Definition of a single payer, as per the Congressional Budget Office:
"Healthcare systems are typically considered single-payer systems if they have these four key features:
- The government entity (or government-contracted entity) operating the public health plan is responsible for most operational functions of the plan, such as defining the eligible population, specifying the covered services, collecting the resources needed for the plan, and paying providers for covered services;
- The eligible population is required to contribute toward financing the system;
- The receipts and expenditures associated with the plan appear in the government's budget; and
- Private insurance, if allowed, generally plays a relatively small role and supplements the coverage provided under the public plan."
The following information is taken from the World Health Organization's Health In Transition series, which does a comprehensive report on countries around the world. You can access these reports by clicking on each country's name.
|Criteria:||Defines eligible population?||Specifies covered services?||Collects resources needed for plan?||Pays providers for covered services?||Eligible population required to contribute?||Receipts/expenditures in govt budget?||Private insurance supplements public coverage?|
|Austria||Yes - Membership in an SHI fund is determined by law according to place of occupation, type of occupation or occupational status||Yes - The minimum benefits package is determined by law, irrespective of the SHI fund and the law governing mandatory insurance...In addition to the minimum benefits package, SHI funds may cover certain complementary benefits. Cost-sharing requirements are the main area of variation in coverage between SHI funds||MIX- Health care in Austria is mainly financed through a mix of income-related SHI contributions (about 60% of public health expenditure) and general taxes (about 40%). SHI funds collect contributions independently. Employers pay SHI contributions, including both the employers’ and the employees’ share, to one of the 18 SHI funds. The federal state pays the employer contribution for pensioners (through pension insurance) and for the unemployed.Contribution rates are determined by law and can only be changed by the Austrian Parliament.||Yes - the SHI pays physicians directly||Yes, required to pay through general taxation as well as employer/emplyee contribution||Mix- Contributions are pooled by the Main Association of Austrian Social Security Institutions and subsequently allocated to SHI funds for payment of health care providers.||Yes - VHI has mainly a supplementary function and can take various forms. The most common type of supplementary health insurance covers extra amenities in the hospital sector like accommodation in “special fee class” rooms in hospitals (e.g. single rooms), costs of transportation to hospitals and free choice of hospital physicians. The second most common type of VHI offers more choice of ambulatory care providers, covering fees of physicians without SHI contracts, medicines and medical aids in the ambulatory care sector.|
|Belgium||Yes - Almost 99% of the population is covered by the compulsory health insurance. There are two main schemes: (1) the general scheme for the whole population except for the self-employed, and (2) the scheme for the self-employed. The general scheme covers a large but limited number of categories of people such as employees, employees in incapacity, the unemployed, retired people, widows, orphans, students, residents and so on. Residents are defined as people who are registered in the Belgian National Registry.||Yes - The services that are covered by compulsory health insurance are described in the nationally established fee schedule (called the nomenclature), which is extremely detailed and lists more than 8000 services. The fee schedule is negotiated yearly or biennially between representatives of the sickness funds and of the health care professionals. |
Compulsory health insurance is managed by the NIHDI (National Institute for Health and Disability Insurance) which gives a prospective budget to the sickness funds to finance the health care costs of their members, and the budget for public health expenditure is fixed by a legal real growth norm (4.5% since 2004).
|Yes - Contribution rates are fixed by law as a percentage of income. In the employed workers’ scheme, there is an employee’s contribution (13.07% of gross income) and an employer’s contribution (24.77% of gross income without the social contributions paid for annual holidays), which are paid to the NSSO-RSZ-ONSS. (National Social Security Office)||Yes- the sickness funds pay providers.||Yes - employer/employees pay contribution rates determined by the government. The self-employed also have a different rate, also determined by the government.||Yes - The compulsory health insurance is managed by the NIHDI (National Institute for Health and Disability Insurance) which gives a prospective budget to the sickness funds to finance the health care costs of their members.||Yes - The sickness funds provide two kinds of additional insurance for their members beyond the compulsory health insurance – the so called “complementary” and “voluntary” insurance. Private profit-making health insurance companies account for only a small part of the non-compulsory health insurance market. The services covered include orthodontics, homeopathy, osteopathy and supplements for hospitalization in a double room among others.|
|Bulgaria||Yes - According to the Health Insurance Act (1998), all Bulgarian citizens are compulsorily insured. In addition, the following groups are covered: Bulgarian citizens who are also citizens of another country but permanently live in Bulgaria; foreign citizens or individuals without citizenship but with a longterm residence permit; and individuals with a refugee or humanitarian status or those granted the right of asylum.||Yes - The Health Insurance Act determines the basic benefit package of the National Health Insurance Fund (NHIF).||Yes - SHI contributions are collected by the National Revenue Agency through its 28 divisions at the district level and transferred to the NHIF on a daily basis. The authorities of the NRA are responsible for controlling revenues from health insurance contributions and interest. SHI contributions are earmarked for health and can be used only for provision of health services and medical goods to the insured individuals. The contribution rate is 8% (defined by law) of an individual’s income. There are minimum and maximum thresholds to determine the income base for health insurance contribution calculation. The minimum insurance income for employed and self-employed individuals is defined annually by the Law on the State Social Security Budget and depends on the industry and individual position...