Newer Comparisons

In these books, Professors Rice (UCLA) and Toth (Bologna) offer sophisticated, updated, and manageable contributions to the literature comparing health care arrangements across more than a few of what Harold Wilensky (2002) called “rich democracies.”Although there are some fine comparisons of just a few countries (e.g., Tuohy 1999, 2018), larger comparisons can tell us much more about the range of possibilities and, although often much less appreciated, the relative impossibilities (for example, if none of 10 countries has managed to equalize the supply of doctors in rural and urban areas, maybe that is really hard). Having more cases allows attention to more variables and thus better analysis of both policy and political causes and effects. Yet all but the most motivated readers might be overwhelmed by a very broad set of cases such as in Ellen Immergut and colleagues’ fine 2021 handbook on European health systems, or by the deep exploration of system dynamics in work such as William Glaser's (e.g., 1991) classic studies. Rice's and Toth's books are likely to be widely read by general health policy scholars as well as assigned in classrooms.Each study defines a scope or what is covered (for example, long-term care is excluded from each) and builds typologies of national systems. Rice reports on 10 countries: six of the G7 (Canada, France, Germany, Japan, United Kingdom, United States) plus four others that are mainstays of the comparative literature: Australia, the Netherlands, Sweden, and Switzerland. The first seven are the systems I studied three decades ago (White 1995), and my reasoning was that larger rich democracies were the best comparisons to the United States, except that for many reasons Australia would seem to Americans a better comparison than Italy. Rice's extra countries, as he says, add important variation. Toth analyzes the 27 member countries of the Organization for Economic Cooperation and Development (OECD) for which OECD Health Statistics provides a complete dataset.1These selections require different structures. Rice introduces themes or variables, has individual chapters about each country, and then has four chapters comparing the national cases. Twenty-seven country chapters would not be manageable, so Toth has thematic chapters that use individual countries as leading examples, and he presents tables that show each country's policies or rankings on the issues he highlights. The books also differ in the range of policies they cover. Rice focuses more on insurance and less on how care is organized and delivered than Toth does. His structure will give many readers a clearer sense of how the United States compares to other rich democracies, but it offers a less rich overview of policy and politics across nations. Both authors argue that the traditional distinction between “Beveridge” health service systems (like Sweden and the UK) and “Bismarck” social insurance systems (like France and Germany) is no longer so useful, yet their discussions then resurrect some of that distinction in different terms.Rice (13–14) identifies four types of insurance based on how risk is pooled within a geographic area (see also White 2009): * “Universal coverage systems with a single primary insurer” include the “insurance” systems of Australia and Canada as well as the “service” systems of Sweden and the UK.* “Universal coverage systems with multiple primary insurers but no choice” have multiple insurers within a geographic area, but people are assigned to an insurer according to some demographic trait, mainly occupation. This describes France and Japan, in which neighbors in Paris or Tokyo could have different coverage based on their employment.* “Universal coverage systems with competing primary insurers” allow most people to choose an insurer, as in Germany, the Netherlands, or Switzerland.* “Systems without universal coverage” means the United States, which is unique in many ways, but Rice sees partial coverage as the most fundamental of these.In chapter 2 Rice then defines “key system components,” or variables, that following chapters describe for each of the 10 countries. These include: * Governance, such as the extent to which government agencies or private actors make key decisions or the extent to which central or subnational governments take the lead.* Financing, which includes sources of revenue and the progressivity or regressivity of those sources, and so both horizontal and vertical equity.* Coverage, which he very nicely defines in terms of breadth (across the population), scope (which benefits are covered), and depth (what proportion of the cost for a service is covered, i.e., cost-sharing issues).* The role of voluntary private insurance as a supplement to the primary coverage (so US employer-sponsored coverage does not count).* Choice both of insurer and care provider, which varies mostly in the use of forms of gatekeeping.* Provider payment—of hospitals, of physicians, and for pharmaceuticals. For hospitals he particularly emphasizes the national versions of diagnosis-related groups as well as capital budgeting. For physicians he emphasizes differences among fee-for-service, capitation, and salaried payment, plus any use of “pay for performance.” For pharmaceuticals he emphasizes versions of reference pricing, either “external” (reference to other countries) or “internal” (reference to hopefully similar domestically available drugs).* Policies to assure access and equity, in particular, forms of solidarity. Rice does not discuss undocumented individuals, which makes sense because they are not normally included in national concepts of solidarity.