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While the Grand Old Party kicks the can down the road—and seemingly ever farther from the then President-elect’s promise of “insurance for everybody“—amid turmoil about how much health care to strip from relatively many Americans to pay for a tax break for relatively few Americans, I figured there would be no better way to honor the 4th of July than to celebrate the freedom of living in a country where no political party opposes the goal of universal health care.

That probably sounds obnoxious on this tender occasion, but I’m actually not trying to gloat. Instead, I offer the following in the spirit of expanding horizons and to provide food for thought for what I hope will be a continuing and constructive debate about health care reform in the United States. I should also note that my experience hardly makes me a policy expert, and I don’t have the foggiest idea about what would and wouldn’t work given the lay of the land in the US. That will be for you to decide!

Introduction

First things first. I live in Austria, a country about the same size as South Carolina with a fairly homogeneous population the size of Virginia’s. Health care is integrated into the overall social security system which is based on the “solidarity principle.” This basically means that all who can contribute must contribute and that all who have needs will receive the best care available regardless of their individual risk.

In practice this means that everyone with income of at least EUR 425.70 per month (capped at EUR 4980 per month) pays a fixed percentage in social security contributions. These percentages vary somewhat depending on whether one is self-employed and what kind of work one does if one is employed. For most employees, the total social security contribution amounts to 37.75% of gross wages, split between the employer (20.63%) and the employee (17.12%). Of that, 7.64% (split almost evenly between employers and employees) is health insurance. The self-employed pay 27.68% of their revenue with 7.65% earmarked as health insurance.

This Pflichtversicherung or statutory insurance is mandatory—one is not able to choose whether to pay it. If you are an employee, your social security contributions are automatically withheld. If you are self-employed, well, I would rather have the IRS come knocking on my door than the statutory health insurance fund—just like the Royal Canadian Mounted Police, they always get their man, and the 9.3% fine makes the ACA’s 2.5% tax look like chump change.

So for people who hate mandates, well, you’re not going to find a free lunch here. Then again, a mandate of some kind is the key to providing comprehensive health care to all (well, not quite, but close; more on that later) at a reasonable price, whether in Austria, the United States or elsewhere—the able-bodied must contribute if the system has any hopes of being sustainable. Nevertheless, there is a world of difference between the philosophical underpinnings of the Austrian mandate and anything the US has come up with so far, including the ACA, that I believe helps the medicine go down.

Let’s compare and contrast (based on the information here). On the left we have the mandatory insurance required by the solidarity principle; I’ll call it the solidarity mandate. On the right we have an ACA-style mandate designed to discourage healthy individuals from underinsuring themselves. I’ll call it the individual mandate.

Solidarity Mandate Individual Mandate Legally defined benefits apply to everyone; coverage is immediate with no exclusions. Individuals must find their own insurance policy and coverage is often subject to waiting periods or exclusions. No risk assessment! Everyone who is covered is entitled to the same benefits regardless of age, sex and pre-existing conditions. Risk assessment! Coverage can be limited or denied for risks relating age, sex and pre-existing conditions. Coverage with no additional premiums for close relatives (e.g., spouse, children, step-children, grandchildren, foster children) Premiums for each insured person Contributions are a fixed percentage of income and do not fluctuate according to risk; no coverage limits. Premiums and coverage are a function of individual risk and benefits may be capped. Straightforward coverage: all benefits are included in one transparent deduction. Varying premiums, co-pays, benefits, etc. Care is an enforceable right. Care depends on the terms of the contract. Not for profit For profit Relatively efficient

(2.5% administrative costs) Relatively inefficient

(8% administrative costs)

I’m open to the possibility that I’ve missed advantages of ACA-style mandates; if so, make the case in the comments below! I’d be grumpy too if I lost a plan that had worked pretty well and had to buy crummy and expensive insurance in its stead. But I actually feel pretty good about contributing to the Austrian system, though of course it too is not without its shortcomings (more on that below). But first a few more background details that strike me as relevant.

The solidarity principle applies across the board, which means that medical school is, get this, free (assuming you are a citizen and you complete your studies within the minimum time required plus a grace period of two semesters)! If you choose to take your time, you contribute EUR 363.36 per semester to the cost of your education. Since foreign students are not expected to stick around as tax payers after they complete their education they pay more: EUR 726.72 per semester. Doctors here might complain about not being reimbursed enough for their services, but being able to graduate from medical school without six or seven figures of debt put them ahead of the game at least initially in comparison to their American peers.

Also, it’s worth noting that Austria doesn’t have a single payer to manage all of the statutory insurance contributions. Instead there are:

nine regional entities for each of the nine provinces

six entities that are associated with formerly public companies (historical relics, for the most part)

one social security institution for the self-employed

one social security institution for farmers

one social security institution for civil servants

Total: 18

You have no choice about which entity covers you—it depends on either your profession or your residence with your profession getting first dibs. It is unlikely that this is the most efficient way to run things, but administrative costs are still quite low (see table above), and the lack of choice can be chafing (see shortcomings below).

