Advanced Mediterranean Diet

A few days ago I posted here my brief overview of high-income countries’ healthcare systems. I did more research to see if those countries’ citizens like their systems. Americans bitch about their healthcare system mainly because it’s too expensive, about twice as much as other high-income countries. Why bother with this? I’ve been thinking about ways to improve the U.S. healthcare system.

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It would be interesting to check healthcare system satisfaction levels of residents in high-income countries: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States.

I’ll stipulate at the outset that it is very difficult to find accurate, up-to-date, numbers on healthcare system satisfaction, particularly comparing one country to another. I found one survey in which 25-30% of respondents were “neither satisfied nor dissatisfied.” Furthermore, accuracy of satisfaction surveys can be affected by bias of the surveyors, source of the funds paying for the survey, specific wording of questions,  number and economic class of survey participants, etc.

But first let’s consider satisfaction in the U.S. based on data from a 2023 Gallup poll. Surveyed residents rated the overall quality of healthcare as excellent (10%), good (36%), or only fair (34%). They rated coverage as excellent (5%), good (25%), or only fair (37%). Regarding the healthcare industry as a business, 49% of respondents had a somewhat negative (31%) or very negative (18%) view. Regarding cost of the system, 19% were satisfied, 81% were dissatisfied. When asked if the system was in crisis or had major problems, 14% said “in crisis,” 55% said “major problems,” and these numbers were fairly steady over the prior 20 years. When asked if they preferred a government-run system versus one based on private insurance, 54% said private insurance, 44% preferred government-run. So even if you prefer socialized medicine, a majority of U.S. residents is not on board, at least not yet.

Ipsos in 2023 published a multinational survey that touched on healthcare satisfaction. Unfortunately for us, the 28 countries did not include New Zealand, Norway, or Switzerland. Ipsos asked residents to “rate the quality of healthcare that you and your family have access to in your country.” Options included “very good/good” and “very poor/poor.” (You may well argue that the general public is in no position to judge the quality of their healthcare.) The global country average response of “very good/good” was 42%. Here are the “very good/good” responses by country:

• Australia: 64%
• United States: 61%
• Netherlands: 58%
• Sweden: 56%
• Great Britain: 48%
• Canada: 44%
• Germany: 41%
• France: 39%

Malaysia, by the way, was the top performer at 66%. Singapore was #4 at 63%. Most of the countries had a 25-30% “no opinion” gap between good and poor quality. You’ll note several mentions of Malaysia in these survey results; I suspect respondents were in urban areas, and the rural residents would not be so positive. The Legatum Prosperity Index’s health pillar ranked Malaysia #42 out of 167 countries.

Ipsos asked “How satisfied are you with the government’s healthcare policies?” These are the “very/fairly satisfied” responses (the global country average was 48% “very/fairly satisfied”):

• Australia: 67%
• Netherlands: 62%
• Canada: 52%
• Germany: 50%
• United States: 45%
• Great Britain: 45%
• Sweden: 45%
• France: 36%

Singapore was tops at 81%.

Ipsos asked respondents to agree or not that it was easy to get an appointment with a local doctor. Here’s the % that “strongly/tend to agree” (global country average was 39%);

• Netherlands: 55%
• United States: 48%
• Australia: 47%
• Sweden: 37%
• Canada: 35%
• Germany: 33%
• Great Britain: 29%
• France: 25%

India won at 62%.

Next, Ipsos asked if respondents agreed or not with, “I trust the healthcare system in my country to provide me with the best treatment.” Global country average of “strongly/tend to agree” was 42%. Our residents at hand that “strongly/tend to agree:

• Australia: 58%
• Netherlands: 54%
• France: 48%
• Great Britain: 46%
• Sweden: 45%
• Canada: 44%
• Germany: 44%
• Unites States: 43%

Singapore and Malaysia were top of the chart at 63 and 61%, respectively.

