# Health Care: US and Canada vs. Europe



## TRG

There is a great deal of debate going on in the United States about reforming our health care system.  Much of the debate centers around whether or not we want the government to be the primary provider of health care.  No one is advocating for a publicly owned health care system, only that the government pay for it, but everyone who is opposed to more government involvement assumes that this will ultimately lead to a complete government take over of the health care system.  I personally do not find this too frightening, but many people are very afraid of having only public health care.  There are numerous anecdotes being circulated about poor health care in European countries.  They typically revolve around long waiting periods or being dictated to by the health care bureaucracy as to what procedures you can have and when you can have them if at all.  There are a couple of facts in all of this that I find intriguing; European countries evidently spend about half as much per person as in the US for health care and life expectancy in Europe is high than in the US so whatever else the European health care system is doing, it's apparently not shortening lives. 

Would anyone with experience with European health care systems care to try to make sense out of all this for me?


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## Frank78

Well, I can only write about the German healthcare system. It is divided into several (half-) state owned insurances and into a private sector. But one cannot choose. If you are employed and earn less than 2500 € a month you have to be insured in one of the state owned insurances. You must pay around 14% of your gross income.
If you are self-employed or earn more than 2500€ then you can go to a private insurance. They have fixed dues (something between 100-300 € depending on the benefits).
So it´s much cheaper if you have the possibility to be insured privatly (especially if you are young). Those insurances don´t have larger bureacracies and don´t need huge representative buildings. 
State-owned and private insurances basically offer the same things and pay for the same treatments, but doctors earn 3 times as much from private patients as from state insured. So those people have an advantage, less time in the sitting room for example, single rooms in hospitals, chief physician treatment.


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## Epilio

In Spain the health care system is, basically, provided by the State. It is public and 'free'. Everybody has the right to receive treatment regardless his earnings. Every taxpayer contributes, obligatorily, to sustain the system; no one can evade it. There is also a private system, but it is more restricted and limited because it has to compete with the public system with great disadvantages (the State has always "taken care of ourselves").

Waiting periods and the bureaucracy of the Administration are matter of concern, at least in Spain, which deteriorate the effectiveness of the whole system. Besides, the financing of the system comes from the taxes paid by the workers and because of the Spanish population pyramid (low birth rate and aging), there are risks of a worsening of the services upon lacking resources to maintain them. Another problem is that people usually does not have the perception of the cost of services and they (we) overuse it.

One advantage of a State-owned health care system is that no one will die because he does not have enough money, or a good insurance, to pay a treatment. As anecdote; in Spain it is known the _health-care tourism_, i.e; people from other countries (UK and USA as far as I know) that come here to get free surgery.


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## kirsitn

In Norway there's a tax funded, public health system for everyone. When you go to a doctor you have to pay a fee, but it's much lower than the actual cost of the appointment (130 NOK versus an actual cost of at least 700 NOK, maybe even 1000 NOK). There's also a limit on how much you have to pay in total during one year if you need to see the doctor on a regular basis. This limit is around 2000 NOK. Treatment at public hospitals is in general free, with the exception of treatment which is not medically required such as sterilization and fertility treatment. Dental care is free for children up to the age of 18.

In the same way as for Spain, you may have to wait a while to get treatment for conditions which are not serious/life threatening, but the system guarantees medical treatment for everyone regardless of socioeconomic status. In larger cities you also have a number of private clinics where you can get treatment for less serious conditions at short notice - provided that you are willing to pay a considerably larger fee (or have a private health insurance in addition to the public system).


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## TRG

Epilio said:


> Besides, the financing of the system comes from the taxes paid by the workers and because of the Spanish population pyramid (low birth rate and aging), there are risks of a worsening of the services upon lacking resources to maintain them. Another problem is that people usually does not have the perception of the cost of services and they (we) overuse it.
> 
> One advantage of a State-owned health care system is that no one will die because he does not have enough money, or a good insurance, to pay a treatment. As anecdote; in Spain it is known the _health-care tourism_, i.e; people from other countries (UK and USA as far as I know) that come here to get free surgery.



In the US we also tend to overuse health care (in my opinion) because the consumer does not pay anything; it is paid either by the employer or the government (for elderly, children, and the poor).  

No one dies here for lack of medical care because hospitals and emergency rooms must treat people regardless of their ability to pay.  This does cause people to not see doctors regularly and only go when their problem becomes severe; for cancers, this can be a fatal mistake.  In effect, people who have insurance are paying for those who do not and get medical care without the ability to pay.  The so called uninsured are a central issue in our health care debate.  It would be better if everyone would participate in some kind of program, even if their ability to pay is limited.  Of course, some of our uninsured are simply people who don't sign up for programs that are available and some of these people are people who are in the country illegally.  It's a very complicated issue.


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## Dmitry_86

TRG said:


> There is a great deal of debate going on in the United States about reforming our health care system. Much of the debate centers around whether or not we want the government to be the primary provider of health care. No one is advocating for a publicly owned health care system, only that the government pay for it, but everyone who is opposed to more government involvement assumes that this will ultimately lead to a complete government take over of the health care system. I personally do not find this too frightening, but many people are very afraid of having only public health care. There are numerous anecdotes being circulated about poor health care in European countries. They typically revolve around long waiting periods or being dictated to by the health care bureaucracy as to what procedures you can have and when you can have them if at all. There are a couple of facts in all of this that I find intriguing; European countries evidently spend about half as much per person as in the US for health care and life expectancy in Europe is high than in the US so whatever else the European health care system is doing, it's apparently not shortening lives.
> 
> Would anyone with experience with European health care systems care to try to make sense out of all this for me?


 
To tell the truth, I really find it amazing to hear such from an Amercan!!! In our heads there is a stereotype that the best treatment (medical) schools are in Germany and the USA. Not only because doctors there are better, more skilled and careful - fortunately, there are talented ones everywhere - but because the USA always has/have the best, the most novel, up-to-date and state-of-the-art equipment and a lot of well-equipped hospitals and clinics. Moreover, we often compare the best medical service with that in the USA adding that all the countries in the world should strive for having the one as is currently there.