||Yes||Yes - The SHI contributions paid by employers and employees traditionally account for the largest share of the total contribution revenue...The SHI contributions are paid by employees (40%) and employers (60%) individually at full rate or by the state (see Table 3.4). For some insured, such as individuals receiving compensation for temporary incapacity to work due to illness, pregnancy, childbirth or maternity leave, the contributions are paid only by the employer. In these cases, contribution is equal to the employer’s due part of the contribution, calculated on the minimum insurance base.||Yes - the national assembly determines the budget of the NHIF||Yes - Voluntary health insurance covers complementary services and user charges not covered by the NHIF (such as specific laboratory tests, dental services and drugs), supplementary services (for example, better service and free choice of a hospital physician or team), as well as services included in the NHIF benefit package (visits to specialists, hospital treatment, prophylaxis). This means that for some services, individuals with VHI have double coverage|
|Croatia||Yes - All persons with residence in Croatia and foreigners with permanent residence permits must be insured under the MHI scheme, unless an international agreement on social insurance states otherwise.||Yes - Certain health care goods and services provided to specific population groups are covered in full (100%) by the Croatian Health Insurance Fund.||Yes - the State Treasury collects all revenues.||Yes, the Croatian Health Insurance Fund pays providers.||Yes - Employees/employers pay compulsory health insurance contributions, which account for about 75% of the total revenues, and funding from the State budget (taxation), which accounts for about 15% of the Croatian Health Insurance Fund's revenues.||Yes - The key sources of the Croatian Health Insurance Fund's revenue are: compulsory health insurance contributions, accounting for 76% of the total revenues of the CHIF, and financing from the State budget (15%).||Yes - There are two types of VHI scheme in Croatia: complementary VHI covering user charges in the MHI scheme (in Croatia called supplemental insurance); and supplementary VHI covering a higher standard of care (called additional insurance)...Complementary VHI plans cover all patient co-payments. Supplementary VHI plans provide services targeted at active people in good health (they cover preventive systematic and cardiovascular examinations; direct access to specialists, diagnostic imaging, laboratory tests and physiotherapy; a better standard of hospital accommodation). Supplementary group plans are available to employees at the managerial level (anti-stress programmes, preventive cardiovascular examinations). No VHI plan provides better or faster access to sophisticated therapies needed in case of serious illnesses, for example, oncologic or other major surgery|
|Cyprus||Yes - Cyprus transitioned to a single-payer, national health insurance plan in June 2019. There isn't a lot of information in English on the new system yet.||Yes||Yes||Yes||Yes||Yes||Yes|
|Czech Republic||Yes - Entitlement to coverage in the Czech Republic is based on permanent residence rather than on direct SHI contributions. Individuals who are not permanent residents are also covered if they are working for an employer based in the Czech Republic.||Yes - Czech law stipulates that insured individuals are entitled to any medical treatment delivered with the aim of maintaining or|
improving their health status. Benefits are determined by a combination of means, including: (a) legislation, (b) formularies, (c) an annual negotiation process between the health insurance funds and providers aimed at defining specific conditions of reimbursement and (d) a fee schedule known as the List of Health Services. The List is updated annually by the Health Services Working Group, which is based at the Ministry of Health.
|Mix - Each health insurance fund has its own revenue collection system. On a monthly basis they collect SHI contributions from employers and employees (the responsibility for contributions remains with employers), from self-employed people, and from individuals without taxable income who are not state-insured...Spending from state, regional and municipal budgets (not counting insurance contributions for state-insurees) accounted for 4.5% of total health expenditure in 2012. These budgets are financed through general taxation.||No - the health insurance funds serve as the main purchasers of health-care services in the Czech SHI system - these insurers compete. However, the purchasing of health services by the health insurance funds is regulated by the state, as is the relationship between the health insurance funds and providers.||Yes - The main sources of health expenditure in the Czech Republic are (1) SHI contributions (consisting of wage-based contributions and state contributions from general taxation), (2) state and territorial budgets and (3) private expenditure... Compulsory, wage-based SHI contributions are the main source of health-care financing in the Czech Republic, accounting for 74% of revenue within the SHI system in 2012 (Ministry of Health, 2013b). The remaining 26% of revenue that year came from the state in the form of SHI contributions for certain groups of economically inactive people.||No||Yes - VHI in the Czech Republic typically provides health-care
coverage when travelling abroad; sickness benefits over and above those afforded by the social security system; coverage of foreign nationals who are not eligible for care under SHI; and coverage of certain services not catered for under the SHI system, such as cosmetic surgery and some types of dental
|Denmark||Yes - residents of the country are entitled to health care services. Non-residents are entitled to acute treatment but not to elective treatment.||Yes- the benefit package is decided at the region level. If a region|
declines to provide a service provided by another region, the patient can choose treatment in the other region, which then bills the home region. In general, clinicians are free to introduce new techniques if they can stay within their budget and if the intervention is not covered by the national specialty planning.