More Ipsos poll questions:

Agree or disagree?: “Waiting times to get an appointment with doctors are too long in my country.” Global average for “strongly/tend to agree” was 60%. Here are “agrees” in our countries:

• Great Britain: 76%
• France: 68%
• Canada: 67%
• Germany: 65%
• Sweden: 61%
• Netherlands: 56%
• Australia: 55%
• United States: 42%

Agree or disagree?: “The healthcare system in my country is overstretched.” Global average for “strongly/tend to agree” was 56%. Our countries:

• Great Britain: 83%
• Sweden: 79%
• France: 75%
• Netherlands: 71%
• Australia: 70%
• Canada: 69%
• Germany: 62%
• United States: 52%

Japan won this contest with only 14% thinking their system was overstretched.

Not surveyed by Ipsos were residents of New Zealand, Norway, and Switzerland.

In 2023 a satisfaction survey of Swiss adults found that 63% rated quality of care as very good or excellent. That percentage was 74 in 2020. Regarding medical care by their “regular doctor,” 89% responded that it was very good or excellent. However, 60% noted it was somewhat or very difficult to get care on weekends, evenings, or holidays without going to an emergency department. (Isn’t that an issue everywhere?) One out of every four adults had visited an ED in the prior two years. A quarter of the adults admitted foregoing a medical service (most often a doctor visit) due to the cost. Similar to France and Netherlands, Switzerland’s chronic disease burden is somewhat lower than that in the U.S. and Australia.

Regarding system satisfaction in New Zealand, a Gallup World Poll in 2018 asked citizens “if they were satisfied with the availability of quality healthcare in the city or area where they lived.” OECD reported that 82% of New Zealand citizens reported they were satisfied. The average citizen satisfaction response for all OECD countries was 70% in 2018. For comparison, the satisfaction number for Netherlands was 90%, Norway 89%, Switzerland 88%, Australia 86%, Germany 81%, Sweden 79%, U.S. 76%, Canada 75%, and France 69%. I was not able to find a more recent Gallup World Poll for all these countries other than 2018’s.

A less extensive 2021 poll by OECD Trust Survey asked citizens, “On a scale of 0 to 10, how satisfied or dissatisfied are you with the healthcare in [country] as a whole?” The “satisfied” responses for a few of our countries were South Korea 79%, Norway 77%, New Zealand 72%, France 64%, Sweden 57%, and Japan 51%. The average for OECD overall was 62%.

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After wading into the weeds of these mind-numbing satisfaction numbers, we find only a few clues about how we might devise a better system for the U.S. We can’t necessarily conclude that single-payer, social insurance, or private insurance systems is better than all others. Many high-income countries have a mixture of public and private insurance, plus significant out-of-pocket costs, like the U.S. Whether single-payer, social insurance, or private insurance predominates, most countries have supplemental private- or employer-based insurance to help cover co-pays, dental, drugs, out-of-pocket costs, and other non-covered services. I had heard good things about the Singapore system before; Malaysia was a complete surprise. Australia and Netherlands are looking pretty good, too. U.K., Germany, and France may not be the best countries for the U.S. to emulate. We may also see some of the downsides to socialized medicine, such as difficulty getting a timely appointment with a physician. Nevertheless, the U.S. stands out as paying too much for healthcare.

If disagree with the above, or have newer/better data, please leave a comment below.

Steve Parker, M.D.

I’ve been thinking about the U.S. healthcare system for several years: How can we make it better? Provide more access? Make it less expensive? This has led me to consider systems in other countries. Up front, I’ll tell you I’m not a world traveler. I made a couple shallow excursions into Mexico years ago when you didn’t even need a passport. I only got my passport four months ago. Haven’t used it yet. My wife wants to go to Italy. I’m interested in Ireland (my sister say’s we’re 75% Irish) and have developed an unexpected interest in Russia.

Don’t worry, I’m not going to review healthcare in all 195 countries. I’ll focus on mostly high-income countries.

Feel free to correct me in the comments section.

First, lets’ consider the broad types of healthcare financing.

