Comparing Six Health-Care Systems in a Pandemic

An attending physician listens to the breathing of a patient who is recovering from COVID-19 at a hospital in the Netherlands.
An attending physician listens to the breathing of a patient who is recovering from COVID-19 at a hospital in the Netherlands. Remko De Waal/ANP/AFP/Getty Images

Here’s how different health-care systems, including single-payer and government-run, have contended with the coronavirus.

April 15, 2020

An attending physician listens to the breathing of a patient who is recovering from COVID-19 at a hospital in the Netherlands.
An attending physician listens to the breathing of a patient who is recovering from COVID-19 at a hospital in the Netherlands. Remko De Waal/ANP/AFP/Getty Images
Backgrounder
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The coronavirus pandemic has stressed health-care systems around the world, testing their capacities to care for patients and protect health workers in a time of crisis. Authorities have sought to implement widespread testing, make room in hospitals, and secure critical medical equipment such as ventilators and masks. 

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But results have been mixed. Some countries quickly implemented pandemic-response plans, helping them to significantly limit the spread of the coronavirus disease, known as COVID-19. Others failed to act early, and their health systems have been overwhelmed with patients. In some cases, decisions by federal and local leaders aimed at halting community spread, such as travel bans and lockdowns, have made the difference in keeping outbreaks manageable.

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Despite ranking among the top global spenders on health care, the U.S. system has struggled in its response. Unlike other high-income democracies, the United States faces the additional challenge of providing testing and care to millions of uninsured people.

Here are snapshots of six different health-care systems and how they are coping with the pandemic.

Taiwan: Single-Payer System, Effective COVID-19 Response

Health-care system. Taiwan’s National Health Insurance is a single-payer system, meaning that nearly all citizens and foreigners residing there for at least six months are covered by one government insurance plan. Its benefits are comprehensive, including coverage for primary care, hospital services, prescription drugs, dental work, and mental health care.

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The system is largely financed by payroll taxes and supplemented by additional taxes on tobacco and the lottery. Taiwan’s health expenditure totaled 6 percent of its gross domestic product (GDP) in 2017. There are generally co-payments for physician visits (capped at $14) and prescriptions (capped at $7), as well as fees for hospital stays, which also have cost limits. People visit their physicians an average of fifteen times per year, nearly double the number of physician visits in other developed countries. That means hospitals and clinics are often crowded and their staffs overworked.

COVID-19 response. Despite densely populated urban areas and close links with mainland China, where the coronavirus was first detected, Taiwan has had only a few hundred cases. Experts say that’s because the Taiwanese government, led by President Tsai Ing-wen, quickly implemented its epidemic response plan, established after the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS). It used technologies including cell phone applications that track user data and body-heat sensors to determine coronavirus patients’ close contacts, enforce quarantines, and monitor body temperatures. It also banned manufacturers from exporting medical supplies and increased production of masks. Coronavirus tests are free, and hospitals were required to test patients early on.

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United Kingdom: Government-Run Care, Delayed Effort

Health-care system. Health care in the United Kingdom is fully funded and delivered by the government to nearly all people. Some analyses give the country’s National Health Service (NHS) high ratings for many health-care metrics, including preventive care, equity, and access. The NHS, paid for mainly by taxes, provides comprehensive coverage, including for preventive care, hospital services, pharmaceuticals, and mental health care. Services are largely free at the point of use; out-of-pocket spending averaged about $630 per person in 2017. About 10 percent of the population has supplemental private insurance, which allows for faster access to some medical care.

In 2018, the UK’s expenditure on health was 9.8 percent of its GDP, among the lowest in the developed world. The system has faced criticism over a lack of funding and decreasing quality, particularly for primary care. Capacity is also an issue: the country has just over two acute-care hospital beds per thousand people, at the lower end of Organization for Economic Cooperation and Development (OECD) countries.

COVID-19 response. Though the country was ranked near the top [PDF] for pandemic preparedness by the Global Health Security Index, the virus took a heavy toll as Prime Minister Boris Johnson’s government opted against mass closures for weeks after its peers in Europe implemented lockdowns. By mid-April, the UK had close to eighty thousand coronavirus cases—including Johnson himself—and around ten thousand deaths. The NHS said it would free up tens of thousands of hospital beds by postponing nonemergency procedures and buying space in private hospitals. A London convention center was also quickly repurposed into a makeshift hospital. Additionally, thousands of former health workers were being retrained to assist in the crisis, while specialists in other areas were being redeployed. However, many have raised alarm about a lack of ventilators and protective equipment. The government has imported some ventilators, loaned some from the armed forces, and urged companies to produce more. The country was testing around four people per one thousand, compared to South Korea’s nine per thousand, and aimed to boost that by mid-April.

South Korea: Public-Private System, Swift Response

Health-care system. Nearly all people in South Korea are covered by the government’s National Health Insurance program. Its benefits include emergency care, pharmaceuticals, and dental care. Health-care services are primarily delivered through the private sector, with most health facilities being privately run. Experts say South Korea does not have a well-developed primary care system.

The government program relies heavily on cost-sharing with patients, with out-of-pocket costs making up 34 percent of health-care expenditures, compared with an OECD average of 20 percent. The government maintains ceilings on co-payments, but patients are often required to pay the full cost for services not included in the benefits package, leading most people to sign up for supplemental, private insurance plans. This has resulted in unequal access to care. 

