Vox policy reporter Dylan Scott traveled the world last fall to explore what the US can learn from other countries’ health systems, visiting Taiwan, Australia, and the Netherlands. His trips were the foundation for Everybody Covered, a Vox series on health care that also reported on health systems in the United Kingdom and Maryland.
Dylan did a Reddit Ask Me Anything session on Wednesday, January 29, discussing everything from how countries pay for universal health care to what it will take to achieve further health care reform in America. Here’s a roundup of some of the most interesting questions and answers, lightly edited for clarity.
1) How do countries pay for public health insurance?
Icantnotthink: Where does the payment for public health care come from in other countries?
Dylan: Most of these countries use some mix of 1) payroll taxes for individuals, 2) employer contributions, and 3) general government revenue and progressive/sin taxes. To be honest, there isn’t one model to follow. Each country had its own health funding plan that has since been reformed to meet the needs of their current system, just as the US would. But other countries are looking for health care dollars in many of the same places Medicare-for-all supporters think we should here.
2) When it comes to covering everyone, is a country’s population density important?
Verybalnduser: How important would you say a country’s population density is to keeping total cost down?
Dylan Scott: It’s a huge asset. Taiwan has been able to keep its overall spending low — people on the left would say their single-payer program is actually underfunded — and cost sharing low for patients in large part because its urbanized nature makes it easier for a smaller workforce to meet the needs of its patient population. The Netherlands has been very innovative in delivery reforms, meant to keep costs in check, something that’s clearly been aided by its density. Australia, on the other hand, even with a universal public insurance plan, has still struggled with access in its more rural areas.
3) Is there a lot of paperwork in a single-payer system?
ZenBacle: How much paperwork do patients in single-payer systems have to fill out? And how much time do those patients have to spend fighting with health care providers to get them to honor their coverage?
Dylan Scott: One of the benefits of single-payer is there’s a lot less administration. We visited a hospital in Taipei, Taiwan, and while all the clinic lobbies were full, the cashier’s desk was basically empty. One survey finding that stuck out to me showed the doctors in the Netherlands (with private insurance) are more annoyed about paperwork than their peers in more socialized systems. So while I wouldn’t want to try to quantify it off the top of my head, there seems to be less of a paperwork headache.
4) Between Taiwan, Australia, and the Netherlands, which policy would translate most easily to the US?
Doctor_YOOOOU: Which of these universal health care systems is “closest” in terms of the amount of reform required to the United States?
Dylan: This is a tricky one — no country looks much like the US status quo. The Netherlands does have a lot of the same features as Obamacare (ban on preexisting conditions, individual mandate, government assistance to cover the costs), but it’s available to everybody and it’s stricter. The mandate penalty is harsher, the government rules on cost sharing are more stringent, and the government actually helps set prices and an overall budget for health care. So it’s much more involved than the US government is in administering that private health insurance. And almost all of the insurers are nonprofits.
So we’re talking about huge changes to move the US system to something that looks more like the Dutch — and that’s one I’d name as closest (along with Japan) to what we have right now.
5) Do solutions exist within the US that can be applied to the rest of the country?
Blakestonefeather: You traveled the world to explore what the US can learn, but did you also travel the US to learn if the US can learn? [In other words,] what are the barriers we in America face to learning/being able to learn?
Dylan Scott: We actually did one story in the US, on Maryland’s unique system for paying hospitals. (Every insurer — private, Medicare and Medicaid — pays the same rates for the same services.)
But there is a huge challenge in translating policies from abroad to the US. Taiwan and Australia have about the same population as Texas, but Taiwan’s is contained to a tiny island off the coast of China and Australia is a continent. The Netherlands is one of the most densely populated countries in the world; the United States is one of the least.
Then you’ve got political differences; Princeton economist Uwe Reinhardt famously didn’t believe single-payer could work in the US, not because it’s not a good idea but because the government was too beholden to corporate interests. The recent failure of surprise billing legislation in Congress in the face of industry opposition is certainly a warning sign to any aspiring reformers.
So the dissatisfying answer to “so what can the US learn from these other countries’ successes?” is: It’s complicated. But my hope for this series is it would speak to the kinds of values and strategies, if less the specific policies, that are necessary to achieve universal health care.
6) What does the American health care system get right?
taksark: What’s something good about the American health care system that could be kept and improved on in a better version?
Dylan Scott: The geographic immensity of the US has forced a lot of experimentation with telemedicine, and that is both a necessity and an area where other countries have tried to draw from what the US has done. I heard a lot from doctors about coming to the US to learn the latest on best practices for delivering care.
I think the US is still seen as a leader in innovative medicine — the question is why can’t we give more people access to it?
7) Besides America, what other countries have private health insurance?
To_Much_Too_Soon: How many other countries besides America have private health insurance?
Dylan: The US relies much more on private health insurance than any other country I’m aware of. About half of US citizens depend on private insurance as their primary coverage, and about 8 percent of our GDP is private health spending; most other developed economies don’t top 4 percent of GDP for private spending.
There are countries like the Netherlands with universal private insurance. But their private insurance is a lot different than ours: Almost all of the insurers are nonprofits, the government sets rules about premiums and cost sharing, there is a global budget for health care costs, etc.
Some countries with single-payer programs, like Australia, allow private insurance as a supplement — so you can get more choice in doctor or can skip the line for surgery. But no developed economy I know of is so dependent on private insurance as the US and with comparatively few regulations about its benefits.
8) What surprised you the most throughout your reporting?
JoseyGunner: What shocked you the most during your travels?
Dylan Scott: I was surprised how often people I talked to were shocked by the worst parts of US health care. The uninsured rates, the deductibles we have to pay, the very idea of a surprise medical bill — all of it was unfathomable to many of the people I met.
9) What are the biggest hurdles to any future health reforms in the US?
Flogopickles: What do you see as America’s biggest hurdle to achieving any sort of movement in affordable care for our citizens?
Dylan Scott: The status quo is powerful for two reasons: One, it’s good enough for enough people that big change feels like a risky proposition to a lot of the population and, two, health industry interests are so influential in Washington, DC. Overcoming those two things — people’s inherent aversion to risk in health care and the power of industry to constrain policymaking, especially price constraints for medical care — are the biggest hurdles to any future health reforms.