We also have mainly state-run polyclinics, clinics and hospitals. There are a lot of problems because of this since the company where we are employed offers insurance but this insurance is very limited and if, for example, a more complex examination is required (which cannot be carried out in a clinic located in the district where one lives because this clinic does not have special equipment needed) there are two possible solutions: to do this for money (in this case you do not have to wait much but it might prove pricey) or make an appointment with a doctor that sees patients in hospital or a bigger medical center. The latter, though, is followed by a very long wait - sometimes  half a year or even longer. As you might guess, this is intolerable because some people cannot wait - they need examining urgently and so they are forced to pay. Hence, insurances are often useless at all. 

The same situation is in stomatology. State-run insurance companies agree to pay actually only for the general examination and for drilling or extracting a tooth. If you need to be given an injection, you have to pay. The same with fillings - there are free ones but they usually fall out in a month or so. If you want it to be long-lasting you again have to pay.

I will stop decribing different branches of medicine in my country now and say a few words about private clinics. Well, there are many of them now, they work effectively and efficiently but again not everyone can afford to go there. Besides, as everywhere, we are lened towards suspecting that doctors in private clinics tend to gain money more than cure a patient. Of course, it does not mean that they do harm purposely, it means that they sometimes tell one to take some medical procedures which are actually not necessary at all.

Now, and it will remain so at least for the next 10-20 years, most of our clinics are state-run. Otherwise, pensioners and the poor would already have vanished for obvious reasons. We want to improve the medical system, to extend the number of services encompassed by state insurancies. The first and most important step to do so - to increase the salary of doctors.

--------------------------------------------------------

Finally, again I want to say that probably the problems in the USA are a bit exaggerated. At least, it seems to me so.


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## Dmitry_86

Frank78 said:


> Well, I can only write about the German healthcare system. It is divided into several (half-) state owned insurances and into a private sector. But one cannot choose. If you are employed and earn less than 2500 € a month you have to be insured in one of the state owned insurances. You must pay around 14% of your gross income.
> If you are self-employed or earn more than 2500€ then you can go to a private insurance. They have fixed dues (something between 100-300 € depending on the benefits).
> So it´s much cheaper if you have the possibility to be insured privatly (especially if you are young). Those insurances don´t have larger bureacracies and don´t need huge representative buildings.
> State-owned and private insurances basically offer the same things and pay for the same treatments, but doctors earn 3 times as much from private patients as from state insured. So those people have an advantage, less time in the sitting room for example, single rooms in hospitals, chief physician treatment.


 
I have friends and colleagues who are now living in Germany and they told me something similar. I do not remember these threshold salaries that distinguish between the types of theatment but I know that Geraman medicine is considered very prestigious in Russia and the entire world. For example, many Russian sportsmen who get injuries are operated on in Germany. Also some politicians prefer Germany when some serious treatment is needed.


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## TRG

Dmitry_86 said:


> Finally, again I want to say that probably the problems in the USA are a bit exaggerated. At least, it seems to me so.



I agree with that.  

Part of the problem is that people, including politicians, see that the growth in cost of medical care is not sustainable.  Such problems tend to be self correcting because we're not going to wind up spending everything on heath care which is what appears to be the case if you draw a straight line projection from our current trends.  We, like Europe, are also suffering from the shifting demographics, especially population aging, so there are fewer young healthy people to pay for the medical care of the aged.  I don't really think anyone really has an answer for this problem except that sooner or later the elderly or going to have to take more responsibility for their own care, when they are able.  However, the politics of this don't work very well.  It's extremely difficult to deny social benefits that have been promised even when the people getting it do not need it.


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## Dmitry_86

TRG said:


> I agree with that.
> 
> Part of the problem is that people, including politicians, see that the growth in cost of medical care is not sustainable. Such problems tend to be self correcting because we're not going to wind up spending everything on heath care which is what appears to be the case if you draw a straight line projection from our current trends. We, like Europe, are also suffering from the shifting demographics, especially population aging, so there are fewer young healthy people to pay for the medical care of the aged. I don't really think anyone really has an answer for this problem except that sooner or later the elderly or going to have to take more responsibility for their own care, when they are able. However, the politics of this don't work very well. It's extremely difficult to deny social benefits that have been promised even when the people getting it do not need it.


 
Well, although the cost might be or seem unsustainable, this cost includes more services in comparison with our insurancies that may cost the same or nearly the same. For example, as far as I am aware, if a person in the USA needs urgent transportation to hospital from a place where there are no hospitals within several kilometres, it is possible to call a helicopter (to be more exact, a helicopter will be called for you) which will tranfer one to the destination place. However in Russia - and our president recently talked about this on the air - this experience does not exist now unless there is some disaster involving many people (a terrorist act, a bomb blast, a flood, etc.). Therefore, since our country is very big and has rather remote places where hospitals are almost unavailable, there might be problems in such situations. 

Besides, some solvent companies offer their employees (their staff) special insurancies that differ from the ordinary ones because they include a wider variety of services. But this practice is not yet common throughout Russia and is come across mainly in big cities (Saint-Petersburg, Moscow) and for those that occupy high positions.


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## TRG

That's a good point.  Some of the reasons for our high cost are things like helicopters.  It is a fine thing to have such services available but at some point we may not be able to afford it all and then difficult choices will have to be made.  Everyone wants the highest quality and highest availability of services; it's just a  question of can you afford it and arriving at an equitable way of paying for it.  Our political system does not seem to be able to deal with such problems.  Right now we are living on borrowed money and eventually those debts will have to be paid.


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## sdgraham

TRG said:


> In the US we also tend to overuse health care (in my opinion) because the consumer does not pay anything; it is paid either by the employer or the government (for elderly, children, and the poor).



The above statement is profoundly inaccurate. 

I am retired, and I hate to admit it, elderly. The government (Medicate) picks up only a portion of the cost of care. Part of the rest is paid for by supplemental insurance paid partially by my former employer and myself. I STILL have to pay something for care although it's nowhere near what it would be if I paid it all myself. 

My wife and I have to pay for dental care in its entirety.

Before retirement and Medicare, my employer paid the major portion of my health insurance, but I still had to pay part of it. I believe that's the normal situation in the U.S.

Part of the high cost is because treatment is not denied those who can pay nothing at all and those of us who can pay, pay dearly.


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## Frank78

The costs for dental and general medical treatment are managable. But what´s the situation in the US if it comes to major operations. You quickly reach a 5 digit number in costs. 
I don´t know if it´s a media myth. In some US films or series it is often mentioned "they can´t afford this or that operation because they don´t have the money".