COVID-19 response. After struggling to battle an outbreak of Middle East Respiratory Syndrome (MERS) in 2015, South Korea invested heavily in emergency preparedness and designated the Ministry of the Interior and Safety as the main coordinator in health crises rather than the prime minister or the president, currently Moon Jae-in. Experts have commended the country’s quick efforts to “flatten the curve” and keep total deaths below two hundred. After the first case appeared in January, the government rapidly developed a diagnostic test and has tested millions of people for free. Many South Koreans have taken advantage of drive-through testing sites. The government designated specific hospitals for COVID-19 patients and required patients seeking other medical care to visit non-COVID-19 hospitals. It also mobilized the private sector to produce medical supplies for public use.

CFR’s World101 library explains how health care works around the world.

Australia: Hybrid System Avoids Widespread Outbreak

Health-care system. The Australian system offers a mix of public and private insurance. The universal public health insurance program, Medicare, is funded by the federal government. It’s generally considered affordable, but there are trade-offs: public hospitals, for example, have been known to become overcrowded, particularly during health crises.

About half of Australians also purchase private insurance—which the federal government encourages—though this proportion dips down to about one-fifth at lower income levels. Private insurers, comprising both for-profit and nonprofit providers, offer coverage for hospital and ambulance services as well as general care such as dental and chiropractic services. In 2018, spending on health totaled 9.3 percent of Australia’s GDP. Australians paid on average around $830 in out-of-pocket health expenses in 2016.

COVID-19 response. Also ranked among the highest countries for epidemic preparedness and response, Australia has not been as hard-hit by the pandemic, reporting around 6,300 cases of the virus and just under sixty deaths by mid-April. Prime Minister Scott Morrison’s government and state officials sustained strict containment measures even as the rate of new infections appeared to be decreasing, fearing that without such measures, intensive care units could become overwhelmed within weeks. Tens of thousands of hospital beds and thousands of doctors and nurses were moved out of private hospitals and into public ones to ease stress on the public system. The country has also had among the highest rates of testing per capita, averaging ten thousand tests per day in late March. Health experts have credited the high testing levels, along with early social-distancing measures, with preventing widespread, undetected community transmission.

Netherlands: Private Insurance for All, Partial Lockdown

Health-care system. Under the highly regulated Dutch system, people are required to purchase health insurance from private providers, though these generally operate as nonprofit organizations. Almost all hospitals also operate as nonprofits. The market is dominated by four insurance conglomerates, accounting for about 90 percent of enrollees.

The government covers much of the costs, financed through taxation. Other funding comes from insurance premiums, which are set by each insurer at the same price for all people regardless of age or health status. Dutch citizens pay relatively low premiums ($115–150 monthly) and out-of-pocket costs (roughly $600 annually), and employers also make contributions. Those with lower incomes receive additional subsidies, and costs for children are entirely covered. More than 80 percent of the population buys voluntary, complementary insurance to cover benefits such as dental and eye care. In 2018, total spending on health care reached nearly 10 percent of GDP. Though analysts warn that health costs are rising faster than wages, the system is hailed for its accessible, high-quality care.

COVID-19 response. The Netherlands has a national public health institute with guidelines in place for epidemics. Following the institute’s recommendations, Prime Minister Mark Rutte’s government implemented social-distancing measures in March, but decided against a full lockdown, arguing that a controlled spread of the virus could build immunity. By mid-April, around twenty-five thousand people in the Netherlands were infected and more than 2,500 had died. Though the rate of transmission appeared to be slowing, authorities warned that hospitals’ intensive care units could reach capacity. Private venues, including a concert hall and hotels across the country, have been turned into makeshift emergency centers to alleviate stress on hospitals, which have had high rates of infection among staff. Some Dutch patients have received care in neighboring Germany. As of April 6, the country’s per capita testing was on par with that of the United States, but was far behind South Korea’s.

United States: Public-Private Mix, Disjointed Response

Health-care system. The United States, whose health system is a mix of private and public sources, is one of the only high-income countries that has not achieved universal health coverage: around 8.5 percent of the population go without coverage. The 2010 Affordable Care Act required most Americans to have insurance, but that requirement was eliminated by President Donald J. Trump’s administration in 2019.

Private insurance, whether employer-based or individually purchased, accounts for two-thirds of the market, while the remaining one-third of people are covered by public insurance plans including Medicare, Medicaid, and veterans’ programs. Medicaid generally covers vulnerable groups, including low-income families, and Medicare covers people over sixty-five years old and some individuals with disabilities.

Americans spend far more on health care than residents of any other OECD country. Individuals pay an average of $10,000 [PDF] annually, and nearly 17 percent of U.S. GDP was spent on health in 2018.

COVID-19 response. After the United States reported its first coronavirus case in late January, the Trump administration banned travelers from China. However, experts say that in the following weeks the federal government failed to implement a plan for a wider outbreak. Despite being ranked as the most prepared for a pandemic, the country did not ramp up capacity in hospitals or substantially boost production of medical supplies. Some states, such as California, implemented early lockdown measures and had more success in curbing the virus’s spread. An initial diagnostic test designed by the Centers for Disease Control and Prevention (CDC) proved to be faulty, delaying testing nationwide for weeks and preventing health officials from having an accurate picture of the disease’s spread. By mid-April, the United States reported the most coronavirus cases and deaths in the world. With many states facing shortages, Trump has used emergency powers to compel private companies to manufacture ventilators for patients and masks for health-care workers. March 2020 legislation made coronavirus tests free, but costs for treatment vary.

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Resources

The Commonwealth Fund profiles nineteen countries’ health-care systems.

CFR’s Thomas J. Bollyky joins health experts Tara Templin and Simon Wigley in arguing that autocracy is hazardous for health.

This CFR Backgrounder lays out what to know about the coronavirus pandemic.

In Foreign Affairs, William C. Hsiao discusses how to fix American health care.

This OECD database includes statistics on health and health systems for thirty-six countries.

Vox explains what the United States can learn from other countries’ health systems.

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