|Yes - healthcare is funded through general taxation.||Yes - providers are paid by national and municipal funds.||Yes - via taxes||Yes - The annual national budget negotiation results in agreement on resource allocations, such as the recommended maximum level of municipal taxes, the level of state subsidies to the regions and municipalities, the level of redistribution or financial equalization between municipalities, and the size of additional grants earmarked for specific areas that need additional resources||Yes - VHI in Denmark, mainly provided by non-profit-making associations, covers co-payments for services such as adult dental services, drugs and physiotherapy.|
|England||Yes - the purpose of the NHS is to make health care accessible to all legal United Kingdom residents, regardless of their ability to pay.||Yes - while there is no explicit list of benefits, legislation from the 1970s charges ministers with ensuring the delivery of necessary health services. The NHS Constitution for England in 2009 established a set of rights for people working for and using the NHS, but this constitution mostly pulled together laws and rights that were already established||Yes - the vast majority of tax revenue is collected by Her Majesty’s Revenue and Customs (HMRC), including income tax, VAT, corporation tax and excise duties (on fuel, alcohol and tobacco) from across the United Kingdom. Generally, taxes are not earmarked for a specific purpose.||Yes - the NHS contracts with nearly all providers.||Yes - through general taxation.||Yes - the health budget is centrally decided.||Yes - (VHI) can be purchased by individuals or by employers for their employees. Private medical insurance is usually used to finance services not offered by the NHS or to access NHS-covered services more quickly. Co-payments are costs shared with the NHS, and can include dental care and, in England, outpatient prescription
|Estonia||Yes - entitlement to coverage is based on residence in Estonia and the law defines detailed entitlement rules of specific groups||Yes - the range of health care benefits covered by the Estonian Health Insurance Fund is very broad. The few services excluded are cosmetic surgery, alternative therapies and optician services.||Yes - the Estonian Tax and Customs board collects contributions via an earmarked payroll tax.||Yes - the EHIF acts as a single purchaser of care.||Yes - the system is financed by a payroll tax and other taxes collected at the state and municipal levels.||Yes - the EHIF acts as a single purchaser of care, and the EHIF budget has always predominantly been determined by generated revenue from social tax.||Yes - As a result of mandatory health insurance, without the possibility of opting out, and with the relatively low share of people without insurance, the role of substitutive VHI is rather small and targets primarily non-Estonian nationals.|
|Finland||Yes - determined by residency||Yes - the National Health Insurance covers a certain amount of all treatments which a physician has deemed necessary for treating a disease, pregnancy or childbirth. Additionally, legislation defines the maximum fees which municipalities can charge for health care services and also the services which must be provided free of charge.||Yes - Municipalities finance 40% of total health care costs, with a further 21% being financed by the state, 17% by NHI and 22% by private sources.||Yes - There is not a genuine purchaser–provider split in Finnish public health care, since municipalities both fund and own the service provision organizations.||Yes - More than half of state tax revenue comes from the progressive gross income tax (about 20% of total tax revenue) and value added tax (VAT) (about 35%). Other major sources of tax revenues are corporate tax, capital income tax, alcohol tax, energy tax and car tax.||Yes - In primary health care, municipalities prospectively fund the budget of the health centres they maintain on their own.||Yes - Voluntary health insurance has a very marginal role in the Finnish health care system.|
|France||Yes - Every resident has the right to healthcare, and residents are assigned to a scheme based on work/employment situation. Which scheme applies depends mainly on where people work; the schemes do not compete, and residents can not choose.||Yes - The positive lists are defined at the national level and apply throughout France in all regions. Drugs and medical devices are added to the list by the Ministry in charge of Health, while procedures are added by National Union of Health Insurance Funds on the advice of an independent public body (HAS).||Yes - the national health insurance system is funded primarily by taxes, including earned income, capital, corporate, etc. ||Yes - providers are paid by the insurance fund, but patients in the ambulatory care sector may have to pay the provider and claim reimbursement by the fund afterwards.||Yes, via progressive taxation||Yes - collected by taxation and the money levied flows into a single national pool managed by the Central Social Security Agency and is distributed among the different national branches on the basis of contribution rates defined by law.||Yes - VHI is not used to jump public sector queues or to obtain access to elite providers, unlike in some other countries. VHI provides complementary insurance, such as for co-payments and better coverage for medical goods and services that are poorly covered by the fund, notably dental and optical care, for which extra-billing is the norm. VHI may also be of a supplementary type, providing access to private amenities (such as a private room) that are not included in the benefit basket.|
|Germany||Yes - Sickness fund membership is mandatory for employees whose gross income does not exceed the opt-out threshold. Those earning above the threshold may choose to remain with statutory health insurance as so-called voluntary members or take out private health insurance.||Yes - the broader framework of the benefit package is defined by legislation. Specifics are determined by the Federal Joint Committee, which is a quasi-public body comprised of representatives of the federal associations of providers and payers, as well as of the German Hospital Federation and several neutral members. A uniform contribution rate is set by federal law; the funds do not determine their own contribution rates. |
The services covered by the resulting contracts are usually
accessible to everyone with SHI and do not require prior authorization from an individual’s sickness fund. Independent of the status, the amount of contribution paid or the duration of
insurance, members and their dependents are entitled to the same benefits.