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## JamesM

Frank78 said:


> The costs for dental and general medical treatment are managable. But what´s the situation in the US if it comes to major operations. You quickly reach a 5 digit number in costs.
> I don´t know if it´s a media myth. In some US films or series it is often mentioned "they can´t afford this or that operation because they don´t have the money".


 
In my experience the person has the operation anyway (if the person has any insurance at all) and then the trouble begins. It often involves bankruptcy and the selling of all assets to reduce the debt. I'm not sure what happens if the person has no insurance at all. I have recently been asked in multiple cases to donate to a fund for one family or another to pay for an operation because it wasn't covered by their insurance.


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## Pedro y La Torre

JamesM said:


> In my experience the person has the operation anyway (if the person has any insurance at all) and then the trouble begins. It often involves bankruptcy and the selling of all assets to reduce the debt. I'm not sure what happens if the person has no insurance at all. I have recently been asked in multiple cases to donate to a fund for one family or another to pay for an operation because it wasn't covered by their insurance.



I think there is something very wrong with a country when this sort of thing is allowed to happen.

In Ireland there is a dual public/private system, the private system is admittedly much better but people would never be left on their own to pay for operations that they cannot afford, such as is (seemingly) the case over there. With all due respect to American sensibilities, what an absolutely horrendous system.

The most ironic thing I have noticed in viewing the debate from afar is the attitude of most GOP-voting Evangelicals who are some of the most fervent oppenents of "socialism" and "socialized medicine". The hypocrisy (and blatant disgregard for the precepts of their own religion) is shocking.

Articles I have recently read on the subject, such as this one, only serve to illustrate the urgent need for reform in such a profoundly unequal and unjust system.


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## TRG

sdgraham said:


> The above statement is profoundly inaccurate.



Ok, it wasn't completely accurate, but it's my opinion.  One of the problems with trying to use market forces in our health care system, which is what we seemingly keep trying to do, is that this economic model doesn't work very well with the way health care is delivered.  Price discrimination is not a critical factor for most consumers (again my opinion) when they seek out medical care so the consumer's behavior doesn't affect pricing the way it does in other parts of the economy.  How many people negotiate with their doctor or hospital over prices.  I don't think very many do, and when their cost is limited to some small deductible they don't have that much incentive.  For this reason I am inclined to feel the "insurance model" does not work very well as a cost efficient way to deliver health care.  However, you must have some kind of risk pooling because people who have a serious problem aren't going to be able to afford to deal with it.  There is not a really good way to have everyone share the cost and at the same time get people to make cost conscience decisions.


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## TRG

Pedro y La Torre said:


> I think there is something very wrong with a country when this sort of thing is allowed to happen.
> 
> In Ireland there is a dual public/private system, the private system is admittedly much better but people would never be left on their own to pay for operations that they cannot afford, such as is (seemingly) the case over there. With all due respect to American sensibilities, what an absolutely horrendous system.
> 
> The most ironic thing I have noticed in viewing the debate from afar is the attitude of most GOP-voting Evangelicals who are some of the most fervent oppenents of "socialism" and "socialized medicine". The hypocrisy (and blatant disgregard for the precepts of their own religion) is shocking.
> 
> Articles I have recently read on the subject, such as this one, only serve to illustrate the urgent need for reform in such a profoundly unequal and unjust system.



We got to where we are over a long period of time.  If we were starting from scratch it might turn out differently.  I think that there was a time when the employer based model worked very well, but I no longer think that is the case.  Of course it still works well if you are one of the people who works for a company that can afford top notch health insurance, but if you're not then it's not so good.  The difficulty is making the transition from where we are to something better.  Everyone agrees that it should be done, but there is little agreement on where to go or how to do it.

I think your view of Christians as hypocrites is a bit harsh.  They are as generous, probably more so, than the average person, but I think they are more inclined to want to deal with social problems through private charities rather than having what are essentially government run charities.  I understand why you might think this way about them; it is a common failing of political liberals in this country to see the Christian right as hypocrites, but I think it's not the case.


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## JamesM

I think there is a key point in what TRG said about an underlying approach to government in the U.S. that is different from the European mindset and it plays a part in this healthcare debate. Generalizations are dangerous, but I think there is a difference in the sense of how closely the government should be a model of the collective priorities of the society. I think there is a large portion of the U.S. population that holds government as an intrusion or imposition on the workings of society and its role therefore should be minimized. For these people the government should only perform those tasks that individuals or smaller groups are unable to do, such as defending the borders of the entire country. This group doesn't see the government doing any job well but there are some jobs only it can do. There are others who think differently and see government more as an instrument to carry out the priorities of the people. This is speaking in ideal terms, of course.

I think the heat that we see in the debates now is a reflection of that fundamental distrust of government that is, in some ways, inherited by Americans from our history. (I've noticed that same heat in some French people's faces when the Catholic church is discussed. It is a visceral mistrust and resentment.) I think this is borne out by the fact that communism, facism (with Obama posters doctored to make him look like Hitler) and Big Brother are some of the scare tactics that are being used by those who oppose these changes to health care here, and to great effect, which is unfortunate and saddening to me personally. The level of hysteria is dismaying and a little frightening. Rational discussion, for the most part, isn't even happening.

I don't think there is a thought on anyone's part that all people should not get adequate health care, but the underlying mindset is that the government is the worst entity to provide such a thing. I don't happen to agree with that point of view but I do recognize it. Personally, I think a healthcare system motivated by profit has proven itself capable of producing far more byzantine bureacracies in order to avoid providing the care they've contracted with you to provide than any government has succeeded in creating.


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## JamesM

> I believe it's a case of we support what suits us and oppose what doesn't.


 
I think that's just basic human nature. 

I think we're drifting from the topic of health care.  I hope I didn't contribute to that.  It would be very easy to get in a discussion of conservatism versus liberalism in the U.S.  I was just trying to say that the health care is so charged here because some people see it as a natural extension of the government's role in their lives while others see it as an area where the government should be involved as little as possible.  Ironically, Medicare/Medicaid/CHIP, our most successful public health care programs, are already a significant portion of our annual Federal budget (20%) and are considered "sacred cows" in Washington.  Anyone proposing cuts to these programs - particularly Medicare - is treading on thin political ice.

