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JANUARY 2016 2015 International Profiles of Health Care Systems AUSTRALIA CANADA CHINA DENMARK ENGLAND FRANCE GERMANY INDIA ISRAEL ITALY JAPAN NETHERLANDS EDITED BY Elias Mossialos and Martin Wenzl London School of Economics and Political Science Robin Osborn and Dana Sarnak The Commonwealth Fund NEW ZEALAND NORWAY SINGAPORE SWEDEN SWITZERLAND UNITED STATES T he C ommonwealth F und is a private foundation that promotes a high performance health care system providing better access, improved quality, and greater efficiency The Fund’s work focuses particularly on society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries 2015 International Profiles of Health Care Systems Australia, Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, The Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, and the United States EDITED BY Elias Mossialos and Martin Wenzl London School of Economics and Political Science Robin Osborn and Dana Sarnak The Commonwealth Fund JA N UA RY Abstract: This publication presents overviews of the health care systems of Australia, Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, the Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, and the United States Each overview covers health insurance, public and private financing, health system organization and governance, health care quality and coordination, disparities, efficiency and integration, use of information technology and evidence-based practice, cost containment, and recent reforms and innovations In addition, summary tables provide data on a number of key health system characteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts Commonwealth Fund pub 1857 CONTENTS Table Health Care System Financing and Coverage in 18 Countries Table Selected Health System Indicators for 17 Countries Table Selected Health System Performance Indicators for 11 Countries Table Provider Organization and Payment in 18 Countries The Australian Health Care System, 2015 11 The Canadian Health Care System, 2015 21 The Chinese Health Care System, 2015 31 The Danish Health Care System, 2015 39 The English Health Care System, 2015 49 The French Health Care System, 2015 59 The German Health Care System, 2015 69 The Indian Health Care System, 2015 77 The Israeli Health Care System, 2015 87 The Italian Health Care System, 2015 97 The Japanese Health Care System, 2015 107 The Dutch Health Care System, 2015 115 The New Zealand Health Care System, 2015 123 The Norwegian Health Care System, 2015 133 The Singaporean Health Care System, 2015 143 The Swedish Health Care System, 2015 153 The Swiss Health Care System, 2015 161 The U.S Health Care System, 2015 171 Table Health Care System Financing and Coverage in 18 Countries HEALTH SYSTEM AND PUBLIC/PRIVATE INSURANCE ROLE Government role Public system financing BENEFIT DESIGN Private insurance role (core benefits; cost-sharing; noncovered benefits; private facilities or amenities; substitute for public insurance) Caps on cost-sharing Exemptions and low-income protection Australia Regionally administered, joint (national & state) public hospital funding; universal public medical insurance program (Medicare) General tax revenue; earmarked income tax ~47.3% buy complementary (e.g., private hospital and dental care, optometry) and supplementary coverage (increased choice, faster access for nonemergency services, rebates for selected services) Caps for pharmaceutical OOP expenditure only, dependent on income and total OOP expenditure in the same year Low-income and older people: Lower cost-sharing; lower pharmaceutical OOP cap and lower OOP maximum for 80% Medicare services rebatea Canada Regionally administered universal public insurance program that plans and funds (mainly private) provision Provincial/federal general tax revenue ~67% buy complementary coverage for noncovered benefits (e.g., private rooms in hospitals, drugs, dental care, optometry) No There is no cost-sharing for publicly covered services; protection for low-income people from cost of prescription drugs varies by region China Supervision by health authorities (Health and Family Planning Commissions) at the national, provincial and local levels; some direct provision through public ownership of hospitals There are three main publicly financed health insurance types with local-area risk-pooling: urban employer-based (mainly payroll taxes, for formally employed urban residents), urban resident basic (mainly government funded, for urban nonemployed residents), and rural cooperative medical scheme (government-funded, for rural residents) Complementary to cover cost-sharing and gaps, as well as better health care quality and/or higher reimbursements No data on coverage, but growth has been rapid No Government subsidies to low-income families for insurance contributions and OOP; emergency assistance by local governments for specific diseases and unpaid emergency department or other expenses Denmark National health care system Regulation, central planning, and funding by national government; provision by regional and municipal authorities Earmarked income tax ~39% have complementary coverage (cost-sharing, noncovered benefits such as physiotherapy), ~26% have supplementary coverage (access to private providers) No Decreasing copayments with higher OOP drug spending Drug OOP cap for chronically ill (DKK3,775 [USD498]); financial assistance for low income and terminally illa England National health service (NHS) General tax revenue (includes employment-related insurance contributions) ~11% buy supplementary coverage for more rapid and convenient access (including to elective treatment in private hospitals) No general cap, but OOP payments almost exclusively apply to prescription drugs and medical appliances only For drugs, prepayment certificate with GBP29.10 [USD41.10] per three months or GBP104 [USD147] per year ceiling for those needing a large number of prescription drugs.a Drug cost-sharing exemption for low-income, older people, children, pregnant women and new mothers, and some disabled/chronically ill; financial assistance with transport costs available to people with low income; vision tests free for young people, older people, and low-income people France Statutory health insurance system, with all SHI insurers incorporated into a single national exchange Employer/employee earmarked income and payroll tax; general tax revenue, earmarked taxes ~95% buy or receive government vouchers for complementary coverage (mainly cost-sharing, some noncovered benefits); limited supplementary insurance No EUR50 [USD60] cap on deductibles for consultations and servicesa Exemption for low income, chronically ill and disabled, and children Germany Statutory health insurance (SHI) system, with 124 competing SHI insurers (“sickness funds” in a national exchange); high income can opt out for private coverage  Employer/employee earmarked payroll tax; general tax revenue ~11% opt out from statutory insurance and buy substitutive coverage Some complementary (minor benefit exclusions from statutory scheme, copayments) and supplementary coverage (improved amenities) Yes 2% of household income; 1% of income for chronically ill Children and adolescents