Great Ideas from Czechia and Switzerland
Thoughts on Healthcare, Part 1
President-Elect Trump, empowered by Republican majorities in the House, Senate, and Supreme Court, may well make good on his threat to abolish Obamacare and replace it with “concepts of a plan.” We might be tempted to panic about this, but I prefer to treat this moment as an opportunity to consider ideas for improving our healthcare system so that it serves all of us better.
I have lived in Europe for more than a decade and have personal experience with healthcare in two countries, both of which offer models for how we could achieve excellent, affordable, universal healthcare in the US. So here’s the plan for the next three weeks:
Part 1, this week, discusses the systems in Czechia and Switzerland.
Part 2 will argue that rationing is good, actually.
Part 3 will offer ideas to improve our system and will pose some questions for discussion in the comments.
Too often when we argue about healthcare, we fall into binary thinking. Some of us seem to believe that Medicare for All is the only alternative to our flawed system. Insisting on Medicare for All is not helpful: We are unlikely to get single-payer anytime soon, if ever, but we do badly need to reform our healthcare system, which costs us an astonishing nearly $5 trillion per year (17.6 percent of GDP) and which yields a life expectancy, at about 80 for women and 75 for men, that is near the bottom in the developed world (we rank 26th of 35 OECD nations).1 Talk about poor value for money!
Fortunately, there are other ways to achieve universal healthcare than single-payer, and in the rest of this essay I’ll discuss two of them.
Czechia
Healthcare in Czechia is provided through compulsory insurance. Although private insurance does exist, the majority of health insurance—about 77 percent—is public and heavily subsidized to keep it affordable. (Public insurance covers children, pregnant women and new mothers, and seniors, for example.) Whether public or private, insurance in Czechia covers nearly everything—preventive care, specialist care, hospitalization, psychiatric care, medications, etc.2 The exceptions are ambulance services, which are paid to the paramedics in cash (about $250 in my experience), and private hospital rooms.
Czechia spends about 8 percent of its GDP on healthcare, and Czech life expectancy, at about 83 for women and 77 for men, is considerably higher than in the US.
I have ample personal experience with the Czech healthcare system because when our family lived in Prague I had an annus horribilis, during which I was treated for both thyroid cancer and appendicitis (but at least not at the same time!).3 The care I received in the Czech hospitals was superior to what I would have received in the US. After my thyroidectomy, I stayed in the hospital for three additional days to recover and to receive expert wound and follow-up care. (Thyroidectomies are typically outpatient procedures in the US.) For all of this I paid nothing, and the cost to my insurance company was about $3000. (The cost of a thyroidectomy in the US—which, again, doesn’t include a hospital stay—ranges between five and ten times as much.)
Similarly, after my appendectomy,4 my doctor was concerned about my white-blood-cell count, so he admitted me to the hospital for a week so he could put me on IV antibiotics. My experience was not exceptional; adequate hospital stays are the norm in Czechia. For example, women who give birth in Czechia are entitled to five days in the hospital for a vaginal birth and two weeks for a C-section.
Switzerland
You may be surprised to learn that with the exception of diplomats and people on expat contracts, no one in Switzerland receives health insurance through their employer. Instead, everyone living here must purchase insurance from private, nonprofit corporations. Switzerland has no public health insurance, not even for kids or seniors. However, to keep healthcare affordable, government subsidies reimburse people for all costs above 9 percent of their income. Insurance companies are not allowed to refuse any applicant for basic insurance, and they may ask only our age and sex before they quote a rate. The basic insurance covers all medical care, including medications and psychiatric care. If we are unhappy with our insurance, we can change to another company at any time.5
According to a doctor friend who lived in Geneva for several years, Switzerland has an ingenious way of ensuring that insurance companies don’t shirk their duty to their customers:
The company that paid the lowest portion of [the] premiums collected on healthcare claims in the last year must pay double the difference of the average of all other companies. . . . The idea is [that] . . . companies know that it could harm their bottom line if they are too greedy, or at least greedier than their competitors.
Switzerland spends about 12 percent of its GDP on healthcare, and Swiss life expectancy, at about 86 for women and 82 for men, is among the highest in the world.
Thankfully, I don’t have much personal experience with healthcare in Switzerland. But I am happy to report that our family has never had to exert any effort whatsoever on wrangling with our insurance company. We just hand over our insurance card at the doctor’s office, hospital, or pharmacy, and, once we’ve met our deductible of $500 per year, our insurance pays everything, no questions asked. If we want to see a specialist, we call our family doctor, and she sets up the appointment for us. The couple of times we have needed specialists, we got appointments within a week or two. Easy peasy!