Here's an interesting quick overview of our Federal expenditures this year:

http://www.cbpp.org/cms/index.cfm?fa=view&id=1258

What I've always thought was humorous and so typically human is our constant debate over expenditures that, compared to our big expenses,  are drops in the bucket:  welfare (1%), NASA (0.7%), or even the National Endowment for the Arts (0.00004%  !!!).  Somehow I think it's safer to argue about these than the bigger problems and positions on these are safer tokens of our political points of view than tackling the big budget items.


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## TRG

I think one of the fundamental differences in the way Americans view government vs. Europe is that the US is a organization of states which in the past were more autonomous than they are now.  A healthy distrust of central government has a long tradition here.  

What I would like to see, as a way of making some progress, is for one of our smaller states to convert wholesale to public health care.  It could serve as a laboratory for seeing what works and what doesn't and what's the best way to get there.  In fact, there is nothing stopping any state from doing this on their own.  Massachusetts has gone part way in an attempt to see that everyone has some kind of health insurance coverage but it's still a conglomeration of public and private and it evidently is costing much more than was anticipated.  I believe that if people were convinced that the public option would really save money then there would be much less objection to it.


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## JamesM

Not trying to be inflammatory, but the fact that we in the U.S. currently have a system where a person can be basically blackballed from coverage for life once a condition develops should have people up in arms here. It's amazing to me that there isn't more outrage about that aspect of our "system".

For example, if I develop a tumor and I am treated for it under my current employer's current insurance, I can be denied coverage for any further treatment for that condition or_ any related condition (_as determined by the new insurance company) if I leave my employment (voluntarily or involuntarily) and have to change insurance carriers or my employer changes insurance carriers. If I end up being uninsured at any time during that period I may find it almost impossible to get insurance when I am once again working. I suppose we'll have to wait until this affects a large enough portion of our population to demand a change in this setup. It's absurd, in my opinion.

I am self-employed and pay many thousands of dollars a year for "catastrophic-only insurance", meaning that _all_ my health care expenses are uncovered for the first $5000. I switched my family to this because I couldn't afford the premiums under my old plan. 

As much as I'd like to be objective and impartial, I find it astounding that anyone thinks our current system is working well for the average person in our country.


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## TRG

JamesM said:


> As much as I'd like to be objective and impartial, I find it astounding that anyone thinks our current system is working well for the average person in our country.



The people who have good insurance are inclined to think the current system is working well, but that is not the most charitable way to look at things IMO.  I do agree that the issue of pre-existing conditions is one of the most significant flaws in our current system.  A system that allows insurance companies to sift out the high risk people is the exact opposite of the purpose of insurance.  I believe the current reform effort will take care of this problem.  I have little love for insurance companies, but the way things are, they have to compete with other insurance companies on a purely business level.  Insurance companies should only be competing on the basis of being efficient at providing a service, not at being good at avoiding risk and avoiding paying claims which is how they are forced to operate in a strictly market based system.


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## JamesM

> Insurance companies should only be competing on the basis of being efficient at providing a service, not at being good at avoiding risk and avoiding paying claims which is how they are forced to operate in a strictly market based system.


 
I have never heard it put more clearly.


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## Mate

Moderator note: 

A word from the Cultural Discussions Guidelines:



> The purpose of this forum is to help participants and other readers learn about cross-cultural aspects of different countries and groups of people. It is neither a chat board, nor a place to advocate or promote personal viewpoints about _the way things ought to be_; rather, it seeks to help us learn how things are, and how they are changing over time, and not what I think of things and how I would like them to go.


Also, for this discussion to remain open, posts must adhere to the original topic as stated in the thread title and they must respond to this question (post #1): _Would anyone with experience with European health care systems care to try to make sense out of all this for me?         
_

Thank you.


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## Epilio

TRG said:


> No one dies here for lack of medical care because hospitals and emergency rooms must treat people regardless of their ability to pay.  This does cause people to not see doctors regularly and only go when their problem becomes severe; for cancers, this can be a fatal mistake.  In effect, people who have insurance are paying for those who do not and get medical care without the ability to pay.  The so called uninsured are a central issue in our health care debate.  It would be better if everyone would participate in some kind of program, even if their ability to pay is limited.  Of course, some of our uninsured are simply people who don't sign up for programs that are available and some of these people are people who are in the country illegally.  It's a very complicated issue.



Well, in Spain is similar. Everybody has the right to receive treatment, no matter your wage nor even if you're working and paying taxes. So those who are taxpayers pay for those who aren't part of the labor force. It's equitable since those without means have the possibility of be cured 'freely' but it's a little inefficient upon wasting many resources. 

On the other hand, let's suppose that someone has a car accident and has to be taken to the hospital. There it's discovered that he is uninsured, however he has the right to be attended. What are the consequences?, does he have to pay the treatment after recovering?. In Spain he wouldn't have to pay anything at all (at least directly), being unimportant the seriousness of the accident (and the subsequent treatment).


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## TRG

Epilio said:


> On the other hand, let's suppose that someone has a car accident and has to be taken to the hospital. There it's discovered that he is uninsured, however he has the right to be attended. What are the consequences?, does he have to pay the treatment after recovering?. In Spain he wouldn't have to pay anything at all (at least directly), being unimportant the seriousness of the accident (and the subsequent treatment).



People are required to pay their bills, medical or otherwise, to the limit of their financial ability.  Often, people without insurance have little ability to pay so the hospital just has to write it off.  To make up for this, they have to charge their paying customers more.  A person with assets can be forced into bankruptcy to pay medical bills and their assets will be taken as provided by bankruptcy laws.


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## Auryn

The American system sounds remarkably like the pet insurance scheme we have over here: facing massive bills for the tiniest thing if for some reason you aren't insured, and if you _are_ insured having to pay part of each bill yourself on top of monthly premiums, pre-existing conditions being excluded, this, that and the other not being covered or only being covered up to a certain amount, missing a payment meaning the policy is invalidated and so on... it's like reading the insurance policy for my cat! Not exactly the most flattering comparison but there you go.

The weird thing (to me) is that in the US _people_, not animals, are treated this way. It's strange how the concept of universal health care as a basic right is alien to many Americans, whereas the idea of running a (human) health care system as a profit-driven business would never take off in Europe.