Then of course there is a private insurance market. Because by law the same level of coverage ought to be provided to all, private insurance marketed to those who are already covered by statutory insurance usually promises a more pleasant stay or coverage for recreational accidents. For example, someone with private insurance might get a hospital room to themselves rather than having to share one with other patients. And since according to a strict interpretation of the law only accidents that happen at or on the way to or from work are covered by statutory insurance, you might get private insurance if you are a weekend warrior type and want to rest assured that a helicopter will come pick you up off the mountain if you get in over your head. Private insurance is also available to those who are either not eligible for statutory insurance, such as tourists and illegal aliens, or who may opt out, such as diplomats. Thanks to everyone else keeping costs down, however, even the privately insured (and uninsured) enjoy relatively low premiums and out of pocket costs. So if you like the freedom of American-style care but don’t like the prices, come freeride over here.

Access to the system is simple and the administrative burden for the individual is light. Upon being registered by your employer or signing up with the entity for the self-employed, you receive an insurance card that is scanned at each visit to the doctor. That’s pretty much all the paperwork you have to worry about. There’s no payment at the point of service and having to field bills or file a claim is a rare occurrence. Prescriptions cost the patient an extra EUR 5.85 each, though this is capped and under certain circumstances waived.

You are free to choose your own doctors, though there is a gate-keeping system in place. Except in emergencies, visits to the doctor always begin with a visit to a general practitioner; this doctor can be changed under normal circumstances only one a quarter. The GP either takes care of you right then and there or refers you to a specialist of your choosing, though the GP may make a recommendation. If the specialist can’t help, you may be referred to another specialist or regional clinic. Some health insurance funds also have in-house health centers with various specialists under one roof to keep costs down and increase patient convenience. Public and private hospitals, rehab and geriatric centers, universities, etc. also play various roles in the national health care system.

You can wait to go to the doctor when you feel sick and/or you can take advantage of an annual physical to identify problems before they become acute. Women are covered when pregnant and usually spend four (!) days in the hospital after giving birth.

My Experience

So what does all this look like for a regular schmo? Since my wife and I are both employed our child is covered by us both. So my wife can take her to the doctor on her insurance and I can pick up the prescription on mine. Or vice versa. If my wife were to lose her job, she would be seamlessly covered by my insurance by virtue of being related to me (see the table above). Once the relevant authorities are informed about marriages and children, all switching back and forth is automatic. It is truly an administrative marvel.

A couple of anecdotes. A few years ago I injured my knee slipping down some icy stairs while running in the wintertime. As I mentioned above, sports-related and other recreational accidents are not covered, only workplace accidents are, but in practice the distinction is a difficult one to make. So I hobbled in to the GP and he figured nothing major was wrong, I should just give up dreams of becoming a professional soccer player, take it easy and not worry about it. But my knee still didn’t feel quite right so after a few weeks I went back and asked if it was possible to actually, you know, look inside my knee. Well, sure, I could have an MRI but I would need to get a second opinion from the regional entity itself (gatekeepers not only keep hypochondriacs at bay but also doctors with fast and loose prescription pads). So I went down to the neighborhood branch of the regional entity, took a number and waited 20 minutes or so. A doctor took a look at the prescription and asked if I’d hurt myself. Indeed, I replied. Ok. You’re approved. It took all of 1 minute. Then I went to the closest lab that offered such services, made an appointment and a few days later had a picture of my knee, which I took to a specialist who commenced treatment. At the end of the year I received a statement of the services I’d consumed during the reporting period. Total cost to the regional insurance entity for the MRI: $250. I paid nothing beyond the usual contribution deducted from my wages.

On another occasion, our daughter became ill on Christmas Day. We were visiting relatives in the countryside far from our home and regular pediatrician. Most doctors are not in the office on holidays, of course, but there is a rotating roster of doctors who are on duty during holidays, weekends and at night. We drove 20 miles or so to see the one on duty who prescribed medication and, if things didn’t get better, an ambulance ride to the nearest hospital. Our daughter’s condition worsened through day and evening and so around 10 pm we called a nationwide hotline for medical advice, they advised a hospital visit and shortly thereafter an ambulance arrived and took the three of us to the nearest hospital (50 miles away). Upon arriving we were seen within fifteen minutes or so, prescribed a different medication and sent on our way again. The next day our daughter’s condition didn’t improve, so we went to a different doctor on duty that day (still on a holiday schedule) and received a third medication that finally helped. Later we received a statement for what that adventure cost the insurer(s). I don’t remember all the details, but I do recall that the 50 mile ambulance ride cost about $50, though it was driven by Red Cross volunteers, which no doubt helped keep costs down. The miraculous thing about all this is that even during a major holiday far from home, medical care remains just as available and free of charge at the point of service as it is at home and with no additional administrative overhead for the patient—we simply show our insurance cards and the wheels of health care are set into motion.