|Mix - The sickness funds are responsible for collecting contributions, from both the employers and the employees – directly from the employers or public agencies, which they transfer to a Central Reallocation Pool (administered by the Federal Insurance Authority). The pool collects the SHI contributions centrally and subsequently reallocates them among the sickness funds according to a morbidity-based risk-adjustment scheme. Funds have to make up any shortfall by charging a supplementary premium. ||Yes - the sickness funds pay providers.||Yes - all employees pay a uniform premium, based on income (15% - split between employer and employee). Taxation also finances the system.||No - expenditures flows in and out of sickness funds.||Mix - PHI has two facets in Germany: (1) to fully cover a portion of the population (substitutive PHI) and (2) to offer supplementary and complementary insurance for SHI-covered people... The second market for private health insurers is supplementary and complementary insurance for those with SHI; the former, for example, might cover extra amenities like hospital rooms with one or two beds or treatment by the head-of-service|
|Greece||Yes - all citizens and documented residents are eligible for health insurance. Coverage is mainly linked to employment status through SHI for employees; unemployed are covered by the same benefits package. ||Yes - all benefits package services covered by the single insurer - EOPYY (National Organization for the Provision of Health Services) - are explicitly defined in the EKPY (Integrated Health Care Regulation).||Yes -the Unified Social Security Fund collects all SHI contributions and transfers the portion corresponding to health insurance to the national health insurance fund (EOPYY). ||Yes - The National Health Insurance Fund pays providers.||Yes - the National Health System is financed by the state budget via direct and indirect tax revenues and social insurance contributions.||Yes - the financial resources for publicly provided health care that come from the state budget are transferred from the Ministry of Finance to the Ministry of Health through the annual budget, which is based mainly on the previous year’s allocation, adjusted for inflation and overall budget growth.||Yes - VHI mainly plays a supplementary role, with private companies providing cover for faster access, better quality of services and increased choice. VHI usually covers expenses in private inpatient and outpatient care and provides managed care programmes covering an integrated package of services|
|Hungary||Yes - participation in the system is compulsory for all residents of Hungary.||Yes - the central government determines the benefits package.||Yes - contributions are pooled in the Health Insurance Fund (HIF), which is administered by the National Health Insurance Fund Administration (NHIFA). ||Yes - the HIF is the single purchaser of provider services.||Yes - funded primarily through compulsory, non-risk-related contributions, the rate of which is determined by the National Assembly and in the case of employees take the form of a payroll tax, split between employer and employee. |
General tax revenue and corporate taxes also fund the system.
|Yes - the central government sets the budget.||Yes - the voluntary health insurance system in Hungary has no substitutive, but only limited complementary and supplementary functions.|
|Iceland||Yes -the health insurance system automatically covers everyone who has been legally residing in Iceland for six months, regardless of nationality.||Yes- decisions about which medical goods and services are to be included or excluded from the statutory benefit package are made by the Minister of Health.||Yes - All tax and duties receipts are pooled by the GFA (Government Financial Authority) and the Minister of Finance has overall responsibility for supervising and coordinating the implementation of the national budget.||yes - the Icelandic Health Insurance Fund is responsible for negotiating and purchasing health-care services from public as well as independent health-care providers.||Yes - the IHI is mainly financed by general taxation.||Yes - the health budget is determined by Parliament on an annual basis. Health-care spending represents a significant percentage of the annual government budget in Iceland.||Yes - currently, Voluntary Health Insurance (VHI) plays virtually no role.|
|Ireland||Yes -- Coverage in the Irish health care system is universal for anyone ordinarily resident within the country.||Yes - The Health Service Executive operate most of the benefit schemes. |
The HSE is responsible for both the budget and management of health services as a single national entity, accountable directly to the Minister of Health.
|Yes - the Irish health system is primarily financed|
through general taxation, supplemented by an earmarked “health contribution” collected alongside the payroll taxes.
|Yes - the fund pays providers.||Yes - the Irish health system is primarily financed|
through general taxation, supplemented by an earmarked “health contribution” collected alongside the payroll taxes.
|Yes - the Health Service Executive manages the health budget.||Yes - private health insurance, which has both complementary and supplemental elements, accounted for just 8% of total health expenditure in 2006. Private health insurance fulfils two roles in Ireland: first, it acts as a complement to the public health system, providing coverage against charges levied on non-Medical Card holders for inpatient bed use, together with a more
limited reimbursement of some out-of-pocket charges in the primary care sector.
|Italy||Yes - The National Health Service covers all citizens and ordinarily resident foreign nationals. Coverage is automatic and universal.||Yes -Health-care services provided within the National Health Service are identified by positive and negative lists determined by the central government. ||Yes - the main source of finance for the Italian National Health Service is a mix of taxes applied at both regional and national level. Thus, collection is performed partially at national and partially at regional level, although pooling of funds is managed at national level.||Yes - the Italian National Health service pays providers.||Yes - compulsory taxation funds the system.||Yes - the regions are financed by and provided a budget in the NHP (National Health Plan) through the Ministry of Health.||The VHI market plays a double role: a complementary role, covering
user charges and co-payments required within the SSN, expenditures associated with hospital stays (per diems for private rooms or rehabilitation) or services excluded from the public system or partially covered such as dental care, home care, etc. And a supplementary role to ensure faster access and/or go privately due to perceived better quality in the private sector, etc.