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## COF

If all these town-hall protests are typical of middle America, then Americans strike me as quite a selfish people. Middle Class Americans are in a good position now, they are given preferential treatment at hospitals due to their employer paid-for comprehensive health care package and they don't want anyone else having a slice of the cake. 

Contrary to popular believe America has a very strong class system.


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## TRG

I think it is fair to say that, relative to Europe, Americans are disinclined towards the kinds of social cooperation through government entities that exists in Europe.  This is probably more true for the federal government than the state and local governments.  The further away it is, the less people trust it.  For reasons that escape me, we keep trying to do more and more at the federal level instead of at the state level.  It's very difficult to get everyone in a country this large all agreeing to the same thing.  I'm not that familiar with the European central government, but I suspect it has little involvement in the health care systems of individual countries.  Perhaps someone here could enlighten me.


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## TRG

COF said:


> If all these town-hall protests are typical of middle America, then Americans strike me as quite a selfish people. Middle Class Americans are in a good position now, they are given preferential treatment at hospitals due to their employer paid-for comprehensive health care package and they don't want anyone else having a slice of the cake.
> 
> Contrary to popular believe America has a very strong class system.



I don't think it's that they don't want others to have what they have except to the extent that they are going to be asked to pay for it.  There is also the concern that not only will they have to pay for health insurance for others, but that the health insurance they already have will be reduced to pay for it.  Those are not unreasonable concerns.


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## Sepia

Frank78 said:


> The costs for dental and general medical treatment are managable. But what´s the situation in the US if it comes to major operations. You quickly reach a 5 digit number in costs.
> I don´t know if it´s a media myth. In some US films or series it is often mentioned "they can´t afford this or that operation because they don´t have the money".


 

The five-digit numbers are not a media myth. However, as a privately insured patient who pays for the actual treatment in a hospital and not you easily reach five digit numbers as well. For those who are not familiar with the German system: Puplic health insurance pays a fixed daily charge per day and patient. Private insurances pay for the actual service. Even 20 years ago when I was working in travel health insurance services world wide a typical surgery - like a relatively simple leg fracture - would easily reach an amount of around 30.000 DM - today probably some 20-30.000 Euros. But I have definitely also seen six-digits on invoices from US hospitals!

Currently an American friend of mine has the problem that he cannot afford surgery. What he needs is a couple of new hip joints, but he does not have a job with health insurance. He served many years in the Air Force and there is a chance they are going to pay, but it is not sure. 

In Germany or in Scandinavia he would probably have gotten a couple of brand new titanium hip joints long time ago.


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## TRG

Some care needs to be taken when citing cost figures, at least here in the US.  Last year I had abdominal surgery (for prostate removal) which required an overnight stay in the hospital.  The bill which I received from the hospital came to about $25,000.  The amount which was paid against this by my insurance company was about $5000.  The rest of the bill just goes away because the provider and the insurer have an agreed to rate which is well below the list price for the services provided.  This is also true for Medicare (which pays for health care for people 65 and older).  So, if someone here says they had a five or six figure medical bill that may not actually represent what was paid by the insurer, whether it's private insurance or the government.


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## trance0

In Slovenia, most of the Health Care is funded, controled and organised by the state. This brings the good and the bad into the same pot. The good is that every citizen has some type of medical insurance, which usually consists of two parts, obligatory(paid for by the state for every citizen, regardless of their employment and medical history status) which usually covers 90% of all medical costs for treatments, stays in hospitals etc, and optional additional insurance, which costs 21 EUR per month and almost every citizen pays for it from his/her own pocket. This additonal/optional insurance policy then covers all medical costs regardless of the treatment, even the most difficult and expensive operations and treatment for incurable/life threatning diseases like cancer. I think AIDS is always treated, no matter if you have any insurance or not, free of charge for every citizen. The bad part of this system are of course waiting queues for some surgeries and some specialist examinations. Dental care is terrible, mostly private, expensive and although there are public dentists, they usually avoid working through the state insurances and prefer to collect money for their work directly from the patients. This system s*u*c*k*s, and I really mean what I am saying here. One example of how this works in our country is the following. My friend`s sister has a very serious form of epilepsy. She used to have seizures almost on a daily basis, sometimes several times a day and this put her in a life threatning situation. Medication proved inadequate and so the public insurance policy made it possible for her to be operated in a German clinic(because no Slovene hospital does such operations), ie to have a brain surgery performed, which is very rarely carried out(only for the most extreme cases of epilepsy) and costs about 100.000 EUR. The state paid for all the costs, including transportation to Germany and hospitalisation and of course the surgery itself. I doubt something like this would ever happen in USA, but correct me if I am wrong. I believe health is public good and one should not make profit out of it. But that is only my opinion. And Slovene Health Care system has its share of problems, of course, some of them similar to those already mentioned here in this topic.


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## TRG

trance0 said:


> ... I doubt something like this would ever happen in USA, but correct me if I am wrong. I believe health is public good and one should not make profit out of it. But that is only my opinion. And Slovene Health Care system has its share of problems, of course, some of them similar to those already mentioned here in this topic.



Where people have great need a way is almost always found to help people.  I have not heard many anecdotes during the current debate about people like your friend's sister who were not able to get medical help when it was really needed.  If this were common here, the advocates for a public health system would be bring such stories to the public's attention.  I'm not saying it doesn't happen, just that it's not common.  I think what tends to happen is that people who don't have insurance (and many who do) do not see a physician as soon as they should so their problems are not attended to until they become severe.  This causes many people to live with chronic problems (like bad teeth) and lead less productive and satisfying lives than they otherwise would.  

I'm glad you like your health care system and I agree that it is a public good.  I wish more Americans thought of it that way, but by and large that is not our way of thinking and until more people come around to that view it's going to be hard to get much done.


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## sokol

TRG said:


> I personally do not find this too frightening, but many people are very afraid of having only public health care.  There are numerous anecdotes being circulated about poor health care in European countries.  They typically revolve around long waiting periods or being dictated to by the health care bureaucracy as to what procedures you can have and when you can have them if at all.