* Expenditure control, which he calls “rationing.” He separates “demand-side rationing” largely through cost-sharing from “supply-side” rationing. In the latter he includes the standard capital limits (e.g., on hospital beds, equipment, and number of physicians trained) as well as limits on what treatments are included (purportedly through scientific evaluation, as by the UK's National Institute for Clinical Excellence, or NICE). He also includes price-setting or budget limits. The distinction here is really between policies that rely on patients choosing to consume less (demand) and other policies.These are all factors that are useful to learn about for any system, although one can question some of the definitions. I do not see how lower prices, for example, need be classified as “rationing.” Rice also emphasizes progressivity far more than seems necessary to me. Proportional finance, in which everyone pays the same share of their income, is extremely redistributive already.His discussions of each country are about 15 pages of text plus source material, except for giving 26 pages to the far more complicated US case. The chapters are solid and useful even for a specialist like myself. My few concerns were matters of judgment (e.g., I think the Dutch had strong cost controls before their reforms, and that the UK's NICE is less important than he says). Along the way Rice makes many neat observations. For example, a key point about Japan's system, with its “bewildering array of thousands of insurers to which people are assigned,” is that because of the standard fee schedule, patients “are worth the same amount to hospitals and doctors, thus helping to ensure that one patient does not receive favorable status over another” regardless of which insurance they have (123). He carefully uses a variety of data—both patient satisfaction surveys and OECD material from medical records—to track waiting times (69–70). And he emphasizes the nearly incomprehensible scope (never mind the complexity) of the US system, which according to WHO in 2017 accounted for 45% of world health care spending (191).Rice's final four chapters focus on comparing the cases, with chapters on “System Characteristics,” “Equity,” Efficiency,” and in conclusion “Some Insights” that should be especially relevant to US readers. The chapters combine analytic text with useful tables. His discussion of issues, such as the extent of primary care versus specialist care (234), comparisons of health outcomes (280–84), or patient self-reports about financial barriers to care (253–55), is careful and sometimes a bit surprising. Although the book's takeaways may be most useful (though least likely to be used) in the United States, there are also some implications for other countries—especially that satisfaction is greatest in the social insurance countries and that dedicated funding streams, which limit competition with other parts of the national budget, are one reason (335, 16–17).Toth's book focuses less on comparing countries in search of policy lessons and more on using comparisons to understand the more general dynamics of health care systems. While Rice's final concern is how insurance differences matter for outcomes, Toth's is: “Why do OECD countries adopt different health care organization models?” (3). “Organization” means interactions “among three categories of actors: users, providers, and insurers,” with insurers defined as “entities that collect financial resources to be allocated for coverage for medical expenses of third parties” (3), thereby including governmental payers. These can be viewed as a triangle, with each actor a vertex and each relationship a side of the triangle.Chapters 1–3 discuss funding health care services. That includes who pays and who benefits how much from the arrangements; the number and legal status of insurers; the methods by which users contribute financially; the extent of freedom of choice for citizens; the relationships between insurers and providers; and the level of state intervention (6). He identifies seven ideal-type financing models, arguing that “all national healthcare systems are hybrid systems” and so a form can exist in a country but be limited to particular service types or populations (38). For example, in the “direct market system” there are no third-party payers, only providers and users, with the state regulating providers in matters such as licensing. This model is dominant nowhere, but common for some services, such as dental care (6–8). Similarly, “targeted” finance involves the state supporting only certain categories of residents. Targeted schemes are much more important in the United States with Medicaid, veterans, and in Toth's judgment Medicare (19–20); however, this model also has some role in many other countries.Toth uses individual countries to illustrate key points about each category and argues that each approach has effects on common challenges, such as how to limit “cream skimming” by insurers or the “moral hazard” of overconsuming care (40–41). He identifies two main “families”—social health insurance (SHI) systems and universalist tax-financed systems—that have some common variations within them. In chapter 3 Toth further discusses how patterns of expenditure are related to financing arrangements, emphasizing that total expenditures are more clearly related to a nation's wealth than to the choice between the two main families.Chapter 4’s discussion of “Healthcare Provision” distinguishes more or less “integrated” and “separated” systems (88). He gives meaning to these sometimes vapid terms first by separating “organizational” integration (“formal contractual agreements that bind healthcare providers together”) from “clinical” integration, or how much “different providers treating the same patient coordinate their efforts” (90). While he emphasizes that he cannot estimate or describe the coordination of patient care, he operationalizes “organizational” integration neatly by identifying five dimensions: * insurers and providers, that is, whether one owns the other;* primary and secondary care, that is, whether provided by the same entities;* gatekeeping, with mandatory gatekeeping being more integrated;* patients’ freedom of choice of providers, with less integration if patients have more choice; and* whether general practitioners are organized in