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Some countries,

approach to universal coverage, although the

zens. It collects taxes, administers the supply of

Netherlands has also recently adopted a simi-

health care, and pays providers directly. In

such as France

lar system. The 1993 Clinton health plan, the

effect, this replaces private insurance with a

and Japan,

2006 Massachusetts health care reform, and

single government entity. Typically, the gov-

impose

most of the proposals advocated by the current

ernment establishes a global budget, deciding

Democratic presidential candidates are varia-

how much of the nation's resources should be

significant cost

tions of managed competition.43

allocated to health care, and sets prices or reim-

sharing on

bursement rates for providers. In some cases,

Within these broad categories are signifi-

providers may be salaried government employ-

cant differences. Some countries, such as

consumers in an

ees. In others, they may remain independent

France and Japan, impose significant cost shar-

effort to

and be reimbursed according to the services

ing on consumers in an effort to discourage

discourage

and procedures they provide. In the strictest

overutilization and to control costs. Other

single-payer systems, private insurance and

countries strictly limit the amount that con-

overutilization

other ways to "opt out" of the system are pro-

sumers must pay out of pocket. Some countries

and to control

hibited. This is the type of system advocated by

permit free choice of providers, while others

costs.

Michael Moore, Paul Krugman, Dennis

limit it. In some countries there is widespread

Kucinich, and Physicians for a National Health

purchase of alternative or supplemental private

Program, among others.

insurance, whereas in others, private insurance

is prohibited or used very little. Resource alloca-

Employment-Based Systems

tion and prioritization vary greatly. Japan

Countries with employment-based systems

spends heavily on technology but limits reim-

require that employers provide workers with

bursement for surgery, while France has excep-

health insurance, often through quasi-private

tionally high levels of prescription drug use.

"sickness funds." These insurance funds may

Outcomes also vary significantly. Canada,

operate within or across industry sectors, with

Great Britain, Norway, and Spain all heavily

benefits and premiums set by the government.

ration health care or have long waiting lists for

Often premiums are simply a form of payroll

care, while France and Switzerland have gener-

tax paid directly to the fund. Providers remain

ally avoided waiting lists. At the same time,

independent and reimbursement rates are

France, Italy, and Germany are struggling with

negotiated with the funds, sometimes individ-

rising health care costs and budget strain, com-

ually, sometimes on a national level. Germany

pared with Canada and Great Britain which

has long been the model for an employment-

have done better at containing growth in

based system.

expenditures. And some countries such as

Greece have fallen far short of claims of univer-

Managed Competition

sal coverage.

Managed competition leaves the provision

With all of that in mind, consider the fol-

of health care in private hands but within an

lowing prominent national health care systems.

artificial marketplace run under strict govern-

ment control and regulation.42 In most cases,

France

the government mandates that individuals

purchase insurance, though this is often paired

with a requirement for employers to provide

Some of the most thoughtful proponents

insurance to their workers. Individuals have a

of national health care look to France as a

choice of insurers within the regulated market-

model of how such a program could work.

place and a choice of providers. Although the

Jonathan Cohn of the New Republic has written

government sets a standard benefits package,

that "the best showcase for what universal

health care can achieve may be France."44 Ezra

insurers may compete on price, cost sharing,

and additional benefits. Switzerland is the

Klein of the American Prospect calls France "the

closest thing to a model structure out there."45

clearest example of a managed-competition

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