You might find some interesting points in related discussions (emergency medical service, equality in health systems and some others).
The problem with waiting lists of course is: if you want an *equal *health care system there *have *to be waiting lists else how should everyone be treated equally?
So of course yes, there are waiting lists, and the more equal a health system is the more difficult it is to skip rows. (For that see the "equality" thread. ;-)

Recently an American news channel compared the US health care system with the Austrian one (google for "Österreich US Gesundheitssystem", this will give plenty of hits - and sorry, of course in German only).

Conclusion as reported by Austrian media (I haven't accessed the original news): Austrian health care is "cheaper" and "better" (higher life expectancy) but "not equal" because in Austria you can buy an additional insurance (for that see the thread linked above, "equality in health systems" - here just the short version: everyone in Austria is insured and health care for the most part is nationalised; however those who have this additional insurance may skip rows or get better rooms and so on).

The point however is (not mentioned by that US channel, again according to our news) that in Austria everyone has a right to get treated in hospital without paying for it while in the USA this is not the case.
So from an Austrian point of view I really can't see how the Austrian system should be "less equal" than the US system: no one will have to file for bankruptcy because of medical treatment costs here in Austria,*) and while it is true that those who *can *afford to pay for it *will *get better treatment here the same is true for the USA.

*) Well, more precisely: some guys indeed already have become bankrupt due to medical costs because they chose private patient treatment even though they couldn't afford it - had they chosen to accept treatment on the national health care system they would have paid almost nothing for it. (In Austria you pay a small amount for food if you are treated in hospital, a 3 or 5 euros per day or so, and you pay a percentage of drug costs, again 3-5 euros or so per drug package. Only when it comes to teeth and glasses national health care pays almost nothing, and those treatments - especially teeth - may be quite expensive here.)


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## trance0

There is an ongoing debate in Slovenia about reforming our Health Care system, because it is simply becoming too expensive, however this is a delicate subject and noone knows exactly how to make it better.

As for the dental services, in Slovenia we have public dentists, in fact most dentists have licences that enable them to work as public doctors, however many choose to except money directly from the patients and give them preferencial treatment if they pay, some even collect money from insurance policies and money from the "blue envelopes(=bribes)". However, if you have your personal dentist(they are hard to get, because there is a lack of dentists in Slovenia), ONE WILL GET free service from them for MOST of the dental procedures/treatments. This system of public dental care is however falling apart and has been falling apart since 1991, because of the greediness of many dentists. For example, 11 years ago I needed braces for my teeth and had a choice to either decide and go for a public dental service and wait for this ca. 2 years or pay for it(about 500-1000 EUR) in which case I would get it in one month. I decided to get the free one, but I indeed had to wait almost 2 years. The braces and the service was of the sam quality as it would have been had I decided to pay for it, the procedure was performed by the sam doctor and the regular appointments by the dentist for setting the braces every two weeks were free for the next year and a half. So the public dental system still works to a certain degree, however it has a terminal desease and will die for all practical purposes in quite a short time.

I really prefer the public Health System, but I don`t think Slovenia has the best possible solution. A lot of work will have to be done in order to reform our system, so that everyone will be treated as equal as possible and get the best possible care and treatment without this causing the collapse of the system.


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## TRG

I still think the big difference in the European model vs the US model of health care is cost and no one here has really addressed this.  I ran across this article, which I found particularly interesting.  Unless you are really interested in the US situation, it would probably be boring, but it's the best explanation I've seen so far as to why we spend so much on health care.  To sum up, the answer is simply that we are overconsuming health care and spending money on unnecessary services.  The why is a little complicated, but see for yourself.  In the US, we always want to use "free market economics" to solve every problem and by and large I am in agreement with this, but it reminds me of the aphorism that goes, "If the only tool you have is a hammer, then you tend to see every problem as a nail."  I believe this may be why we are failing at providing health care at a reasonable cost.


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## Sepia

TRG said:


> I still think the big difference in the European model vs the US model of health care is cost and no one here has really addressed this. I ran across this article, which I found particularly interesting. Unless you are really interested in the US situation, it would probably be boring, but it's the best explanation I've seen so far as to why we spend so much on health care. To sum up, the answer is simply that we are overconsuming health care and spending money on unnecessary services. The why is a little complicated, but see for yourself. In the US, we always want to use "free market economics" to solve every problem and by and large I am in agreement with this, but it reminds me of the aphorism that goes, "If the only tool you have is a hammer, then you tend to see every problem as a nail." I believe this may be why we are failing at providing health care at a reasonable cost.


 

It is probably a very popular belief that high costs always mean unnecessary spending - may be true in this case - may also be untrue as long as we don't know the details.

However, the basic difference between Europe - at least in the EU - and the USA is that generally speaking everybody has to contribute to public health insurance in some way or other if the have something to contribute with. In this way it is at least more or less secure there is money to pay for the treatment of people who cannot pay for it themselves. (Bluntly speaking). 

If one has a system, where not everybody can pay for health insurance, and to make up for a government invents sort of "last-straw-insurance" for the poorest of the poorest only two things can happen: Either there is not enough money for these people or the state will often obviously be paying more for the medical treatment of them than they will ever be abele to contribute with, before or after they fall ill. If somebody recognizes these characteristics in their country's healt insurance system they should begin analyzing if the basic principle of insurance has not gone down the drain ...


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## TRG

Sepia said:


> It is probably a very popular belief that high costs always mean unnecessary spending - may be true in this case - may also be untrue as long as we don't know the details.
> 
> However, the basic difference between Europe - at least in the EU - and the USA is that generally speaking everybody has to contribute to public health insurance in some way or other if the have something to contribute with. In this way it is at least more or less secure there is money to pay for the treatment of people who cannot pay for it themselves. (Bluntly speaking).
> 
> If one has a system, where not everybody can pay for health insurance, and to make up for a government invents sort of "last-straw-insurance" for the poorest of the poorest only two things can happen: Either there is not enough money for these people or the state will often obviously be paying more for the medical treatment of them than they will ever be abele to contribute with, before or after they fall ill. If somebody recognizes these characteristics in their country's healt insurance system they should begin analyzing if the basic principle of insurance has not gone down the drain ...



The article I referenced was reasonably thorough in making the case that some parts of the US overspend; it's not just conjecture.