Full substitutive VHI does not exist as it is not possible to opt out of the public system.
|Latvia||Yes - all residents of Latvia are entitled to the (national health plan)||Yes - the National Health Service determines the benefits basket, which includes a number of explicit inclusion and exclusion lists as well as by certain implicit criteria.||Yes - the most important source of revenue for the health system is the general tax system (income, value added and other taxes).||Yes - the Ministry of Health receives an approved budget for the plan.||Yes - opting out is not possible.||Yes - Health services for the entire population are purchased by the NHS.||Yes - VHI accounted for only 0.8% of total health expenditure in 2010. It pays for services not included in the statutory system (complementary coverage) and provides faster access (supplementary coverage).|
|Lichtenstein||Not enough information||Not enough information||Not enough information||Not enough information||Not enough information||Not enough information||Not enough information|
|Lithuania||Yes - the Health Insurance Law requires all permanent residents and legally employed non-permanent residents to|
participate in the compulsory health insurance scheme without an option to opt-out.
|Yes - the state guarantees free access to basic population services, the definition of these services is rather implicit. However, this|
situation is gradually changing as the Ministry of Health is introducing new clinical standards and changes in price lists.
|Yes-- All residents must participate in the compulsory health insurance scheme. Currently, health insurance contributions are mostly collected by the State Social Insurance Fund, while the State Tax Inspectorate collects contributions set as a share of a minimum monthly wage. All collected contributions are then pooled by the National Health Insurance Fund.||Yes - the National health Insurance Fund is the main purchaser of services.||Yes - all are required to pay through taxes for the compulsory health insurance.||Yes - the NHIF is the main financing agent for the health system. A large proportion of NHIF revenue comes from the national budget in the form of transfers for population groups insured by the state (e.g. children, students, unemployed, disabled).||Yes - VHI exists as a supplementary scheme and accounts for less than 1% of total health expenditure.|
|Luxembourg||Yes - coverage is universal and compulsory.||Yes - the CNS (National Health Insurance) provides a standardized benefit basket for their insured individuals. The decision to cover health services is taken jointly by the Ministers of Health and of Social Security, on the basis of a detailed recommendation from the Nomenclature Commission. It is fixed by agreement and is subject to biannual negotiations between the National Health Insurance and the parties, e.g. professional associations.||Yes - the National Health Insurance is the single payer fund for health benefits and long-term care insurance.||Yes - In principle, the costs of care and services are paid|
directly by the insured to the providers, and then reimbursed
by the CNS. However, laboratory tests, hospitalization
costs (except medical expenses), pharmaceutical costs and
long-term care services are paid directly by the CNS (thirdparty payment).
Providers are reimbursed using the tariffs and conditions laid down in the medical procedure frameworks and in the negotiated contracts between professional groups and the CNS.
|Yes - contributions to insurance schemes are compulsory for all persons who are economically active (i.e. directly insured) or receive a substitutive income (sickness compensation; maternity|
pay; unemployment benefit; disability, old age or survivor pension; guaranteed social minimum wage)
|Yes - the overall budget of the health insurance system|
is determined each year by the CNS for the following
year, based on multiannual expenditure forecasts. The
CNS negotiates annual budgets with individual hospitals
for operating costs after the global budget has been
agreed by the government.
|Yes - VHI is not very developed in Luxembourg, and accounts for 4.5% of all health expenditure.|
|Malta||Yes - All those who are covered by the Social Security Act, either through payment of contributions or through a mechanism of exemption from payment, are covered.||Yes - the public system provides a comprehensive basket of health services to all people residing in Malta.||Yes - taxes are collected for the plan. Contribution rates are determined by Parliament and tax rates vary according to the worker’s income. All persons who are active in the labour force pay National Insurance (Social Security Health systems in transition Malta 45 Contribution).||Yes - the Maltese health system is an integrated health system and to date a clear purchaser-provider split has not existed. All health workers in the public sector are salaried civil servants and public facilities are cost centres under the Ministry for Health.||Yes - contribution rates are determined by Parliament and tax rates vary according to the worker’s income.||Yes - All health workers in the public sector are salaried civil servants and public facilities are cost centres under|
the Ministry for Health, funded through annual budget allocations.
|Yes - VHI is only supplementary.|
|Netherlands||Yes - basic health insurance is obligatory for all Dutch residents.||Yes - the central government takes decisions on the content of the basic health insurance package, on cost-sharing, on prices for health services if not negotiable (based on advice from the Dutch Healthcare Authority) and on services that are not subject to free negotiations. The National Healthcare Institute advises the|
Minister on what services should be included in the package.
|Mix - the Tax Office collects the income-dependent contributions. After collecting all the contributions, the Tax Office transfers the collected funds to the Health Insurance Fund, from which the|
money is allocated after risk adjustment to the health insurers. Additional revenue for healthcare is generated from general taxation.
