DECEMBER 2020 AUSTRALIA BRAZIL CANADA CHINA DENMARK ENGLAND FRANCE GERMANY INDIA ISRAEL ITALY JAPAN NETHERLANDS NEW ZEALAND NORWAY SINGAPORE SWEDEN SWITZERLAND TAIWAN 2020 UNITED STATES International Profiles of Health Care Systems EDITED BY Roosa Tikkanen and Robin Osborn The Commonwealth Fund Elias Mossialos, Ana Djordjevic, and George Wharton London School of Economics and Political Science Contents The Australian Health Care System 7 The Brazilian Health Care System 17 The Canadian Health Care System 27 The Chinese Health Care System 37 The Danish Health Care System 47 The English Health Care System 59 The French Health Care System 71 The German Health Care System 83 The Indian Health Care System 93 The Israeli Health Care System 105 The Italian Health Care System 117 The Japanese Health Care System 127 The Dutch Health Care System 137 The New Zealand Health Care System 149 The Norwegian Health Care System 159 The Singaporean Health Care System 169 The Swedish Health Care System 181 The Swiss Health Care System 191 The Taiwanese Health Care System 201 The U S Health Care System 211 Table 1 Primary and Secondary Health Insurance Coverage and Financing 224 Table 2 User Fees and Safety Nets 226 Table 3 Health Care Delivery 227 Table 4 Medical Education 228 The Australian Health Care System Lucinda Glover, with contributions from Michael Woods London School of Economics Australia has a regionally administered, universal public health insurance program (Medicare) that is financed through general tax revenue and a government levy Enrollment is automatic for citizens, who receive free public hospital care and substantial coverage for physician services, pharmaceuticals, and certain other services New Zealand citizens, permanent residents, and people from countries with reciprocal benefits are eligible to enroll in Medicare Approximately half of Australians buy private supplementary insurance to pay for private hospital care, dental services, and other services The federal government pays a rebate toward this premium and also charges a tax penalty on higher-income households that do not purchase private insurance How does universal health coverage work? It took 10 years of political tension to establish Australia’s universal public health insurance program, known as Medicare A universal health care bill was initially introduced in Parliament in 1973 but failed three times to pass through the Senate Because of these failed attempts, a new parliamentary election was called, a procedure known as double dissolution, to resolve the deadlock The new Parliament passed the health care legislation in 1974, establishing free public hospital care and subsidized private care However, following a change in government in 1975, access to free health care services was limited to retired persons who met stringent means tests After another change of government in 1984, the current Medicare system was established Medicare provides free public hospital care and substantial coverage for physician services and pharmaceuticals for Australian citizens, residents with permanent visas, and New Zealand citizens following their enrollment in the program and confirmation of identity 1 Restricted access is provided to citizens of certain other countries through formal agreements 2 Other visitors to Australia, as well as undocumented immigrants, do not have access to Medicare and are treated as private-pay patients, including those needing emergency services Role of government: Three levels of government are collectively responsible for providing universal health care: The federal government provides funding and indirect support for inpatient and outpatient care through the Medicare Benefits Scheme (MBS) and for outpatient prescription medicine through the Pharmaceutical Benefits Scheme (PBS) The federal government is also responsible for regulating private health insurance, pharmaceuticals, and therapeutic goods; however, it has a limited role in direct service delivery States own and manage service delivery for public hospitals, ambulances, public dental care, community health (primary and preventive care), and mental health care They contribute their own funding in addition to that provided by federal government States are also responsible for regulating private hospitals, the location of pharmacies, and the health care workforce Local governments play a role in the delivery of community health and preventive health programs, such as immunizations and the regulation of food standards 3 At the federal level, intergovernmental collaboration and decision-making occur through the Council of Australian Governments (COAG), with representation from the prime minister and the first ministers of each state The COAG focuses on the highest-priority issues, such as major funding discussions and the interchange of roles and responsibilities among governments The COAG Health Council is responsible for more detailed policy issues and is supported by the Australian Health Minister’s Advisory Council The federal Department of Health oversees national policies and programs, including the MBS and PBS Payments through these schemes are administered by the Department of Human Services Other federal agencies involved in health care include the following: • The Pharmaceutical Benefits Advisory Committee provides advice to the Minister for Health on the cost-effectiveness of new pharmaceuticals (but not routinely on delisting) International Profiles of Health Care Systems, 2020 7 AUSTRALIA • The Australian Digital Health Agency is responsible for matters relating to electronic health data, and the Australian Institute of Health and Welfare and the Australian Bureau of Statistics (ABS) also provide health data • The Therapeutic Goods Administration oversees supply, imports, exports, manufacturing, medical devices, pharmaceutical safety, and advertisement • The Australian Health Practitioner Regulation Agency ensures registration and accreditation of the workforce in partnership with national boards • The Australian Prudential Regulation Authority regulates private health insurance, and the Australian Competition and Consumer Commission promotes competition among private health insurers The state governments operate their own departments of health and have delegated the management of hospitals to Local Hospital Networks These hospital networks are responsible for working collaboratively with federally funded Primary Health Networks, which were established in 2015 to improve the efficiency, effectiveness, and coordination of care Primary Health Networks have boards comprising medical professionals and community advisory committees ORGANIZATION OF THE HEALTH SYSTEM IN AUSTRALIA Australian Parliament State Parliaments Council of Australian Prime Minister & Cabinet Governments (COAG) State Premiers & Cabinets Federal Health Minister COAG Health Council State Health Ministers Australian Health Ministers Advisory Council State-run aged care Key regulatory bodies Community services Pharmacy Aged Care Quality and Agreement Public Safety Commission with community Pharmacy Australian Health health Guild of Practitioner Regulation services Australia Agency Public Australian Prudential Local hospitals Regulatory Authority (in Primary hospital (including Treasury portfolio with health networks oversight of private networks outpatients) health insurers) Australian Radiation Medical and Public dental Protection & Nuclear pharmaceutical services Safety Authority benefits to (including patients hospitals) Food Standards Australia New Zealand Therapeutic Goods Hierarchical (may include funding) Administration Negotiation Funding Source: L Glover, 2020 8 The Commonwealth Fund AUSTRALIA Role of public health insurance: Total health expenditures in 2015–2016 represented 10 3 percent of the GDP, an increase of 3 6 percent from 2014–2015 Two-thirds of these expenditures (67%) were funded by the government 4 Medicare is funded through the national tax system, in part by a government levy, which raised an estimated AUD 114 6 billion (USD 80 14 billion)5 in 2015–2016 6 Since 2014, a share of the money raised from this levy also supports the National Disability Insurance Scheme Role of private health insurance: Private health insurance is readily available and offers coverage for out-of-pocket fees and private providers, greater choice of providers (particularly in hospitals), faster access to nonemergency services, and rebates for selected services Private health insurance may include coverage for hospital care, general treatment, or ambulance services General treatment coverage provides insurance for dental, physiotherapy, chiropractic, podiatry, home nursing, and optometry services Coverage may be capped by dollar amount or by number of services For hospital services, patients can opt to be treated as a public patient (with full fee coverage) or as a private patient (with 75% fee coverage) Government policies encourage enrollment in private health insurance through a tax rebate (8 5%–33 9%, depending on age and income) and an income-based penalty payment (1%–1 5%) for not having private insurance This penalty, known as the Medicare Levy surcharge, applies only to singles with incomes above $90,000 and families with incomes above $180,000 7 The Lifetime Health Coverage program provides a lower health insurance premium for life However, there is a 2 percent increase in the base premium for each year after age 30 Consequently, sign-up is highest among those 30 and under, with a trend to opt out starting