In the US we have public insurance for the elderly which is paid for by payroll taxes so everyone who works pays into it so they will be assured of medical care when they are no longer able to work.  People are generally very happy with this system as far as the health care it delivers and what it costs.  The only problem is that the system is not actuarially sound.  In the not too distant future this system is going to run out of money so there will necessarily have to be huge tax increases or unacceptable cuts in benefits. This is the Medicare system and comprises about one third of all health care dollars spend in the US.

I would agree that we seem to be unable to recognize what it is that isn't working.


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## Forero

Where I live, we are often denied coverage, at the time of need, that we have been paying for for months, years, or decades. I work for state government, and I think some state agency actually decides what is covered, but what they say is covered when we agree to pay the premiums and what is covered after we start to pay them is different. We agree in October to pay premiums over the next calendar year, but changes are made to the lists of discount providers, covered medicines, covered conditions, and covered procedures in the spring and in the fall.

In Europe, are such lists relatively stable? For example, were AIDS patients denied the same percentage of coverage as other patients when it became evident that AIDS was epidemic? Are mental conditions such as PTSD and developmental disabilities such as ADHD excluded from coverage when diagnostic tools improve to diagnose less "clinical" cases?

By the way, can we find out about how long the wait actually is for various treatments? Is it waiting for an appointment, or waiting at the place where the treatment is given?

Do European doctors ever go to the patient rather than always having the patient come and wait in their office?


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## sokol

Forero said:


> We agree in October to pay premiums over the next calendar year, but changes are made to the lists of discount providers, covered medicines, covered conditions, and covered procedures in the spring and in the fall.


I can only speak for Austria.

In Austria there exist lists of treatmens which are provided for by national health care and those that aren't; but each condition which needs to be dealt with from a medical point of view is indeed included - if possibly not the most modern, up-to-date technologies.
So AIDS patients certainly have a right to medical treatment (and will get it for free, minor fees as described above included) but _probably _won't get the newest, best drugs available - however I can only guess here as I'm not very well informed about this topic.
I do know however that the extracorporeal shockwave therapy for kidney stones (= ESWT) only recently was accepted as "preferred treatment" (which means that it is paid) by Austrian health care, and googling showed that this treatment still might not be accepted by German health care (the link I found might be outdated already so I'm not sure*)).
*) Edit: found a link which has a date in it (2008 - see here, in German of course), so this might still be the case for Germany.

I hope this illustrates what I want to say: the best technologies *might *not be available through national health care in some European nations; in this case I think it took more than a decade for Austrian health care to include ESWT.

But as soon as a treatment is accepted it won't be put off the list - not easily anyway. (And in the times before ESWT-acceptance each patient of course had a right to conservative treatment through operation, for free of course.)



Forero said:


> By the way, can we find out about how long the wait actually is for various treatments? Is it waiting for an appointment, or waiting at the place where the treatment is given?


Well that's really difficult to generalise.
I once had to wait 6 weeks for knee surgery but it depends on the hospital and on season (there are more surgeries like that in winter, classical skiing accident), and also wether you're working manually in which case you couldn't work at all even with minor meniscus damage, which will make it easier to get an immediate appointment (as national health care also has to pay for your sick leave, that is if you're waiting 6 weeks at home and can't work then you still get paid by your employer who is refunded those costs - partially only I think - by national health care).

A brother of mine once hadn't to wait at all for the very same kind of surgery - even though he also used an "ordinary" national health care hospital.

So waiting lists very much depend on the treatment, and the urgency as considered by doctors and national health care.

For some cases you may have to wait for an appointment for weeks and months, for others you get immediate treatment (you might have to wait some hours in the waiting room).
However it is true that in Austria those who have an "additional insurance" (as described in that other thread) have shorter waiting list, quite significantly shorter in many cases.

Of course the Austrian health care system is far from being perfect, and it isn't really equal; but what I've described above is about how it works.



Forero said:


> Do European doctors ever go to the patient rather than always having the patient come and wait in their office?


They do go to patients in exceptional cases but usually you have to wait in their office.

Before everyone had a car (that is, in the 70ies) doctors used to visit patients on an almost regular basis, especially in rural regions (where I grew up; I wouldn't know about cities but I guess it must have been different there, with public transport being available): I can remember this vividly from childhood, we only had measles and the doctor came to our house.

Nowadays however doctors only do this if it is really necessary and unavoidable.


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## trance0

According to Slovene AIDS specialists every citizen in Slovenia gets the best available treatment and the newest medication. But with cancer treatment often the biological drugs that have less side effects than classical chemotherapy aren't prescribed. As for waiting lists, the situation is similar to that in
Austria. All in all the quality of health care in Slovenia has droped significantly for most citizens in comparison with the system which had existed in socialism till the end of 80s.


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## Sepia

Forero said:


> Where I live, we are often denied coverage, at the time of need, that we have been paying for for months, years, or decades. I work for state government, and I think some state agency actually decides what is covered, but what they say is covered when we agree to pay the premiums and what is covered after we start to pay them is different. We agree in October to pay premiums over the next calendar year, but changes are made to the lists of discount providers, covered medicines, covered conditions, and covered procedures in the spring and in the fall.
> 
> In Europe, are such lists relatively stable? For example, were AIDS patients denied the same percentage of coverage as other patients when it became evident that AIDS was epidemic? Are mental conditions such as PTSD and developmental disabilities such as ADHD excluded from coverage when diagnostic tools improve to diagnose less "clinical" cases?
> 
> By the way, can we find out about how long the wait actually is for various treatments? Is it waiting for an appointment, or waiting at the place where the treatment is given?
> 
> Do European doctors ever go to the patient rather than always having the patient come and wait in their office?


 
I know of no case in any of the European systems that I had to do with (mainly Scandinavia and Germany) where a patient's treatment was not covered, period! There are certanin types of treatment that are not covered, OK, but treatment not covered at all is, for what I know, unheard of, if the patient is insured.

I know only of cases in Denmark where catastrophically ignorant personel of the public health insurance denied coverage to various EU-citizens living there, but that was an obvious violation of the laws.


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## Ritoha

Hi,
I know it's slightly off track but there are many U.K. citizens who live abroad,under retiring age that are not entitled to treatment as they do not live in the country.They are not entitled to health care in the country they live in unless they pay tax/social security and not entitled to EC.reciprocal health care as they are not in receipt of a pension.In addition any U.K. citizen,in receipt of a state pension who goes abroad (normally for better weather in the winter) for more than 90 days, legally loses the right to U.K. health provision/reciprocal EC healthcare,even if they own a house, pay tax etc; in the U.K. When they return they are ,legally, required to re-register with the system and must wait 6 months.This does not apply to emergency treatment.Estimates vary but the consensus is that at any one time their is between 1- 2 million people not entitled to any form of healthcare.