Premiums, which account for the other 50% of the plan, are collected directly by the insurer.
|No - insurance companies pay providers. |
Each insurer negotiates with each hospital. Some insurers negotiate a lump-sum budget, others negotiate on price and/or volume for individual treatments.
|Yes - the system is compulsory. If it finds that a person has failed to purchase insurance, it will send a letter requesting that they do so. From that moment they have three months to purchase a health plan. If after three months the person still does not have an insurance policy, a penalty of €352 will be charged. After another three months, another €352 penalty will be charged. If the person nevertheless fails to purchase insurance, the National Healthcare Institute will purchase a plan on behalf of the uninsured for the duration of 12 months.||Yes - The Ministry of Health decides upon the national budget for healthcare. The Health Care Budget indicates the maximum allowed healthcare expenditure. If providers and insurers spend more, the Minister may decide to charge insurers or providers to repay the excess, for instance by payments cuts or repayment of part of the overspending. The Minister also decides upon the budget for both municipality-based decentralized healthcare and home nursing care. The municipality budget is paid into the municipality fund (which is broader than decentralized healthcare and covers about 90% of all expenditure by the municipalities). The budget of this fund is allocated over the municipalities, based upon certain indicators, such as number of citizens, the physical size of the municipality and the number of people entitled to social security||No - private insurers deliver the public plan. There is additional VHI that's allowed to reject applications and charge as they will, about 5% of THE|
|Northern Ireland||Yes - the basis for entitlement for NHS services in Northern Ireland is that the individual is “normally resident” in the province.||Yes - while there is no explicit list of benefits, legislation from the 1970s charges ministers with ensuring the delivery of necessary health services.||Yes - health services in Northern Ireland are financed almost entirely out of general taxation.||Yes - the NHS contracts with nearly all providers.||Yes - health services in Northern Ireland are financed almost entirely out of general taxation.||Yes - the health and social care system is predominantly publicly financed via allocations from the executive to the Department of Health.||Yes - VHI in the UK accounts for just 2.9% of all health spending. There is no substitutive option.|
|Norway||Yes -- Every person residing in Norway is entitled to publicly funded health-care services.||Yes - the scope is determined by national legislation. Benefits are implicit and comprehensive.||Yes - general taxation finances the system.||Yes - the Norwegian National Insurance Scheme pays almost all providers.||Yes - through taxation.||Yes - the Ministry of Health determines the NIS budget.||VHI constitutes less than 1% of all health spending. The most common VHI schemes provide supplementary cover, offering shorter waiting times for publicly covered elective services and specialist consultations in private facilities.|
|Poland||Yes -- the Polish Constitution stipulates that all citizens, regardless of their financial circumstances, have the right to equal access to publicly financed health services.||Yes - benefits are determined by national legislation.||Yes - contributions are pooled by the National Health Fund head office and allocated to NHF branches. Allocations among branches are based on algorithms defined annually by the government and depend on the number, age and gender of the insured regional population.||Yes - the National Health Fund contracts with and pays providers.||Yes - membership in the SHI scheme is mandatory, and contributions take the form of a withholding tax borne entirely by the employee. The state budget covers contributions for vulnerable groups.||Yes- the responsibility for planning the financing of|
health care services falls to the Ministry of Health and the National Health Fund.
|Yes - There is no VHI with complementary or substitutive functions, and existing VHI forms play a supplementary role.|
|Portugal||Yes - all residents in Portugal are covered by the NHS, irrespective of their socioeconomic, employment or legal status.||Yes - the NHS determines the benefits basket.||Yes - the NHS is mainly financed by general taxes, which are not earmarked. Tax revenue also funds the employer contributions for government and public sector employees. The main tax fund sources are taxes on income (47% of total tax revenue in 2014), followed by indirect taxes (42.3% of total tax revenue in 2014)||Yes - the NHS contracts with providers and institutions.||Yes - The NHS is mainly financed by general taxes, which are not earmarked. There is no possibility to opt-out of the system.||Yes- the Central Administration of the Health System draws up budgets for each sector.||Yes - the main role of private VHI is supplementary, speeding access to elective hospital treatment and ambulatory consultations and choice of provider) and, only rarely, complementary, covering services excluded from the NHS.|
|Romania||Yes - the social health insurance system is compulsory for all citizens, as well as for foreign residents in Romania.||Yes - the National Health Insurance House and the Ministry of Health draft the Framework Contract, which details the basic benefits package. Benefits are standard across the whole covered population and includes health care services, pharmaceuticals and medical devices.||Yes - contributions are collected by the National Agency for Fiscal Administration, under the remit of the Ministry of Public Finances. ||Yes - the district (regions) purchase services on behalf of the insured population in their respective geographical areas, through a budget they receive from the National fund.||Yes - revenue of the NHIF comes from contributions paid by the insured population and employers, state budget subventions and transfers, etc. |
Contribution rates vary for the insured population and employers. The contribution rates are set by Law 95/2006.
|Yes - each district receives a budget from the National Health Insurance Fund.||Yes - in 2014 the share of VHI represented 0.1% of total health care spending. VHI plans mainly offer access to superior accommodation in hospital, choice of provider and private care (supplementary cover) rather than access to services that are fully or partly excluded from the statutory scheme (complementary cover). It is not possible to opt out of the statutory scheme and purchase substitutive VHI cover.|
|Scotland||Yes - the purpose of the NHS is to make health care accessible to all legal United Kingdom residents, regardless of their ability to pay.||Yes - while there is no explicit list of benefits, legislation from the 1970s charges ministers with ensuring the delivery of necessary health services. Under the NHS (Scotland) Act 1978, Scottish ministers are required to provide or secure a comprehensive and|
integrated health service.