group practices (more integrated) or solo practices.Toth then offers an index that displays the 27 countries on a continuum, from mostly separated on all five dimensions (Austria, Belgium, Czech Republic, Germany, Japan, Republic of Korea) to meaningfully integrated on all five (Finland, Portugal, Spain). The chapter thus provides a neat overview on a topic that is common in health policy reform discourse, although it is important to remember his caveat that what can be said does not tell us much about the common dream of clinical integration.In chapter 5 Toth combines the two dimensions, financing and provision, in a 2-by-4 table. Financing, he reports, has four dominant forms: “universalist,” “social health insurance,” “mandatory residence insurance (MRI)” (Rice's three countries with universal coverage systems and competing insurers), and mixed systems. The more integrated systems are essentially what used to be called Beveridge systems, and all are universalist. The more separated systems include Australia and Canada (universalist), the mandatory-residence insurance countries (Germany mostly, Netherlands, Switzerland), and then the SHI countries that look a lot like an old “Bismarck” list. The mixed systems are Greece, Israel, and the United States.This table (112) has two revealing empty boxes: none of the SHI or MRI finance systems are also “integrated.” Toth also explains variation within the boxes, such as the number of funds in each SHI system or different contribution rules between SHI systems; or whether there are subsidiary SHI schemes in a “universalist” system (such as Portugal). Similarly, integrated universalist systems can differ in important ways, including the extent of gatekeeping, whether general practitioners are employed by the payer, and the degree of centralization. The chapter shows both that the variables he has emphasized are a good basis for classification and that they are only part of the story.In chapter 6, Toth addresses the provider side of the health care system triangle, specifically hospitals, doctors, and nurses. This includes variation in supply (e.g., of hospital beds, doctors, or nurses per capita), trends in supply (generally growing in almost all countries for doctors and nurses, but not for beds), the predominant methods of paying each type of provider in each of the 27 cases, recruitment of physicians and nurses from abroad, the share of physicians who are specialists (with very different results for the United States in Toth's account than in Rice's, because of different data sources), and ratios of physicians to nursing staff (which reflect different divisions of labor).The previous chapters set the stage for chapter 7, which focuses on health care reforms since about 1990, and chapter 8, which offers an overview of health care politics.Toth's reform discussion emphasizes five ideas propagated across national elites. They are increased competition, promoting integration, decentralization, strengthening the rights of patients, and extending insurance coverage by filling remaining gaps in national systems. He highlights both how themes relate to broader policy patterns (e.g., the rise of neoliberalism) and how they normally spread after a “forerunner” (180) reform case. However, he also points out how the themes were pursued differently from different starting points. For example, competition was expanded among providers in national health service systems and among insurers in SHI systems (181). He emphasizes that reforms can also spark counterreforms (as with “decentralization”), and one initiative might respond to perceived ill effects of another, as with integration efforts following competition problems (186–88). He offers a series of good distinctions, such as that decentralization, “the transfer of competences in healthcare organization from a higher to lower level of government,” could be either “deconcentration” (to lower levels within an administrative body) or “devolution” (to different governments with authority over subpopulations).Toth's discussion of politics uses core ideas in the field, such as path dependence and the varying effects of ideas, interests, and institutions. It is a good overview, although I might emphasize some different factors. For example, while he shows that SHI systems were often expanded by “conservative” governments during the 20th century, he does not note that the leading parties were often Catholic, nor that European midcentury conservatism was not antistatist in the ways Americans might expect. In his concluding chapter, Professor Toth then summarizes major points from his analysis in a way that should help remind readers of what they have learned.There are ways in which both books could be better. I wish either provided a better opening discussion of core challenges in health care policy such as risk segmentation, how patients depend on physicians, and the difficulties of managing medical care. Those challenges help explain system failures, the targets of reform, and the churning of reform efforts. As time passes, I think it also is becoming more necessary to discuss managerialism, or efforts to manage, and especially the use of measurement, data, and electronic “health” records in different countries.Nevertheless, each of these books merits a place on the shelf (or in the cloud) of any scholar interested in the big issues of health care finance and organization. Each could also be used in a graduate or undergraduate health policy course. On balance Rice's book might be better for American audiences, and Toth's for other countries—although I suspect Rice could also be used in any of the 10 countries he studies. Rice provides a clearer introduction to the importance of comparing countries, yet Toth's work is richer. I could even imagine using it to introduce students to the range of health policy issues. I would be tempted to use both if I taught a comparative health policy and politics course.

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