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Japan and UK health care

Healing America continues!


As said last time, Japan uses the Bismarck model. This becomes obvious in retrospect: when the Meiji Restoration and Taisho period sent reformers crawling over the then-industrializing world for models to copy, Germany *was* the universal health care model. The local twists:

* 3500 insurers -- yet no competition, since which one you end up in depends on your job or employment situation. You can pick your doctor or hospital, not your insurer.
* Patients pay 30% of their bills -- up to $650 in a month; insurers pay anything after that.
* The individual mandate is considered being responsible; of course you should get yourself insured! For the 1% who refuse -- no rich person exception as in Germany -- you don't get a fine or go to jail, but you do get enrolled anyway by your local city government, and get dunning letters, and if you get sick you have to pay your outstanding premiums before the insurance will cover anything. If you're unemployed or poor, the government pays your premiums.
* Like France, the government sets all the medical fees. And sets them really low. $105 for an MRI. This has spurred innovation: Japanese doctors demanded cheaper MRI machines, and now they can get a compact no-frills machine for $150,000, a tenth of US prices. Guess who dominates the MRI market in the developing world... Doctors still make decent income. Reid *says* $130,000 for a GP, which sounds pretty good, but his named example is of two married doctors running a clinic and jointly making $160,000, or $80K each, a standard college graduate salary.
* Those same doctors had medical school tuition of $1500/year, and their local government helped pay that. They couldn't say how much they pay for malpractice insurance, it's part of their medical association fees, so less than $1200/year (compare to $50,000 US). They had no lawsuits in 40 years.
* Doctors have high status even if not high pay, with medical soap opera manga about them, and TV shows about brilliant attractive doctors who treat exotic ailments. "Like in the US", though sounds like they have more. I don't really know my medical TV, though. House, and, uh.
* Japan will pay for traditional Chinese medicine and other "alternatives".
* Local government will mail you a letter around your birthday, urging you to go get your free physical. This is contrast with the UK NHS, which has decided annual physicals for healthy people aren't cost-effective.
* Japanese go to the doctor a lot, and spend a lot more time in the hospital. Like, 3-5x as much as Americans do. They also live longer than anyone.
* Japan spends 8% of GDP on health care, and unlike most countries, has actually kept costs from growing, or even pushed them down.

As a side note, Reid goes through a list of the models the Meiji reforms brought back. German army, British navy, British railroads, American telegraph lines, French Code Napoleon, German elementary and middle schools (with uniforms), and Oxbrige universities (with top hats?), Dutch naval engineers (Mitsubishi), and Midwest dairy farms (on Hokkaido).

United Kingdom

We finally leave the Bismarck model behind, for the Beveridge, or Beveridge-Bevan model. Beveridge was an aristocratic social reformer who designed the NHS; his report, the sexily titled Social Insurance and Allied Services, sold 100,000 copies in a month and was distributed to British soldiers to boost their morale. Aneurin (ah-NY-rin) (WTF, Welsh orthography) Bevan was a Welsh coal miner turned Labour politician, who got tapped by Clement Attlee's 1945 government to implement it, and made the compromises (like GPs remaining private, and being able to take non-NHS business on the side) that got it passed through medical opposition.

The basic principle was "no bills, ever!" This has been compromised a bit: Bevan gave ground on prescription drugs, then resigned over eyeglasses and dentures and other dental care. But the rot hasn't spread; a move to introduce co-pays got hurriedly withdrawn in the 1990s.

The NHS pioneered the gatekeeper system copied by US HMOs, where your GP has to refer you to a specialist. There's logic to that: many ailments can be analyzed or treated by your GP. US has 35% GPs, UK has 60%, since unlike most places, they get paid more than specialists do. UK spends 8% of GDP on health care; both these reasons might be why the infamous queues exist for non-acute or elective specialist care.

And yes, the NHS, or its NICE body, decides what to pay for, Just like your insurance company does, except that NICE is democratic and transparent. OTOH you, my fellow American, get to use market competition and shop around private insurers... oh wait, no you don't, you get to use whoever your employer contracts with. And money NICE saves goes to treating other people, as opposed to profit.

The UK is proud of the US -- as the recent Olympic ceremony showed -- and highly attended to, with "blanket coverage that US media reserve for Britney Spears", and likely getting news articles every day, TV shows every night of the week, a drama "Casualty" that inspired our "ER", and a whole genre of NHS romances (Virgin Midwife, Playboy Doctor, Emergency: Wife Needed).

As usual, tuition fees are low, though at $4000/year probably the most expensive so far. Often paid for by the local government. Malpractice $4200/year, and following NICE guidelines provides immunity from a malpractice claim.

Those private GPs get capitation payments, payment per registered patient. The less they have to see you, the more they make; preventive care is *big*. NICE won't pay for general physicals, but if they think you're at risk for something -- family history of colon cancer, say -- then you *will* be invited for your free annual colonoscopy. They've also started paying for following "best practices", which for a lot of doctors means free money. "More money for doing what I already was? Yay!"

Reid doesn't mention that while Japan leads the world, the UK is at the low end of life expectancy and infant mortality. I mean, for universal health care countries; they still beat *us*, of course, for less than half the price. You can see my 2006 country comparisons here.

Unfortunately, while we got to see three Bismarck countries, this is the only Beveridge one he went to; next chapter will be Canada, representing the Medicare model. Other Beveridge countries are said to be Italy, Spain, most of Scandinavia, and Hong Kong. And of course Cuba, and in the US Department of Veteran Affairs. Fight socialism as a soldier, then get socialized medicine from the US government. o_O

Edit to add: doctors in both countries make house calls.

See the comment count unavailable DW comments at http://mindstalk.dreamwidth.org/329511.html#comments


( 1 comment — Leave a comment )
Jan. 31st, 2013 03:28 pm (UTC)
Greater economic inequality appears to lead to worse health outcomes.
( 1 comment — Leave a comment )


Damien Sullivan

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