|Yes - health services in Scotland are financed almost entirely out of general taxation.||Yes - there is no purchaser–provider separation in Scotland.||Yes - health services in Scotland are financed almost entirely out of general taxation.||Yes - the United Kingdom Government, through Her Majesty’s Treasury, provides an overall budget to the Scottish Parliament, which budgets the health system.||Yes - VHI in the UK accounts for just 2.9% of all health spending. There is no substitutive option.|
|Slovakia||Yes - all residents in Slovakia are entitled to social health insurance.||Yes - the Slovak Constitution guarantees every citizen health care under the SHI system according to the conditions laid down by law. The law outlines a list of free preventive care examinations; a list of essential pharmaceuticals without co-payment; a list of diagnoses eligible for free spa treatment; and a list of priority diagnoses (roughly two-thirds of ICD-10 diagnoses).||No - compulsory health insurance contributions are collected by the health insurance companies, though 95% of funds are re-distributed according to a risk-adjustment scheme. |
The Health Care Surveillance Authority administers the risk-adjustment mechanism of financial resources between health insurance companies and manages several registers.
|Each health insurance company is allowed to develop its own payment mechanisms and set up its own pricing policy towards contracted providers. The contractual relations between health|
insurance companies and health care providers are supervised by the HCSA
|Employees pay 14% of their gross monthly income as a mandatory insurance contribution. Out of this percentage, employees pay 4% and employers 10%. Self-employed people use 14% of the assessment base for income tax divided by a predefined coefficient. Self-employed people and employees with more serious permanent disabilities are entitled to discounts up to 50% on contributions, as are their employers.||QUESTION TO ANSWER! If insurers collect the funds how can the government be providing 80% of THE||Yes - the role of VHI, which is offered by commercial insurance companies, is still marginal in Slovakia.|
|Slovenia||Yes - the centralized compulsory health insurance system, administered by the HIIS, is defined in the Health Care and Health Insurance Act 1992, and defines those who are compulsorily insured, including almost all residents of the country.||Yes - the Health Care and Health Insurance Act 1992 on compulsory|
health insurance broadly define health services to be covered for the insured population. The benefits package comprises primary, secondary and tertiary services; pharmaceuticals; medical devices; sick leave exceeding 30 days; and costs of travel to health facilities.
|Yes - contributions are collected by the Health Insurance Institute of Slovenia (HIIS).||Yes - the Health Insurance Institute of Slovenia is the main purchaser of services in the health system.||Yes - contribution rates for compulsory health insurance are regulated in the Health Care and Health Insurance Act||Yes - the Ministry of Finance reviews and approves the budget of the Ministry of Health. The national health budget is determined centrally.||Yes - supplemental and complementary private health insurance (VHI), which is mainly used by patients to cover co-payments, is allowed; substitutive coverage is not.|
|Spain||Yes - all residents are entitled to coverage.||Yes - the governing body of the SNS (the Spanish National Health Service) determines the core package.||Yes - the vast majority of public health expenditure in Spain is funded through general taxation, both direct and indirect. ||Yes - the SNS is the main purchaser of health services, and most of the services are public.||Yes - The vast majority of public health expenditure in Spain is funded through general taxation||Yes - regions manage most of the budgeting of the plan.||Yes - VHI in Spain is supplementary. The purchase of VHI plans is mainly driven by faster access to some services. Contribution to the overall health expenditure is minor – 4.3% in 2015.|
|Sweden||Yes - legislation mandates that the system provides coverage for all residents of Sweden, regardless of nationality. In addition, emergency coverage is provided to all patients from the EU and European Economic Area countries, and nine other countries with which Sweden has bilateral agreements.||Yes - the scope is determined by national legislation. Benefits are implicit and comprehensive.||Yes - the Swedish health care system is primarily funded through general taxation.||Yes - the Swedish health care system is integrated to a high degree. The county councils are responsible for both the financing and organization of health care services, and most hospitals are owned and operated by the county councils.||Yes - the system is funded through general taxation. There are no earmarked taxes for health or health care services, which makes it difficult to specify precisely what proportion of the taxes is directly connected with the provision of healthcare services.||Yes - the equalization system is managed by the Ministry of Finance. General state grants are allocated to municipalities and county councils/regions. In addition to the tax equalization system there is a system of reallocation of funds between county councils to pay for certain very expensive pharmaceuticals, for example, for treatment of rare diseases and HIV/AIDS, on the principle of solidarity of funding.||Yes - About 4% of the population have VHI, in most cases paid for by their employer. Funding from VHI constitutes about 0.2% of total healthcare spending.
|Switzerland||Yes - by law, MHI companies must accept all citizens who apply to purchase insurance. (All permanent residents are legally obliged to obtain coverage by purchasing an MHI policy.)||Yes - the exact content of the benefits package is specified by the federal government in several explicit positive and negative lists. The MHI benefits package is standardized across all insurers; companies are not allowed to offer other optional benefits as part of the MHI scheme.||MIX - Resources are raised not only through MHI premiums but also through federal and cantonal taxes|
1) General taxes raised by federal, cantonal or municipal governments (32.4% of THE); and
2) Premiums paid either by MHI policy-holders (30.0% of THE) or by holders of other social health-related insurances (6.2% of THE)
A downside of the extensive choice of insurance is that the pooling of good and bad risks is relatively limited. With a high number of MHI companies in 26 cantons and even more (42) premium regions for 8.2 million people (2014), the insurance market remains fragmented into small risk pools. Pooling is limited to the cantonal level (or even to the subcantonal premium region) because MHI companies have to calculate premiums based on the insured living within a particular canton (or premium region).
