Unit 15 · Health Systems Around the World

In 1942, during World War II, a British economist named William Beveridge wrote a report for the government. He named five great problems he wanted Britain to fight after the war. One of them was disease. His report argued that everyone should be able to get medical care, whatever their income.

On 5 July 1948, Britain opened the National Health Service, or NHS. The health minister, Aneurin Bevan, led the work. The NHS is paid for mainly through general taxes. Most hospitals are owned by the public system, and many doctors and nurses are its employees. Care is mostly free at the point of use, which means patients do not pay a bill when they are treated.

Health experts now call this approach the Beveridge model, after the man whose report inspired it. Spain, Norway, New Zealand and several other countries use versions of it. In the United States, the Veterans Health Administration works in a similar way for many veterans: the government owns the hospitals and employs the staff. Supporters value care that does not depend on income. Critics point to waiting lists and tight budgets.

In 1883, Germany’s chancellor Otto von Bismarck signed a law that created health insurance for many factory workers. Workers and employers both paid in. The money went to sickness funds, which paid doctors when members got sick. It was one of the first national health insurance laws in the world.

This approach is now called the Bismarck model. Most people must belong to an insurance fund. Money comes mainly from payroll contributions, a share of each paycheck, split between worker and employer. Hospitals and doctors are often private, but prices and rules are set closely by law. Germany’s sickness funds are nonprofit. Supporters praise the choice of doctors and short waits. Critics point to high payroll costs for workers and employers.

Germany still uses this model, with more than 90 sickness funds today. Japan, France, Switzerland and the Netherlands use versions of it. In Japan, nearly everyone joined public health insurance by 1961. Patients there pay a share of each bill, and the government sets the price of each service across the whole country.

In 1962, the Canadian province of Saskatchewan began paying for doctor visits for all its people. The provincial leader who pushed for the plan, Tommy Douglas, is still admired by many Canadians. Doctors in the province went on strike for about three weeks in protest. The plan survived. By 1972, every province had a similar plan.

Canada’s approach is called national health insurance. The government acts as the one big insurer, a setup often called single-payer. It collects money through taxes and pays the bills. But most doctors are not government workers. They run their own practices and bill the public plan. In Canada, each province runs its own plan under national rules.

Taiwan started its National Health Insurance in 1995. It covers nearly everyone, and each person carries a smart card that holds some health information. Because one payer handles almost all bills, these systems can keep office costs low and bargain hard on prices. Critics point to long waits for some tests and surgeries, which is a common complaint in Canada.

In a small town in a low-income country, a mother brings her feverish child to a clinic. Before the nurse can give medicine, the mother must buy it at the counter. If she cannot pay, she may go home without it. This is the out-of-pocket model: patients pay directly, at the time of care, from their own money.

Many low-income countries cannot yet fund a full national system. In many of them, a large share of health spending comes straight from families. The World Health Organization tracks catastrophic health spending, which means paying so much for care that a family must cut back on food, housing or school.

The WHO and the World Bank estimate that hundreds of millions of people each year face very high health costs, and many are pushed into poverty by them. For this reason, the United Nations set a goal of universal health coverage: everyone able to get the care they need without money trouble. Many countries are working toward it step by step.

In a busy public hospital in Delhi, patients wait in long lines for free care, while a private hospital across town serves those who can pay. India has both. Public clinics and hospitals exist across the country, but many families choose private care and pay a large share of costs themselves.

In 2018, India launched a program called Ayushman Bharat. One part pays for hospital care for poorer families, up to a set yearly amount per family. It is one of the largest government health insurance programs in the world by the number of people it aims to cover. Another part builds health and wellness centers for basic care close to home.

China built basic social health insurance in steps during the 2000s. Today, government reports say more than 95 percent of people are enrolled. Plans differ for city workers and for rural and other residents. Patients still often pay a large share of each bill, so reformers in China keep working to lower those costs.

A new nurse in Chicago signs her hiring papers and picks a health plan. Her employer pays much of the monthly cost, called the premium, and she pays the rest from her paycheck. When she sees a doctor, she may pay a deductible, a set amount each year before the plan pays much.

Job-based insurance grew in the United States during World War II. The government limited how much companies could raise wages. Many employers offered health benefits instead to attract workers. After the war, tax rules made these benefits even more common, because health benefits were not taxed as income.

Today, about half of all Americans get coverage through an employer, according to the U.S. Census Bureau. Supporters say it lets employers compete for workers and gives people choices. Critics say it ties health coverage to a job, so people can lose insurance when they lose work or change jobs.

On 30 July 1965, President Lyndon B. Johnson signed a bill in Independence, Missouri. Former President Harry Truman, who had long pushed for national health insurance, sat beside him. Johnson handed Truman the first Medicare card. The law created two programs that still shape American care.

