In this article, we present a brief overview of the healthcare systems of four English speaking countries. Each overview covers health insurance, and governance.
In the Australian health system, the federal, state and territory, and local governments collectively are responsible for providing universal healthcare. The federal government mainly provides funding to the states and health professions, subsidising primary care providers through the Medicare Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS) and providing funds for state services. It has minimal role in direct service delivery.
States have the responsibility for funding public hospitals, ambulance services, public dental care, community health services and mental healthcare. They contribute their own funding in addition to that provided by federal government. Local governments take part in the provision of community health and preventive health programs, such as immunisation and the regulation of food standards. In 2014 to 2015 total health expenditures represented 10.0 percent of GDP (gross domestic product) and 67 percent of this was paid by the government.
Medicare is funded by the federal government. It is a universal public health insurance program that provides free or subsidized access to care for Australian citizens, residents with a permanent visa, and New Zealand citizens after their enrolment in the program and confirmation of identity. Restricted access is provided to citizens of certain other countries through formal agreements.
Private health insurance (PHI) is widely available and offers more choice of providers (particularly in hospitals), faster access for nonemergency services and rebates for selected services. PHI does not pay for outpatient services and this is a huge limitation of this service. Government policies support uptake of PHI through a tax rebate and, above a certain income, a penalty payment for not having PHI (the Medicare Levy surcharge).
In 2016, almost half of the Australian population (47 percent) had private hospital coverage.
Insurers are a mix of for-profit and non-profit providers and the products offered vary significantly. PHI can include coverage for hospital care, general treatment or ambulance services. When accessing hospital services, patients can opt to be treated as a public patient (with full fee coverage) or as a private patient (with 75 percent fee coverage). For private patients, insurance covers the MBS fee. If a provider charges above the MBS fee, the consumer will bear the gap cost. The patient may also be charged for costs such as hospital accommodation, surgery fees (implants and theatre fees) and diagnostic tests.
In this health system, the government has a fundamental role in providing for the population’s healthcare needs. Overall the government plays a central role in setting the policy plan and service requirements, and in determining the publicly funded annual health budget.
Responsibility for planning, purchasing and providing health services lies with 20 geographically defined district health boards (DHBs), each of which comprises seven locally elected members and up to four members appointed by the Minister of Health.
All permanent residents have access to a broad range of services, which are largely publicly financed through general taxes. Non-residents, including tourists, are charged the full cost of services by public healthcare providers, unless treatment is related to an accident, in which case they are covered by the Accident Compensation Corporation (ACC) no-fault accident compensation scheme.
Private health insurance is offered by a variety of organisations, from non-profits and ‘Friendly Societies’ to for-profit companies, and accounts for about five percent of total health expenditure. It is used mostly to cover cost-sharing requirements, elective surgery in private hospitals and faster access to non-urgent treatment. In contrast to the Australian model, the private health model provides access to private outpatient specialist consultations. About one-third of the population has some form of private insurance, purchased predominantly by individuals.
Most specialists are employed by DHBs and salaried for working in a public sector. However, they are also able to work privately in their own clinics or treat patients in private hospitals. Private specialists set their own fees, which vary considerably. Insurance companies have little control over those fees, although insurers will pay only up to a maximum amount, meaning that patients pay any difference.
Public hospitals provide all emergency and intensive care. They receive a budget from their DHBs, based on historic utilisation data, population needs projections and government goals in areas such as elective surgery. The budget includes the costs of salaried health professionals and other staff. Private hospital patients with complications are often admitted to public hospitals, in which case the costs are absorbed by the public sector.
Health legislation and general policy is set by Parliament, the Secretary of State for Health and the Department of Health. The Secretary of State has a legal duty to promote a comprehensive health service that provides care free of charge. Rights for those eligible for National Health Service (NHS) care are summarised in the NHS Constitution. Those rights include access to care without discrimination and within certain time limits for some categories, such as emergency and planned hospital care.
Coverage is universal. All those ‘ordinarily resident’ in England are automatically entitled to NHS care, free at the point of use, as are those with a European Health Insurance Card. For others, such as non-European visitors or undocumented immigrants, only treatment in an emergency department and for certain infectious diseases is free.
In 2014, the UK spent 9.9 percent of GDP on healthcare. The majority of funding for the NHS comes from general taxation, and a smaller proportion from national insurance (a payroll tax). The NHS also receives income from co-payments, people using NHS services as private patients and some other minor sources.
In 2015, an estimated 10.5 percent of the UK population had private voluntary health insurance. Private insurance offers more rapid and convenient access to care, especially for elective hospital procedures, but most policies exclude mental health, maternity services, emergency care and general practice.
Publicly funded health expenditure was accountable for an estimated eight percent of GDP in 2016; by that measure, 69.8 percent of total health spending comes from public sources. The provinces and territories administer their own universal health insurance programs, covering all provincial and territorial residents in accordance with their own residency requirements. Temporary legal visitors, undocumented immigrants, those who stay in Canada beyond the duration of a legal permit and those who enter the country ‘illegally’ are not covered by any federal or provincial program.
There is no cost-sharing for publicly insured physician, diagnostic and hospital services. All prescription drugs provided in hospitals are covered publicly, with outpatient coverage varying by province or territory. Physicians are not allowed to charge patients prices above the negotiated fee schedule. In 2014, out-of-pocket payments represented about 14 percent of total health spending, going mainly toward prescription drugs (21 percent), nonhospital institutions, mainly long-term care homes (22 percent), dental care (16 percent), vision care (nine percent) and over-the-counter medications (10 percent).
The main funding sources are general provincial and territorial spending. The federal government contributes cash funding to the provinces and territories on a per capita basis through the Canada Health Transfer, which totalled an estimated US$28.8 billion in 2016 to 2017, accounting for an estimated 24 percent of total provincial and territorial health expenditures. In general the healthcare providers are paid as per fee for service.
Private health insurance
Private insurance covers services excluded from public reimbursement, such as vision and dental care, prescription drugs, rehabilitation services, home care and private rooms in hospitals. In 2014, approximately 94 percent of premiums for private health plans were paid through employers, unions or other organisations under a group contract or uninsured contract.
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