Fragmented risk pools are problematic because they complicate cross-subsidization between the healthy and the sick. Most risk-adjustment systems (including the one in Switzerland) can not at all achieve complete risk equalization across risk pools and, consequently, it remains profitable for MHI companies to select good risks. The persisting large variation in premium levels for similar MHI policies within the same canton is largely related to risk selection and insufficient pooling. In addition, the complexities of designing and offering thousands of different insurance policies within one canton increase administrative costs of the MHI system as well as the search costs for citizens.
|No - MHI companies are the most important purchasers and payers in the system, mostly negotiating collective contracts with providers.||Yes - all residents are required to purchase health insurance.||No - insurers pay providers. Government spending is largely limited to premium subsidies.||Yes - VHI provides coverage for both complementary services (those not covered by MHI) and supplementary services (free choice of
doctor and superior inpatient services such as a single room).
VHI plays a rather small and declining role, financing about 7.2% of total health expenditure in 2012.
|Wales||Yes - all patients in Wales can access the NHS for their care, which is generally free at the point of delivery. Further, all residents of the United Kingdom have access to NHS services in Wales.||Yes - while there is no explicit list of benefits, legislation from the 1970s charges ministers with ensuring the delivery of necessary health services.||Yes - health services in Wales are financed almost entirely out of general taxation.||Yes - the NHS contracts with nearly all providers.||Yes - through general taxation.||Yes - the Welsh Government is funded through a block grant of £15.12 billion from the United Kingdom Government to cover all devolved services. This includes health, which accounts for around 40% of the budget (£6.3 billion, both revenue at £5.9 billion and capital at £0.4 billion).||Yes - VHI in the UK accounts for just 2.9% of all health spending. There is no substitutive option.|
|United States||Yes - by law, insurance companies must accept all citizens who apply to purchase insurance. However, there is no penalty in practice for refusing to do so since the individual mandate was repealed.||No - there is no list of services that must be covered by all plans.||No - only for Medicare. Insurance companies collect premiums directly.||No - only for Medicare. Insurers pay providers.||No - there is no penalty in practice for refusing to do purchase health insurance since the individual mandate was repealed.||No - only for public health plans like Medicare and Medicaid.||No, private insurance is allowed to provide primary coverage.|
Nonprofit Status, Insurer Choice, and Percent of System Funded by VHI
|Country||System||Choice of Primary Insurer?||Primary insurance must be nonprofit?||Supplemental insurance as % of all health spending|
|Bulgaria||Single payer||NO||YES||< 1%|
|Czechia||Private Insurance||YES||YES||< 1%|
|Estonia||Single Payer||NO||YES||< 1%|
|Lithuania||Single Payer||NO||YES||< 1%|
|Romania||Single Payer||NO||YES||< 1%|
|Slovakia||Private Insurance||YES||NO||< 1%|
|Sweden||Single Payer||NO||YES||< 1%|
|UK - England||Single Payer||NO||YES||3.4%|
|UK - Northern Ireland||Single Payer||NO||YES|
|UK - Scotland||Single Payer||NO||YES|
|UK - Wales||Single Payer||NO||YES|
Systemwide Regulation of Prices and Spending
|COUNTRY||Drug Prices Set Nationally?||Pharmacy mark-ups regulated?||Publicly-determined rates for physicians||national spending budget?|
|Austria||YES||YES||Hospital only||national budget cap|
|Bulgaria||YES||YES - both retail and wholesale||YES|
|Estonia||YES||YES - both retail and wholesale||YES|
|France||YES||YES- both retail and wholesale||YES||maximum national ceiling|
|Germany||YES||YES- both retail and wholesale||Hospital only|
|Greece||YES||YES- both retail and wholesale||YES|
|Hungary||YES||YES- both retail and wholesale||YES|
|Iceland||YES||YES- both retail and wholesale||YES||YES|
|Ireland||YES||YES- both retail and wholesale||YES|
|Italy||YES||YES- both retail and wholesale||YES|
|Latvia||YES||YES- both retail and wholesale||YES||yes, cap|
|Lithuania||YES||YES- both retail and wholesale||YES|
|Poland||YES||YES - both retail and wholesale||Hospital only|
|Portugal||YES||YES - both retail and wholesale||YES|
|Romania||YES||YES - both retail and wholesale||YES|
|Spain||YES||YES - both retail and wholesale||YES|
|United Kingdom||YES||YES - both retail and wholesale||YES|
|Wales||YES||YES - both retail and wholesale||YES|
|Scotland||Full Coverage (Negative List)||YES - both retail and wholesale||YES|
|Northern Ireland||YES||YES - both retail and wholesale||YES|