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Opinion: What we can learn from health care abroad

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According to The Commonwealth Fund and other research organizations, the United Kingdom and France have some of the highest quality health care at the lowest cost when compared with other industrialized nations. Ranking at the bottom in both quality (low) and cost (high) is the United States.

To learn more about this, I took a group of my master’s in health administration students in May to London and Paris. Our goal was to come up with a white paper for Congress to consider in regard to changes to the Affordable Care Act in the upcoming election year.

We started our program in the city of Oxford and visited the university. Yes, this is where the dining hall in “Harry Potter” is located and where it serves its students three times a day. The public university system is much different than here, and the training of physicians is significantly different and less costly.

First, tuition is 9,000 pounds a year, or roughly $12,000-$13,000. Students enter medical training right out of high school and attend their medical college for four years. After graduating, they will be in a residency for three to five years, depending on the specialty. In essence, they cut out the four-year cost of college. Most also will graduate debt free, rather than the average $250,000 in debt most U.S. students rack up to get through medical school. However, there is a significant trade-off in earning capacity. Most family physicians earn around 85,000-95,000 pounds a year, equivalent to about $110,000. Specialists will earn more, but most will not get to 200,000 pounds. Costs and salaries were very similar in France.

The medical practice is also very different. Most physicians in both countries are self-employed in one or two person offices. They do not have physician assistants or nurse practitioners. The specialists are located on the campus of the government-owned hospitals in office space they lease. The ratio of specialists to general practice in each country is roughly 50-50. They do not have any physician shortages like we experience here, but they do struggle to get physicians to practice in rural communities, despite some significant government incentives.

I know what you are thinking: A patient has to wait weeks or months to see a physician. It’s not the case. Most patients can get into their physician within a week or two, and this is a metric tracked very closely by the government. A referral to a specialist may take about the same amount of time.

Billing for services is not very complex either. The charges are referred to as tariffs, and there are only three billing levels for general physicians. Comparatively, the U.S. coding system covers over 300 pages. And overseas, there are no copays, deductibles or other patient costs.

The hospital structures are very different than in the U.S. Most of the facilities are owned by the government and are extremely large. We toured the largest and oldest hospital in Paris, and it covered more area than CoxHealth and Mercy combined. Unfortunately, we were not able to meet with hospital administrators to get a better idea of how they control costs, utilization and length of stay. We did learn, though, wait times are up to a year for elective procedures, such as knee and hip replacements, and such ancillary services as MRI and CT scans. Cancer care and very acute diseases are treated timely and with current technology. We also learned the hospitals are very dependent on foreign-trained nurses and pay them at a much lower rate than in the U.S. Because of Brexit, these nurses have had to return to their homeland, and London hospitals are having very difficult nurse staffing issues.

One of the most interesting academic visits was a panel discussion with a physician, a National Health Service representative and a principle with Bupa, the U.K.’s largest private insurance company. Almost all of the European nations have universal health care coverage. Private insurance is slowly penetrating in London and Paris. The cost is only 1,000 pounds, or roughly $1,200, per year, and the coverage moves the patient up in the queue to see a physician much sooner.

Both governments would like to see more private insurance coverage to help offset their budgets, but most citizens want to keep their free universal care. I say “free” loosely. In the U.K., everyone has 10% of their income taxed for public services. France is similar – around a 7% tax. There is no cap on the amount and no one’s earnings are exempt from it. Coverage is universal, and it is pretty expansive what the government will pay for. For example, multiple rounds of artificial insemination are covered in the U.K. Both governments also cover abortions.

Our biggest takeaway was that care in the U.S. is not as bad as published, and the European systems are not as good as published. Both have significant trade-offs and there is no one size fits all.

Next stop is Berlin and Prague in May 2021.

Michael Merrigan is a clinical associate professor at Missouri State University. He can be reached at


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