WORLDVIEW: Found in Translation: Examples from Dutch and German Health Reform

Paul Testa — Mon, 14 Apr 2008 21:48:00 -0400

We've always enjoyed looking at European models, and would highly recommend checking out the Alliance for Health Reform's recent briefing on approaches to health reform in Germany and the Netherlands, (a webcast of which is available here). These European States are particularly relevant to the U.S. because they are examples of reform that achieved comprehensive coverage within a private market framework.

The briefing's panel of international and domestic experts offered a sort of Fodor's guide to the health care systems of Germany and the Netherlands with a Berlitz translation of the most meaningful implications for health reform in the U.S. (with background materials available here.)

Our take-home conclusions from Friday's trip to the Continent:

Avoiding apples to oranges: When done right, international comparisons are useful for gauging a country's relative performance. The Commonwealth Fund's Robin Osborn did a particularly good job parsing out the most relevant comparisons, such as the fact that, per capita, the U.S. spends twice the OECD average on healthcare, and while the U.S. publicly finances a comparable level of health care, it finishes last on a list of 19 industrialized countries in terms of mortalities amenable to health care (deaths that could have been prevented with access to the right health care).
Models not roadmaps: When drawing lessons for reform, all the panelists subscribed to what we like to call the "lederhosen" rule: what works in one country isn't necessarily right for another. As Wharton's Patricia Danzon noted, the collective bargaining in Germany between insurers and providers might not work in the U.S., but as Osborn noted, a stronger primary care system would do a lot to help control costs and improve care in our nation.
Government has a role to play: Both Reinhard Busse, Berlin University of Technology and Wynand P.M.M. van de Ven, Erasmus University Rotterdam, were clear that governments play a crucial role in making markets work. As van de Ven said: "You need a visible hand to let the invisible hand work well." Both Germany and the Netherlands require all citizens to purchase health insurance regulated, but not run, by the government. Regulations providing for open enrollment, community rating, and risk equalization help ensure insurance is both available and affordable.
Pay for quality and value, not marketing and underwriting: Both Germany and the Netherlands have used "risk equalization funds" among payers to remove the incentives for risk selection and create an environment where insurers compete on providing value for the benefits offered. This has created rationales to invest in technologies like electronic medical records (used by 98 percent of primary care doctors in the Netherlands) and indicators of performance and comparitive effectiveness.

Nuances are inevitably lost in translation when comparing health care across nations, but some truths remain universal: primary care and medical homes can help improve the quality and control the costs of our fragmented system; the government has a role to play as a steward of our resources; and insurance market reforms could reward insurers who deliver high-value efficient care. After all, whether you're speaking German, Dutch or English, sustainable health reform sounds good in every language.

COVERAGE: Myths About an Individual Mandate: Enforcement

Paul Testa — Wed, 19 Mar 2008 15:18:00 -0400

Myth: An individual mandate is not enforceable.

Fact: Switzerland and the Netherlands have successfully enforced an individual mandate to purchase health insurance. Similarly, some American states have achieved close to 100 percent compliance with a mandate to purchase car insurance.

Enforcing a requirement to purchase health insurance will likely a take series of integrated approaches. Some possible models include:

Electronic Information Sharing: In 2001, Georgia implemented its Electronic Insurance Compliance System for car insurance. In less than two years, Georgia cut its uninsured motorist rate from 20 percent to two percent. For health, electronic information sharing could increase compliance while helping identify and enroll individuals who are eligible for public plans and subsidies.
Proof of Insurance on Tax Returns: While not all low-income individuals file tax returns, the American tax system could be used to identify those people in mid- to high-income brackets who are still not insured.
Auto-enrollment/Insurance checks at point of service: Auto-enrollment into the lowest cost plan available (public or private) provides a way of changing the default status of Americans from unisured to insured. The New America Foundation has outlined how such a program might work to ensure coverage and payment without interfering with care.

Check back tomorrow when we'll examine common myths about mandates and covering all Americans. For more in depth discussion, read New America's recent issue brief.