• Private insurance

• Public insurance: In some countries workers have social insurance, also called public insurance. Usually government withholds part of their wage (a payroll tax), which is divided between employee and employer. Additional funds may come from other taxes.
• Single-payer healthcare: One entity (public or quasi-public) collects funds and pays for healthcare on behalf of an entire population.
• Out-of-pocket

Many countries, like the U.S., are a blend of these financing mechanisms. For instance, the U.S. Veterans Health Administration is single-payer socialized medicine. Medicare is public insurance. Purely cosmetic surgical procedures and insurance deductibles are paid out-of-pocket. Employer-provided insurance is private insurance.

Note that I haven’t defined “socialized medicine” yet. Universal Health Coverage (UHC) is often defined as coverage for all members of a population for any kind of medical care that does not result in a significant financial burden to individuals. UHC could be single-payer or socialized medicine. While socialized medicine is strictly integrated with the government, the government may or may not play a role in single-payer systems. In a socialized system, the government owns the buildings where care is rendered and it employs those who provide care. In a single-payer system, one entity pays for health care while hospitals, primary care clinics and other health care services are run by separate organizations, and doctors, nurses, and other health care providers are often employees of those organizations. “Single-payer” doesn’t necessarily mean the government: the payer could be any insurance company that obtained the entirety of the health insurance market.

Other than the U.S., nearly all high-income countries provide Universal Health Coverage. So do Singapore, South Korea, and Malaysia, which I mention because they rank highly in several “best healthcare systems” lists. While the U.S. does not provide universal coverage, it covers 91% of the population.

Here’s an over-simplified overview of healthcare financing systems in a few high-income countries and Malaysia (upper-middle-income):

