How to fix health care in the United States has been a political focus of 2017.

With Republicans in Congress pushing to repeal President Barack Obama's Affordable Care Act and Democrats advocating to strengthen the legislation or move toward a single-payer system one thing is clear: Change is likely coming to health care in the U.S.

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So what can the U.S. learn from other nations about health care?

Health spending is one area where other countries show better results. The United States spent 18 percent of its GDP on health care in 2016, according to the Center for Medicare and Medicaid Services, far more than any other nation. Expenditures per capita from health care were about $9,364, and all told $3.3 trillion was spent on health care in the U.S. last year. Despite this high rate of spending, about 11 percent of Americans lack health insurance entirely, and outcomes for most conditions are similar to other developed countries.

Chih Ming Tan, an applied economics professor at UND, said the U.S. share of GDP for health spending is noticeably higher than for other nations, and that the trend is only growing.

"What's clear that if we don't get this trend down, it's going to be a long-term threat to our economy," Tan said. "We're going to spend more and more of our GDP on health care, and less on everything else."

A high price

Cost control policies vary widely among health care systems, Tan said. In the United States, costs are controlled from the demand side with copayments and deductibles intended to decrease costs and discourage use.

Americans go to the doctor far less than people in universal systems, according to a Commonwealth Fund study of the 13 wealthiest nations' health care systems. Americans average four doctor visits per year. Canadians average 7.7 physician visits a year. Japanese citizens average nearly 13.

In countries like Canada and Germany, costs are controlled on the supply side. The countries tell doctors what they'll pay for an operation or give providers a fixed amount to provide care.

"The evidence seems to be that demand side cost controls are not as effective as supply side," Tan said.

Most health care costs in U.S. are higher than other nations. For example, in 2015 bypass surgery cost $28,888 in Australia, $14,579 in Spain, $34,224 in Switzerland and an average of $78,318 in the U.S., according to the International Federation of Health Plans comparative price report. A knee replacement in the U.S. averaged $28,184, compared with $6,687 in Spain, $15, 941 in Australia and $18,451 in the U.K.

"In countries like the United States, where we pay a lot more for drugs, for instance, and a lot more for medical technologies and procedures, what we are doing is effectively subsidizing the rest of the world," Tan said.

Poor people have greater medical needs and are less healthy in America, Tan said, and they have the least access to medical conditions.

"It's the poor people who are not doing so well, and the spread is so big in this country."

Tan's native Singapore has a health care system that creates a mandatory health savings account for every citizen. People put in 6 to 9 percent of their income into the saving account, based on their age and income level. There are safety net programs for people with catastrophic conditions, the elderly, disabled and poor to guarantee a base level of universal coverage. Singapore only spends about 4 percent of its GDP on health care, one of the lowest rates in the world.

While the model effectively brings down costs, Tan said it's unclear if such a model could work in larger countries with more complicated health care systems.

Looking north

An emerging proposal to change U.S. health care is to expand Medicare, the social insurance for Americans 65 and over, to all people and implement a single-payer universal health insurance program. Sen. Bernie Sanders ( I-Vt.) introduced a Medicare For All Act in September with 16 co-sponsors in the Senate and 120 for a similar measure in the House of Representatives, the most ever to support single-payer health care in the U.S.

The bill would create a system similar to the one used just 75 miles north of Grand Forks, in Canada.

Tracy Johnson, director of Health Systems Analysis and Emerging Issues at the Canadian Institute for Health Information, said Canadians mostly enjoy their health care system.

"When we look at the general population survey, Canadians overall are fairly happy with their health care providers and the quality of care, generally when they get in to see their provider," Johnson said.

The Canadian Health Act mandates strong federal standards to cover physician services, hospital care and diagnostic care that is universally and equitably accessible. Each province administers its own system within federal standards. Care is free at point-of-service, with physicians and hospitals billing one insurer-the government.

Canadians pay much less per capita and a lower proportion of GDP, about 11 percent, than Americans, while covering all residents with similar health outcomes to the U.S.

Johnson said Canadians have fewer administration costs, as health care providers only bill one insurer, which also makes it easier for physicians to collect fees for service.

About 70 percent of Canada's health care costs are paid for publicly, compared with about 35 percent of U.S. health care costs which are publicly covered via Medicare, Medicaid and the Veterans Administration.

The biggest challenges facing Canadian health care are prescription drug costs, and decreasing wait times to see specialist physicians, Johnson said.

Prescription drugs administered in the hospital are fully covered, but many Canadians have co-payments for prescription drugs, as Americans do. However many provinces have programs to cover the co-payments for seniors or those below the poverty line and programs to help pay for cancer drugs. Canadians pay relatively high prices for prescription drugs, but less than the U.S.

Canadian employers often offer insurance policies for dental care and prescription drugs, Johnson said.

"What we do not have a handle on across the country is waits to see specialist care," she said.

The 2016 Commonwealth Fund International Health Policy Survey found 56 percent of Canadians wait longer than four weeks to see a specialist, compared with the international average of 36 percent. About 27 percent of Americans wait four weeks or longer to see a specialist, according to the survey.

Johnson said Canada is expanding its electronic records system, which could trim time providers spend finding the next available specialist for patients.

She believes wait times are something to balance with receiving quality, affordable care.

"What is more inconvenient?" Johnson said. "To wait a little longer for the MRI and know you're going to get it. Or to wait for your doc or to be told you can't have a test, that your doc can't get it for you because you can't get it funded."