. their generous review of earlier drafts of Federal Ministry for Youth, Family Affairs, Women this article. and Health: Health For All: The Health Care System in the Federal Republic of Germany. Kiel, Germany. REFERENCES Schmidt & IOaunig, February 1988. Fielding, j.E., and Pierre-Jean, L.: Lessons from AbouZahr, C., and Royston, E.: Maternal Mortality A France-'Vive Ia Difference': The French Health Global Factbook. Geneva. World Health Organization, Care System and US Health System Reform. 1991. journal of the American Medical Association Blonde!, B., Pusch, D., and Schmidt. E.: Some 270:748-756, 1993. Characteristics of Antenatal Care in 13 European Gilbert.].. Feldman, W., Siegel, L., et al.: How Many Countries. In Phaff, J.M.L, ed.: Perinatal Health Well-Baby Visits are Necessary in the First 2 Years Services in Europe: Searching for Better Childbirth. of Life? Canadian Medical Association ]ourna/130: London. Croom Helm, 1986. 857·861, 1984.

HEALTII CARE FINANCING REVIEW/Summer 1994/Volume!S. Numl>er4 17 Goodwin, S.: Child Health Services in England and Miller, C.A: Statement Before the Select Committee Wales: An Overview. Pediatrics Supplement on Children, Youth, and Families. Child Health: 86(6):1032-1060, 1990. Lessons From Developed Nations. Washington, DC. Ham, C.: Governing the Health Sector: Power and U.S. House of Representatives, March 20, 1990. Policy Making in the English and Swedish Health Miller, C.A.: A Review of Maternity Care Programs Services. Milbank Memorial Quarterly 66(2):389 in Western Europe. Perspectives on Prevention 2:31 414, 1988. 38, Spring 1988. Hemmelgarn, B.R, Edouard, L, Habbick, B.F., and Mother's and Children's Health Organization: Feather, J.: Duplication of Well-Baby Services. Maternal and Child Health Statistics of japan. Canadian journal ofPublic Health 83:217-220, l 992. Maternal and Child Health DMsion, Children and Ierodiaconou, E.: Maternity Protection in 22 European Families Bureau, Ministry of Health and Welfare of Countries. In Phaff, J.M.L, ed.: Perinatal Health Japan. Tokyo. October 1992. Seroices in Europe: Searching for Better Childbirth. National Commission to Prevent Infant MortaJity: London. Croom Hehn, 1986. Troubling Trends Persist: Shortchanging America's Iglehart, j.K: japan's Medical Care System, Part 1. Next Generation. Washington, DC. March 1992. New England journal of Medicine 319:807-812, Newacheck, P.W., and Halfon, N.: Preventive Care Use 1988a. by School-Age Children: Differences by Socioeconomic Iglehart, JK: Japan's Medical Care System, Part 2. Status. Pediabics 82:462468, 1988. New England journal of Medicine 319:116&1172, Notzon, F.C.: International Differences in the Use of 1988b. Obstetric Interventions. journal of the American Iglehart, j.K.: Germany's Health Care System, Part Medical Association 263(4):3286-3291, 1990. 1. New England journal of Medicine 324:503-509, Pless, I.B.: Child Health in Canada. Pediatrics 1991a. Supplement 86:1027-1032, 1990. Iglehart, j.K.: Germany's Health Care System, Part Politzer, RM., Harris, D.L., Gaston, M.H., and 2. New England journal of Medicine 324:1750-1756, Mullan, F.: Primary Care Physician Supply and the 1991b. Medically Underserved: A Status Report and Ikegami, N.: japanese Health Care: Low Cost Recommendations. journal ofthe American Medical Through Regulated Fees. Health Affairs 10(3):87 Association 266:104-109,1991. 109, 1990. Rodwin, V., et al.: Updating the Fee Schedules for japan International Cooperative Agency: Prevention Physician Reimbursement: A Comparative Analysis and Health Centers. Community National Health of France, Germany, Canada, and the United States. Administration in japan, Vol. 1. Hachioji International Quality Assurance Utilization Review 5:20-27, 1990. Training Center, 1990. Rourke, J.. and Rourke, L Well-Baby Visits: Japan Research Institute on Child Welfare, Inc.: A Screening and Health Promotion. Canadian Brief Report on Child Welfare Services in japan, Medical Association journal131:997-l002, 1985. 1990. Children and Families Bureau, Ministry of Schieber, G.j., Poullier, J.-P., and Greenwald, L.: Health and Welfare of japan. Tokyo, 1990. Health Care Systems in Twenty-Four Countries. Kohler, L, and Jakobsson, G.: Children's Health Health A/fairs 10:22-38, 1991. and Well-Being in the Nordic Countries. Clinics in Schieber, GJ., Poullier, J.-P., and Greenwald, L.M.: Developmental Medicine. Oxford. MacKeith, 1987. Health Spending, Delivery, And Outcomes in OECD Kohler, L, and jakobsson, G.: Children's Health in Countries. Health Affairs 12:120-129, Spring 1993. Sweden. Socialstyrelsen. Stockholm. National Board Select Committee on Children, Youth, and Families: of Health and Welfare, 1991. Children's Well-Being: An International Comparison. Uu, K, Moon, M., Sulvetta, M., and Chawla, j .: A Report of the Select Committee on Children, International Infant Mortality Rankings: A Look Youth, and Families. Washington. U.S. Government Behind the Numbers. Health Care Financing Printing Office, March 20, 1990. Review 13(4):105-118, 1992. Short, P.R., and Lefkowitz, D.C.: Encouraging McAuley, RG.: How Have Other Countries Achieved Preventive Services for Low-Income Children: Their Successes in Primary Care: A Predominantly The Effect of Expanding Medicaid. Medical Care Canadian Perspective. Volume II of the Proceedings 30:766-780, 1992. of the National Primary Care Conference. Washington, DC. March 29-31, 1992.

18 HEALTH CARE FINANCING REVIEW/Summer 1994/Volume !5. Number4