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through their employer.179 Private insurance

Portugal that the system needs some kind of

reform, weak governments and strong struc-

generally pays for hospital and specialty care

tural interest groups have combined to pre-

but not for primary care physicians. Policies

vent the development of any consensus over

are medically underwritten and have no

the direction reform should take.188 For the

requirement for renewability, meaning insur-

ers can raise premiums or drop customers

moment, Portugal drifts.

with extremely high claims.180

Choice of provider is heavily constrained

Greece

under the NHS. Every citizen must choose a

primary care physician from a list of those

available within a specified geographic area.

Although ostensibly an employer-based sys-

This area is usually based on the person's

tem, the Greek system operates more like a sin-

area of residence but may be based on the

gle-payer system in that it is highly centralized

area of employment. The average general

and regulated. Virtually every aspect of health

practitioner serves as many as 1,500 people,

care financing and provision is strictly con-

though some may have more than 2,000

trolled by the Ministry of Social Health and

Cohesion.189 Some attempts have been made

patients, leading to long waits and difficul-

Despite

ties in getting appointments. People may

to decentralize decisionmaking, with 17 regional

overlapping

change GPs only by applying in writing to

organizations having some responsibility for

the NHS and explaining their reasons.181

implementing policy and managing the deliv-

health plans,

ery of health care, but most power remains

Access to specialists or hospital care, except

the Greek system

with the central government.

in emergencies, requires referral from the

falls short of

Greek employers must enroll their work-

patient's GP. Since this is often difficult to

ers in one of 35 "social insurance funds,"

secure in a timely manner, patients often seek

universal

funded in part through a payroll tax and in

care through hospital emergency rooms. By

coverage.

part through general tax revenues. Unlike

some estimates, at least 25 percent of emer-

Germany, where employers have a choice

gency room patients do not need immediate

treatment.182

among competing sickness funds, Greek

social insurance funds are specific to indus-

Despite guarantees of "universal coverage,"

try sectors. The range of benefits offered by

access to care remains a serious problem.

each fund, the contribution rates, and the

Waiting lists are so long and so prevalent that

types of providers that the insured can access

the European Observatory on Health Systems

are all determined by the Ministry of Social

says that they veer toward "de facto

rationing."183 Currently, more than 150,000

Health and Cohesion.190

Portuguese are on waiting lists for surgery, out

Certain funds known as "noble funds," pri-

of a population of just 10.6 million.184 How-

marily used by government workers, the bank-

ing sector, and public utility workers, offer

ever, that may understate the problem in poor-

more extensive benefits and require smaller

er and rural areas, which have fewer health

resources and less access to care.185 Modern

worker contributions. The powerful unions

representing workers from these sectors have

health technology is far less available than in

consistently blocked attempts to merge these

the United States. The United States has

funds with other social insurance funds or to

almost seven times more MRI units per million

people, and 20 percent more CT scanners.186

allow buy-ins from other industry sectors.191

To avoid waiting lists, Portuguese patients

Social insurance funds reimburse doctors in

frequently pay out of pocket to see physicians

two ways. Some providers are employed directly

in private practice. In some cases, Portuguese

by the funds at fund-operated clinics and are

patients have crossed the border to receive

effectively salaried employees. Others practice

treatment in Spain.187

privately but contract with funds to provide

care. Contract physicians are reimbursed on a

While there appears to be a consensus in

20