September 14, 2009

Health Care in Other Countries: Japan

New York Times "Prescriptions":

Timothy Stoltzfus Jost is a law professor at Washington and Lee University and frequently writes on comparative health care policy. His work includes an examination of insurance coverage in Switzerland and a comparison of the Swiss and Dutch systems. He spoke to the freelance writer Anne Underwood.


  • Life expectancy: 82 years (USA: 78)
  • Infant mortality: 4 per 1,000 live births (7)
  • Health spending as a percentage of GDP: 11.3 (15)
  • Percentage of health spending that is private: 40 (54)
  • Doctors per 10,000 people: 40 (26)
Source: World Health Organization.

Q. The Swiss health care system relies on public-private approaches that have been recommended as models for the United States. What are the similarities?

A. In 1996, Switzerland instituted an individual mandate by which people are legally required to purchase health insurance in a competitive market. People buy coverage from private insurers, and the government provides subsidies for those who can’t afford coverage. About a third of the population receives subsidies.

Q. Is there an employer mandate, too?

A. No, it’s an individual mandate. Group health insurance does not exist in Switzerland.

Q. That’s a major difference between the Swiss system and most of the proposals in Congress. Are there others?

A. The most important difference is that health insurance in Switzerland is provided by nonprofit insurers — though some are affiliated with for-profit companies that offer supplemental policies along the lines of Medigap in the United States. The basic benefit package is defined by law and is quite generous. Maximum drug prices are regulated.

Q. Do many people buy supplemental insurance?

A. About a third of the population purchases voluntary supplemental insurance that covers things like private hospital rooms and dental benefits.

Q. Do the Swiss have a choice among policies and insurance companies?

A. They do. The policies differ mainly on deductibles. The standard annual deductible is 300 Swiss francs, or about $200 for adults. There is no deductible for children under 18. Individuals can reduce their premiums by electing plans with higher deductibles — up to 2,500 Swiss francs, or about $2,000. Once the deductible has been met, you pay coinsurance of 10 percent of covered expenses, up to a maximum of 700 Swiss francs. For brand-name prescription drugs, you pay 20 percent of the price if there’s a generic equivalent.

There are also some managed care plans, in which about 12 percent of the people are enrolled.

Q. In the United States, it can be quite confusing trying to purchase an insurance policy on your own. How do the Swiss navigate the system? Is there a national insurance exchange like the one that’s being proposed here — a sort of marketplace where it’s easy for people to go and compare policies?

A. There is no insurance exchange, but Internet comparison sites are available and forms are standardized to minimize switching costs. Most people, however, stay with their insurer and seldom switch.

Q. Are the policies expensive?

A. Yes. In 2004, 40 percent of households — or one third of individuals — received subsidies.

Q. Is there a public option in Switzerland?

A. There is no government-run plan to compete with the private nonprofit plans. But health insurance is considered social insurance. It’s not a for-profit enterprise.

Q. Can the Swiss go to any doctor they want?

A. For the most part, although there are some managed care plans with networks. Otherwise, the Swiss have a free choice of physicians and specialists. There is no “gatekeeper” system limiting their access to specialists.

Q. What does the Swiss health system do particularly well?

A. They’ve achieved near universal coverage. But even before the reform, 96 percent of the population was covered. They’re a very risk-averse society. The culture is that you just don’t go uninsured. Now, with reform, they’re close to 99 percent. But the country is still struggling with how to handle individuals who fail to comply with the mandate — mainly the poor and recent immigrants.

Q. How is the quality of care?

A. The quality of care is excellent. Waiting times are not reported to be a serious problem in Switzerland, and most people can get the services they need quite expeditiously. Modern, high-technology services are readily available. Coverage of some new drugs and procedures, however, is reviewed for effectiveness, and some drugs and procedures available in other countries may not be available in Switzerland if they are not considered to be cost-effective.

Q. What is your biggest criticism of the Swiss system?

A. It hasn’t done well at controlling costs. Switzerland is second only to the United States in the percent of GDP spent on health care. It’s also second to the United States in the rate of health care inflation. Probably the most important reason is that Switzerland is a wealthy nation, and wealthy nations spend more on medical care. But a particular problem is that the Swiss use more health care resources than even we do in the United States, with more doctors, hospitalizations and certain high-tech procedures.

Q. So competition among companies doesn’t keep prices down?

A. In theory, insurers compete with each other to bring down prices. In fact, it doesn’t work all that well. There is also enough wiggle room in the system that insurers are able to cherry-pick — to attract enrollees who are good risks and get rid of those at higher risk. As long as insurers have control over the plan design and some control over the premium classifications, they can manipulate the risk pool. For example, if they give good service to the healthy and less adequate service to the less healthy, the less healthy may try to move on to another insurer.

Q. What is the most important lesson Americans should learn from the Swiss system?

A. You can achieve universal coverage through an individual mandate, coupled with subsidies for people who can’t afford health insurance. But it’s not going to get you cost control unless you enact further measures.

By Anne Underwood
September 18, 2009