Nobody’s Perfect
Joe E. Brown is correct: Nobody—and no healthcare system—is perfect. One problem in Czechia is that doctor salaries are quite low. (In fact several Czech doctors have told me that before Brexit, English-speaking medical professionals from poorer European countries would spend their vacations in the UK working for the NHS to earn extra money.) This situation is partially offset by the free or low-cost training medical professionals receive. At least Czech doctors and nurses don’t have to pay off exorbitant student loans, as they do in the US.
In my experience, the only other disadvantages of the otherwise excellent Czech system are the unattractive facilities and the awful food. The hospitals have no fancy atria, indoor gardens, bubbling fountains, cosy cafés, and grand pianos, as is common in top hospitals in the US. The emphasis is on function rather than aesthetics. As for Czech hospital food, truly it is impossible to overstate how dreadful it is. For example, the day after my thyroidectomy, a nice nurse thought I could use a treat, so she brought me some piškoty, which are Czech cookies that resemble Nilla Wafers, if Nilla Wafers were spherical, dry, and hard enough to crack a tooth.
Because what better food for patients after throat surgery than dry, rock-hard cookies? Anyway, I couldn’t choke down the piškoty, so I laid them on the windowsill for the pigeons. The pigeons refused to eat them.
I hope readers recognize that these minor flaws are actually advantages. The Czechs have quite properly chosen to focus their healthcare expenditures not on fripperies but on patients. Which makes sense: When there’s no profit motive, hospitals don’t have to waste money on five-star elite wings or gourmet food to attract rich customers.
A challenging problem in the Swiss system is the shortage of primary-care doctors. Our family was lucky to get accepted into our doctor’s practice—I have heard of people having to do a lot of research and/or wait months before finding a practice with an opening. Relatedly, if your family doctor is overbooked and can’t see you that day, s/he might send you to the ER even for a minor issue. This happened to me once when I had a rash near my eye; I felt like a total idiot going to the ER for just a rash, but the ER nurses told me it is quite common for people to come to the ER with problems that could have been handled by a family doctor, if only there had been an available appointment.
One other, amusing, disadvantage of the Swiss system: My husband and I are barraged by frequent telephone solicitations from insurance companies that are attempting to get us to switch to them. I suspect the insurance companies are aware that we almost never go to the doctor, and they want more clients like us. Annoying as the calls are, at least they provide me an opportunity to practice my German.
Because the Czech and Swiss systems are both nonprofit, people can be confident that their insurance providers and their doctors are focused on patient health, rather than the health of shareholders’ stock portfolios. The result is high patient trust and excellent, affordable care.
How about you, readers? Which ideas from Czechia and Switzerland do you particularly like? And do you have ideas of your own for improving our healthcare system? Please share your thoughts in the comments!
The Tidbit
It’s time for some fun! Check out this delightful rockabilly cover, by Postmodern Jukebox, of “Stayin’ Alive”:
Some commentators have noted that our low life expectancy is due not just to our healthcare system but also to gun violence, car crashes, drug overdoses, and obesity, all of which are much worse in the US than in other developed countries.
For more information and a history of the Czech healthcare system, see this article.
I’m totally fine now. Thank you so much for asking!
My husband jokes that I am running out of little bits that doctors can cut out of me.
For more information about the Swiss healthcare system, see this article.
Personally, I don't think minimizing hospital stays is necessarily always bad. As anyone who works in healthcare will tell you, the last place you want to linger when you're vulnerable is a hospital — they have all the fanciest (antibiotic-resistent!) infections conveniently on tap. In most cases (though maybe not all), the sooner you're out, the better. They kept my husband hostage for nearly 4 weeks when he had his gallbladder out, and I found it completely terrifying.
So do primary care doctors actually treat patients in Switzerland? That sounds lovely. In Italy your GP is basically just administrative, not to mention impossible to get ahold of, which I find endlessly frustrating and inefficient. I also miss urgent care clinics or really any alternative to the ER. The ERs here are truly dreadful.
Thanks for the interesting review. I'm sure there are countless good suggestions for making U.S. healthcare more affordable and more effective, but currently our political will is to make it as expensive as possible. That seems to be purposefully built into the plan. We can't "demand" afforable healthcare and continue to elect while continuing to elect politicians whose priorities lie elsewhere. But hey, good to know that it's not objectively impossible!