Shortcomings

Despite the objective of universal coverage and provisions for students, the unemployed, retirees, the poverty-stricken and refugees, there are gaps: those who are in the country illegally or who are employed under the table are simply not eligible, for example. Then there are people in transition like those who have graduated but haven’t found their first job yet or the recently divorced who were covered by virtue of their spouses but aren’t yet employed themselves or receiving other means of support. Then there are those who refrain from availing themselves of services provided to the poorest out of shame or on principle. The total number of uninsured that I’ve seen bandied about over the years is 100,000.

The public insurance entities have a fixed number of slots for their networks and doctors compete for a contract (or not; they are free to open a private practice or throw it all to the wind and play guitar in a cruise ship cover band, just like any other private citizen). While a contract will guarantee a steady stream of patients, the rate at which they are reimbursed varies from one public insurance entity to another and can be quite low.

This means that not every doctor can or will accept statutory insurance, and it can change from one quarter to the next, which can be disruptive when a doctor you’d been seeing for years will only continue to see you as a “private,” i.e. cash-only, patient. For example, my wife’s dermatologist will accept her statutory insurance but not mine. If I want to see her, I have to pay out of pocket, though I can submit the bill for reimbursement. My regional carrier reimburses up to 80% of its own reimbursement index, which last time amounted to about $18 of a $100 bill. At those kind of rates, volume becomes an important consideration for doctors who see regionally-insured patients, which can mean long waits and brief consultations, e.g., you might wait an hour and then be hustled out the door after five minutes with the doctor.

Another issue, though not unique to socialized medicine, of course, is the availability of resources. Doctors and hospitals cluster in more densely populated areas, potentially underserving rural areas. At the same time, there might a shortage of resources in urban areas too. An acquaintance, for example, who was diagnosed with cancer, was given a waiting time of six months for the imaging tests she needed for treatment in the Vienna area. However, in another province where she had family, a hospital was able to do the scans right away and another hospital in yet another province, where she also had family, was able to perform surgery in a timely manner and conduct follow up treatment. Both of these hospitals were in relatively low populated areas, and although far away from home, my acquaintance’s family support network made travelling an option for her.

Part of the reason for this state of affairs is that hospitals are built and maintained by the provinces, so you have nine different visions and policies for certain types of infrastructure. Vienna, for example, boasts one of Europe’s largest hospitals with 114,000 inpatients and 551,000 outpatients in 2016. All kinds of good things happen there, but it can be quite the circus at times and patients have to be, well, patient. Meanwhile, another province might have a prestige project in the middle of relatively nowhere with much lower occupancy rates.

A related issue is the use of general practitioners as the front line of medical care. Most such practices are equipped with a reception area and an examination room with little more than a bed, stethoscope and flashlight. Anything more involved than opening up and saying “Ahhh!” almost always means having to traipse to multiple locations through the city for blood tests, imaging, etc. as there are very few group practices, and supposedly the hospitals are for emergencies and those with a referral from a specialist. It’s obviously extremely inefficient for each general practitioner to have all this stuff on hand, but at times the time and effort to make the various trips while sick or injured seem absurd.

For example, there was the time some budding kickboxer took offense at the speed at which I had crossed the street (he was waiting impatiently in his car) and kicked me three times so hard that the next day I had a bruise the size of a football on my thigh and my leg hurt so bad I thought it might be broken. So I went to the nearest GP—across the street, fortunately—to ask if I should be hobbling around on this damaged limb. She looked at me like I was crazy and said “How am I supposed to know? You need an x-ray!” Yeah, well, the point was I didn’t know if I should be walking on it, and now I need to walk on it some more (no crutches—those are somewhere else of course) to find out whether I could walk on it! (It wasn’t broken, FWIW).

Conclusion

In principle, care is rationed and prioritized according to need. In practice, there can be frustrating wait times accompanied by the feeling that one is simply a small cog in a large, uncaring machine (I’m sure this is not unique to the local system, but it is something people worry about here too). Consequently, there is pressure to ration care based on ability to pay, and stories about the time one was able to skip to the head of the line by making an appointment with the head physician as a “private patient” abound. Interestingly enough, a counselor in the stake presidency preached against this impromptu (it’s not a matter of public policy, just boots on the ground trying to get ahead) move towards “class medicine” at the last stake conference, observing that just as we shouldn’t accept separate classes of medicine, we cannot accept separate classes of members in the Body of Christ. You know you’re not in Kansas anymore when a Mormon leader uses an example like that at church.

Anyway, I hope the above gave you in idea about what it’s like to live in a country with a pretty functional approach to universal health care. It’s obviously not perfect, and it could well be that other countries are currently better at generating medical innovations, but overall, the system is pretty great. The trick will be to keep it that way moving forward.

What features would you like to see adopted/improved/dispensed with entirely in your neck of the woods?