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## Sepia

Ritoha said:


> Hi,
> I know it's slightly off track but there are many U.K. citizens who live abroad,under retiring age that are not entitled to treatment as they do not live in the country.They are not entitled to health care in the country they live in unless they pay tax/social security and not entitled to EC.reciprocal health care as they are not in receipt of a pension.In addition any U.K. citizen,in receipt of a state pension who goes abroad (normally for better weather in the winter) for more than 90 days, legally loses the right to U.K. health provision/reciprocal EC healthcare,even if they own a house, pay tax etc; in the U.K. When they return they are ,legally, required to re-register with the system and must wait 6 months.This does not apply to emergency treatment.Estimates vary but the consensus is that at any one time their is between 1- 2 million people not entitled to any form of healthcare.


 

Not quite true - or at least not legal: If they are entitled to a pension they have the right to have it paid out also when living permanently in different EU-country. Other EU-states attempted to block that but were taken to court in Luxemburg and lost. 

If the UK is still causing such problems, take them to court.


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## Ritoha

No, i said under retiring age! The U.K. system is residence based,if you live their even if you don't pay tax and national insurance (social security) you are entitled to healthcare.If you don't live their and are UNDER retiring age, therefore not in receipt of a state pension you are not entitled to healthcare, in the U.K., nor in any other EC. country under the reciprocal agreement.


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## Encolpius

There is *only *public health care system in North Korea, Cuba, or other still existing communist countries. Public health care system in former European communist countries (I mean the richer ones) was pretty good.
In all other countries now there is still the private sphere. I could imagine Her Majesty going to the NHS for a check-up. or waiting 2 years for a hip operation. Although all the Czech presidents are treated in public hospitals. But there are no kings or queens here, so no comparision. 
Now the problem is not with the system, none of the systems is good any longer and it is getting worse and worse thanks to politicians, businessman & other factors as well. I personally think it makes no difference what system you will have in the US. 
By the way, Dutch have the best health care system in the world.


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## Lugubert

ritoha said:
			
		

> No, i said under retiring age! The U.K. system is residence based,if you live their even if you don't pay tax and national insurance (social security) you are entitled to healthcare.If you don't live their and are UNDER retiring age, therefore not in receipt of a state pension you are not entitled to healthcare, in the U.K., nor in any other EC. country under the reciprocal agreement.


The way I understand it, if you're an EU citizen and fall ill in another EU country, you're entitled to care like in your country of residence, meaning practically free.


Encolpius said:


> There is *only *public health care system in North Korea, Cuba, or other still existing communist countries. Public health care system in former European communist countries (I mean the richer ones) was pretty good.
> In all other countries now there is still the private sphere. I could imagine Her Majesty going to the NHS for a check-up. or waiting 2 years for a hip operation.


Despite the private sphere alternatives in Sweden, I wouldn't be too surprised if royalty just stuck to our normal paths. They to the job. My neighbour didn't want to wait two months (not years!!) for her hip thing, but just applied for the job in another county. Smooth, quick, affordable.


> By the way, Dutch have the best health care system in the world.


I don't think you can prove that it's better than the French, German, Swedish or Norwegian or any other EU system, but please try. Any way, it's hands down on to the the totally f'ed up US system.


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## Veentea

Would it be appropriate to include Canada in this discussion?  Although it's North American, it's not like U.S. healthcare.  I think Canadian experiences would be pertinent to the discussion as well.


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## Mate

Veentea said:


> Would it be appropriate to include Canada in this discussion?  Although it's North American, it's not like U.S. healthcare.  I think Canadian experiences would be pertinent to the discussion as well.


I see no problem with that. 

Go ahead, I'll take care of the thread title.


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## Veentea

As Americans, now living in Canada, I can say that we are grateful for the medical coverage we receive here.  However, I cannot speak for all of Canada, but where we live in Quebec it is impossible or nearly impossible to get anywhere near the care I got in the U.S.

Here, there are not enough family doctors or pediatricians, so we do not have a primary care physician.  As a result there are no check-ups and the like for myself or my children.  If we need medical attention (major or minor), we have to go to the emergency room.

In the U.S. my family has experienced the gamut from uninsured to wonderfully insured but we've always had a doctor.  There's always been a clinic or something where we could go.  I don't have that luxury here, but still, I am grateful that we do have some healthcare, rather than none.  (However, even in the U.S. we always had some healthcare, even when we had no insurance.

That's just my experience with the two systems in terms of availability of care.


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## Mirlo

Public health in Panama is administered by two separate entities: Ministry of Health (Ministerio de Salud, MINSA) and the Social Security System (Caja de Seguro Social, CSS). The hospitals and primary healthcare centers administered by MINSA receive funding from the General Budget of the Government. Those administered by CSS are funded with the money collected from the workers' wages. 
Medical Students, regardless of studying in a private or public university, all work in public hospitals. 
Most attending physicians (Médicos Funcionarios) who work in the public sector do so in the mornings. In the afternoons, they leave and go to their private clinics. Others are fully dedicated to either public or private practice. 
After medical students graduate, in order to get an unrestricted license to practice, they must pass through a 2 year paid internship in the public sector. These are considered "Médicos Internos". These are the doctors that work the whole day at the hospital and run mostly all the chores assigned by the attendings and residents. 
The good thing about it it's that everyone gets help no matter how much money they got. And the prescriptions are rather inexpensive compare to the United States. I think that we need a little bit of a "health reform" here in the USA.


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## COF

Epilio said:


> One advantage of a State-owned health care system is that no one will die because he does not have enough money, or a good insurance, to pay a treatment. As anecdote; in Spain it is known the _health-care tourism_, i.e; people from other countries (UK and USA as far as I know) that come here to get free surgery.



Err, why would a British person travel to Spain to get free surgery when the UK has the NHS, one of the biggest public health providers in the world?

Actually, a lot of British people who live in Spain travel BACK to the UK to get treatment because the Spanish state system does not fully cover them.


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