• Australia: Single-payer, government-funded Medicare. Half of residents also buy subsidized supplementary insurance to pay for private hospital care and dental services.
• Canada: Single-payer, government-funded. Canadian Medicare covers 70% of healthcare costs; private insurance pays for 30%. Supplemental insurance is carried by 70% of residents. Two-thirds of Canadians have private insurance to pay for prescription drugs, dental care, etc.
• France: Social insurance. Statutory health insurance is mandatory, funded by various taxes, including payroll taxes paid by employers and employees. Nearly all residents buy private voluntary supplemental insurance to help with co-pays, balance billing, dental and vision care, etc. Employers may help pay for it. Private insurance pays for ~13% of total healthcare expenditures.
• Germany: Public-private social insurance. About 88% of residents are enrolled in compulsory not-for-profit insurance provided by “sickness funds.” Healthcare is funded for by payroll taxes shared equally by ensured employees and their employers. Germans above a certain income level can opt out of public insurance and buy private instead. Chancellor Otto von Bismarck’s Health Insurance Act of 1883 established the world’s first social health insurance system.
• Japan: Public insurance is mandatory (usually government withholds part of wage, divided between employee and employer). Citizens pay premiums and 30% co-insurance for most services. 60% of insurance is employment-based; the rest is “residence-based” (for the unemployed and/or elderly). The national government regulates nearly all aspects of the system. Health expenditures are funded by taxes (42%), mandatory individual contributions (42%), and out-of-pocket expenses (14%). Seventy % of residents have supplementary private insurance but it seems to function more as life or short-term disability insurance.
• Netherlands: Private insurance. Adults must purchase statutory insurance from nonprofit private insurers of their choosing. Otherwise they are fined. Children are automatically covered. Less than 1% of the population is uninsured.  Healthcare is financed through payroll taxes paid by employers, general taxation, insurance premiums paid by individuals, and copayments. A large majority of the population also purchases voluntary supplemental insurance to help with expenses not paid by statutory insurance.
• Malaysia: Public-private mix, two-tiered. The public system, funded by taxes, provides universal access. Most residents use the public system for a nominal fee. There is also a large and thriving private system that caters to higher-income residents and medical travelers from other countries. In 2020, there were more private than government-owned hospitals. Most physicians speak English. Many doctors, especially specialists, gravitate to the private system, presumably for better working conditions, lower patient volumes, and/or higher pay. The private system is sustained by out-of-pocket payments and private insurance. High-tech care and specialists are concentrated in the large urban centers, as they are in many high-income countries. The private system tends to provide nicer amenities and shorter wait times than the public counterpart.
• New Zealand: Single-payer, government funded. Government at national and regional levels is heavily involved. General taxes fund most healthcare. A third of the residents have private insurance to pay uncovered services and copayments. There are private hospitals but public hospitals predominate, providing all emergency and intensive care.
• Norway: Single-payer, government-funded by general and payroll taxes. A tenth of the population pays for private insurance, mainly for quicker access and broader choice of providers. Most hospital care is provided at public, state-owned hospitals. There is a small private supplemental insurance market, mostly provided by employers.
• Singapore: Mixed financing. MediShield Life is a statutory insurance system that covers large hospital bills and certain costly outpatient treatments. (In the U.S., we’d call this catastrophic care.) Premiums for MediShield Life are subsidized by the government based on income and funded by general taxation. Patients pay premiums, deductibles, and co-insurance. A second major program is called MediSave, a mandatory medical savings account that helps pay out-of-pocket expenses. MediSave accounts are tax-exempt and interest-bearing, funded by personal and employer contributions. Singapore utilizes regulation of supply and prices of health care services in the country to keep costs in check. There is a 50:50 mix of private and public hospital, the latter being government-owned. Sixty to 70% of citizens also have supplemental health insurance for coverage of private hospitals or private wards of public hospitals.
• South Korea: Single-payer, government-funded. Compulsory social insurance, called National Health Insurance, is funded largely by payroll taxes split equally between employers and employees. The national government also contributes. Co-payments for hospital care are 20% and outpatient services have co-payments ranging from 30 to 60%. Out-of-pocket payments are ~35% of national health expenditures, perhaps the highest of OECD countries. Out-of-pocket payments are capped, based on income. A large majority of the population also pays for private health insurance to help with co-payments. Low-income folks are in the Medical Aid Program and exempt from premiums and co-payments. Most hospitals are privately owned, but not-for-profit by law. Drug prices are set by the government.
• Sweden: Single-payer, government-funded. Nearly all hospitals are public. Only 15% of healthcare expenditures are private, mostly out-of-pocket for dental care and drugs. There’s a small market for supplemental insurance, mostly employer-provided, to gain quick access to specialists or to avoid wait lists for elective services.
• Switzerland: Mandatory private insurance bought from nonprofit insurers. Adults pay yearly deductibles and 10% coinsurance (with a cap) for all services. Care is largely decentralized, with system governance mainly at the cantonal level. Enrollees are offered several models of care (e.g., HMOs, Family Practice Gatekeeper, call-center before seeing physician) and a choice of deductibles. Funding is from enrollee premiums, taxes, other social insurance schemes (military, old-age, disability), and out-of-pocket. The Federal government and cantons subsidize premiums for lower-income individuals and households.
• United Kingdom: Single-payer socialized medicine. About 10% of residents have private supplementary insurance to gain more rapid access to elective care, choice of specialists, and better amenities.
• United States: Mixed public and private. Single-payer if 65 or older (Medicare). Public insurance for no- or low-income under 65 (Medicaid). Private insurance. Out-of-pocket. Government sources pay for ~45% of total healthcare expenditures.

For additional details of 20 high-income country healthcare systems, check out The Commonwealth Fund’s Country Profiles: International Health Care System Profiles. I note that many of these systems, perhaps a majority, provide free or very-low-cost medical education for physicians. They also limit the number of physicians trained, and limit the number of specialists. New graduates of U.S. medical schools average $200,000 USD in educational debt. That’s about 155,900 Pound sterling or 182,900 Euro. I also noticed that physicians in the U.S. tend to be paid significantly more than in many other top-tier countries.

Steve Parker, M.D.