Medicare is a federal program for people 65 and older, and later also for some younger people with disabilities or kidney failure. It works much like national health insurance for older adults: the government pays private doctors and hospitals. Workers pay into it through a payroll tax during their working years.

Medicaid covers many people with low incomes, including many children, pregnant women, older adults in nursing homes and people with disabilities. It is run jointly: the federal government and each state share the cost, and each state sets many of its own rules. In Illinois, the program is run by the state’s Department of Healthcare and Family Services.

In March 2010, President Barack Obama signed the Patient Protection and Affordable Care Act, often called the ACA. It passed Congress after a long, close debate. Its goal was to cover more of the millions of Americans who had no insurance at that time.

The ACA created marketplaces, websites where people can compare and buy plans, often with government help to pay. It let states expand Medicaid to more adults with low incomes; Illinois did so in 2014, and some states chose not to. It barred insurers from refusing people because of a preexisting condition, an illness a person already has. It also let young adults stay on a parent’s plan until age 26.

The share of Americans without insurance fell after the law took effect. People still disagree about it. Supporters praise the added coverage and protections. Critics point to rising premiums for some buyers and to the role of government. Some Americans want a single-payer plan; others want more private choice. These are open debates.

Economists often compare health systems by health spending as a share of GDP. GDP, or gross domestic product, is the total value of everything a country produces in a year. The share shows how much of a nation’s economy goes to paying for health care.

The Organisation for Economic Co-operation and Development, or OECD, collects these numbers from its member countries. In recent reports, the United States spent about 17 percent of GDP on health. Germany, France, Japan, the UK and Canada each spent roughly 11 to 13 percent. Per person, U.S. spending was more than any other member country.

Why is U.S. care so costly? Researchers point to high prices for drugs, hospital stays and doctors’ services, and to large administrative costs, the money spent on billing and paperwork with many insurers. Some also point to more use of expensive tests. Experts disagree on how much each reason matters and on the best fix.

A man in Toronto may wait months for a knee replacement that is not urgent. A man in Chicago with good insurance might have the same surgery in weeks, while a neighbor with no insurance might put it off. Each case shows a trade-off: gaining one thing often means giving up some of another.

Analysts compare systems on several measures. Coverage is the share of people insured. Wait times show how quickly people get care. Outcomes are the results, such as life expectancy or how many people survive a heart attack. Many wealthy countries cover nearly everyone; the U.S. leaves about 8 percent uninsured. Life expectancy in the U.S. is lower than in most other wealthy countries.

Outcomes depend on more than the health system. Diet, income, safety, smoking and gun injuries all affect how long people live. Supporters of market systems praise choice, new treatments and short waits for specialists. Supporters of public systems praise equal access and lower costs. Thoughtful people weigh these values differently, which is why the debate continues.

In Dr. Kim’s story, the medicine was right, but the plan failed at first. The family’s way of making decisions was not part of the visit. Health workers call the fix culturally responsive care: care that respects a patient’s culture, language and values and adjusts to them.

Culture includes language, religion, food, family roles and ideas about what causes illness. It does not decide what any one person believes. Two people from the same country may think very differently. Good clinicians avoid stereotypes, fixed ideas about a whole group, and instead ask each patient.

Psychiatrist and anthropologist Arthur Kleinman, at Harvard, suggested simple questions to learn a patient’s explanatory model, their own view of the illness. What do you call this problem? What do you think caused it? What do you fear most? What kind of treatment do you hope for? These questions invite the patient to teach the doctor.

In the story, the son translated at first. He loved his father, but he was not trained. He may have left out words, softened bad news, or felt shy about personal questions. A trained medical interpreter knows medical words in both languages and is taught to repeat everything accurately and privately.

In the United States, Title VI of the Civil Rights Act of 1964 bars discrimination based on national origin in programs that receive federal money. Federal agencies have long read this to mean that hospitals and clinics taking Medicare or Medicaid funds must offer language help to people with limited English proficiency. Many hospitals offer interpreters in person, by phone or by video.

Using children as interpreters is discouraged except in emergencies. A child may not know medical terms and should not have to deliver hard news to a parent. A good visit with an interpreter has the doctor speak to the patient, not to the interpreter, in short sentences, with time to ask questions.

Researchers who have recorded doctor visits found that doctors often interrupt patients within the first minute of the visit. When patients are allowed to finish their opening story, most take only a minute or two. What they say often holds the key to the problem.

A saying often credited to the Canadian physician William Osler, who taught around 1900, advises doctors to listen to the patient, because the patient is telling you the diagnosis. Whether or not Osler said it in those words, the idea is widely taught in medical schools today.

