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Waiting lists

ernment actually pays for a smaller amount

too ill or aged for the procedures to be cost-

of total health care expenditures than the

effective may be denied treatment altogether.

are a major

U.S. government, 24.9 percent versus 44.7

Recently, the British government intro-

problem under

percent.250 (See Figure 3.)

duced some tiny steps toward market-based

the Canadian

reforms. Under the experimental London

The Swiss system is based on the idea of

Patient Choice Project, patients who have been

managed competition, the same concept that

system.

waiting longer than six months for treatment

underlay the 1993 Clinton health care plan and

Mitt Romney's reforms in Massachusetts.251

are offered a choice of up to four alternate

providers. This experiment has been extended

Managed competition leaves the provision of

nationwide for coronary heart patients who

health care and health insurance in private

have been waiting longer than six months.245

hands but creates a highly regulated artificial

marketplace as a framework within which the

Some proposed solutions are far more radi-

health care industry operates.252

cal. David Cameron, leader of the Conservative

Party, has proposed that the NHS be allowed

Swiss law requires all citizens to purchase a

to refuse treatment to individuals who don't

basic package of health insurance, an individual

practice healthy lifestyles, for example, who

mandate. Coverage is close to universal, estimated

at 99.5 percent.253 This level of compliance is due

smoke or are overweight. Then again, he has

also proposed that the government pay for

in part to the Swiss national character and may

gym memberships and subsidize the purchase

not be replicable in the United States where the

of fresh fruit and vegetables.246

record of complying with mandates is much

more mixed (even if such a mandate were desir-

A small but growing private health care sys-

able).254 For example, nearly 100 percent of Swiss

tem has emerged in the UK. About 10 percent

of Britons have private health insurance. Some

drivers comply with their country's mandate for

receive it through their employer, while others

automobile insurance, compared with only 83

percent of U.S. drivers.255

purchase it individually. In general, the insur-

ance replicates care provided through the NHS

The term "basic benefits package" is

and is purchased to gain access to a wider

somewhat misleading since the required ben-

choice of providers or to avoid waiting lists.247

efits are quite extensive, including inpatient

and outpatient care, care for the elderly and

Private health insurance is lightly regulated

the physically and mentally handicapped,

and risk-rating is allowed. The British govern-

long-term nursing home care, diagnostic

ment treats health insurance more or less the

same as other types of insurance.248

tests, prescription drugs, and even comple-

mentary and alternative therapies.256

The British public is well aware of the need

for reform. Nearly two-thirds of Britons (63

Insurance is generally purchased on an indi-

percent) say that the need for reform is

vidual basis. Few employers contribute to the

purchase or provide insurance.257 The policies

"urgent," while another 24 percent believe it is

"desirable." Fully 60 percent of Britons believe

are provided by private insurers. Currently,

that making it easier for patients to spend their

some 93 insurers operate in Switzerland,

own money on health care would improve

although not every insurer operates in every

quality.249 Yet Britons are also extremely proud

canton, or region.258 Originally, insurers were

of their health care system and wary of any

required to be nonprofit entities, but that

reforms that would "Americanize" it.

restriction was eliminated in 2002.

Insurers cannot reject an applicant on the

basis of health status, and all policies are com-

Switzerland

munity rated within a geographic area, mean-

ing that the healthier pay higher premiums to

subsidize the less healthy. One exception to

Of all the countries with universal health

community rating is for nonsmokers, who can

care, Switzerland has one of the most mar-

receive premiums as much as 20 percent lower

ket-oriented systems. Indeed, the Swiss gov-

25