One practical tool is teach-back. After explaining a plan, the clinician asks the patient to explain it back in their own words: ’So I know I explained it well, can you tell me how you will take this medicine?’ If something is unclear, the clinician explains again. Teach-back checks the clinician’s teaching, not the patient’s intelligence.

U.S. medical ethics puts strong weight on autonomy, the right of each adult patient to make their own choices. In many families, though, decisions are shared. In many Asian and Latin American families, for example, parents, grown children or elders often take part. A patient may want the family to hear bad news first.

In many Latino families, familismo describes strong loyalty and closeness within the family, including in health choices. In many East Asian families, adult children may be expected to guide care for aging parents. These are patterns, not rules. Each family, and each person, is different.

Clinicians can respect both autonomy and family by asking the patient directly: ’Do you want to hear the results yourself, or would you like me to talk with someone in your family?’ The patient’s own answer then guides the plan. This honors their choice, even when the choice is to share the decision.

In 1997, journalist Anne Fadiman published The Spirit Catches You and You Fall Down. It tells the true story of Lia Lee, a Hmong girl born in 1982 in Merced, California. Her family had come to the U.S. as refugees from Laos. As a baby, Lia began having serious seizures. Her doctors diagnosed epilepsy.

The book’s title comes from a Hmong phrase for Lia’s condition. In the family’s view, the seizures involved her spirit, and they could even be a sign of special spiritual gifts. The doctors prescribed a complex, changing schedule of medicines. Without trained interpreters or shared understanding, the family often gave the medicines differently than prescribed, and both sides grew frustrated.

Fadiman showed that the parents loved Lia deeply and that the doctors worked hard to help her. The problem was not a lack of care but a lack of understanding. The book won the National Book Critics Circle Award and is still read in many medical schools. It helped spread the practice of asking about patients’ beliefs.

In many parts of Africa and Asia, the first person a sick family visits is a traditional healer or herbalist. The World Health Organization notes that for many people, traditional medicine is the most available or trusted care. Ignoring it does not make it go away.

The WHO wrote a Traditional Medicine Strategy for 2014 to 2023. It urged countries to study traditional practices, regulate products and practitioners for safety, and include proven practices in health systems. In 2022, India and the WHO agreed to set up a WHO Global Centre for Traditional Medicine in Jamnagar, India.

Some programs train traditional healers to spot danger signs and send patients to clinics. In several African countries, healers have been trained to refer people for HIV testing. For patients, the key step is simple: tell your doctor, nurse or pharmacist about any herbs, teas or supplements you use, because some can change how medicines work.

From 1932 to 1972, the U.S. Public Health Service ran a study in Macon County, Alabama. It followed about 600 Black men, around 400 of whom had syphilis. The men were not told the truth about their illness. Even after penicillin became the standard cure in the 1940s, they were not offered it.

A news story in 1972 ended the study. In 1997, President Bill Clinton formally apologized on behalf of the nation. The study, often called the Tuskegee syphilis study, led to stronger rules protecting research volunteers, including informed consent: people must be told the truth and agree freely before taking part.

Researchers have found that memory of such harms, along with unfair treatment people meet today, can lower trust in medicine. Trust grows slowly. It grows when clinicians listen, explain honestly, respect a patient’s choices, and when communities see people like themselves working in health care.

Two babies are born on the same day in the same city, a few miles apart. On average, one may live years longer than the other. Researchers have mapped these gaps by neighborhood in Chicago and in many U.S. cities. Such gaps between groups are called health disparities.

Disparities come from many sources. The social determinants of health are the conditions where people are born, live, learn, work and age: income, housing, safe streets, healthy food, schools and access to care. Unequal treatment and lack of insurance add to the gaps.

One well-measured example is maternal death. The CDC’s National Center for Health Statistics reported that in 2021, Black women in the U.S. died from pregnancy-related causes at about 2.6 times the rate of white women. Many of these deaths are judged preventable. Hospitals and states are responding with safety checklists, better follow-up after birth and listening closely when patients report symptoms.

In many countries, community health workers link families and clinics. They are often trusted members of the neighborhood, trained to teach, check blood pressure, help people keep appointments and speak the local language. Studies show they can help people manage conditions like high blood pressure and diabetes.

Researchers have also studied patient-clinician concordance, meaning a patient and clinician share a language, background or experience. Some studies find that shared language improves understanding and satisfaction. The evidence on other kinds of shared background is mixed and still being studied.

Every health worker can build cultural humility. It means staying curious, admitting what you do not know, and learning from each patient for a whole career. It is less about memorizing facts about groups and more about asking good questions, listening, and adjusting care to the person in front of you.