COMPARATIVE HEALTH-CARE SYSTEMShospitals also entered into new arrangements where
they have greater structural independence and
compete among themselves. In 1997, the British
government introduced new proposals that changed
course yet again. The direction of the NHS in the
twenty-first century is unclear (Klein 1998).
Finland’s health-care system also is publicly
owned, financed through general taxation, and
decentralized. In fact, Finland operates with more
health-care decentralization than Sweden. Since
1993, Finnish funding for health-care has been
incorporated into block grants from the national
government that are given annually to each of the
country’s 455 municipalities, some of which form
partnerships for purposes of delivering health-
care (Hermanson, Aro, and Bennett 1994). Within
the parameters of national guidelines, elected offi-
cials in each of these jurisdictions (similar to the
county councils in Sweden) have the responsibility
to obtain and deliver health-care services to the
population. High standards, a comprehensive ar-
ray of services, as well as modest out-of-pocket
payments, make the Finnish system comparable to
the Swedish system. Canada also provides health-
care to its entire population. The Canadian system
is administered by the provinces and is financed
largely by public taxation, roughly three-quarters
of which is from the provincial government. While
basic services remain constant, some specific pro-
visions of health-care in Canada vary considerably
from province to province. Unlike in Sweden,
Finland, and the United Kingdom, Canadian phy-
sicians are paid on a fee-for-service basis. Further-
more, Canadian primary care physicians act as
gatekeepers to specialists and hospitals (much as
they do in Finland and the United Kingdom, but
not in Sweden). As is the case with all the countries
in this group of four, Canadians have extreme
pride in their health-care system. They appear
resolute in maintaining it, although a number of
controversial cost-cutting measures and as yet un-
solved problems raise considerable concern about
the future (Lassey, Lassey, and Jinks 1997).
Germany and Japan, as well as France, have
achieved comprehensive and universal coverage
(92 percent in the case of Germany) with a model
that is closer to that of the United States than the
social democratic model of Sweden discussed above
(U.S. General Accounting Office 1991). In all three
of these countries, medical care is provided by
private physicians, by both private and public hos-
pitals, and patients can choose their physicians.
Benefits are comprehensive and mandated by the
national government, which also regulates enroll-
ment, premiums, and reimbursement of providers.
In contrast to the four countries discussed earlier,
financing in Germany, Japan, and France is pre-
dominantly private with multiple payers. Workplace-
based insurance (financed typically through pay-
roll deductions) covers most employees and their
dependents while other payers cover the remain-
der of the population. Patients make copayments
for physician visits and hospital stays, ranging
from a nominal amount in Germany to as much as
20 percent or 30 percent of the fee in France and
Japan. There is national regulation to ensure con-
sistency. Coverage and care conditions vary from
fund to fund, resulting in greater inequalities of
benefits compared to the public systems of Swe-
den, Finland, Canada, and the United Kingdom.
Arguing that such systems actually help maintain
social divisions and inequality, Esping-Andersen
(1990) refers to them as conservative or corporatist.Although Germany privately finances much of
its health-care system, the national government
plays a strong role. All but the most wealthy of
German citizens are required by law to join one of
Germany’s 750 insuring organizations, called ‘‘sick-
ness funds.’’ In practice, all but about 10 percent
of the population opt to join the system, encour-
aged to participate by the great difficulty of getting
back in later on. Sickness funds are private, non-
profit organizations that collect premiums or ‘‘con-
tributions’’ for each member—half paid by the
individual and half by the employer—and, in turn,
contract for health services with physician organi-
zations and hospitals. One of the biggest problems
for the German system is continuing cost pres-
sures, exacerbated by the reunification of East and
West Germany in 1991. The system uses fixed
budgets for hospitals and strict fee schedules for
physicians, with punitive measures for inordinate
increases in volume, to combat the problem. These
were tightened in a major 1993 reform that im-
posed strict three-year budgets on all major sectors
of the system as well as longer-term structural
reforms. Early results have been positive (U.S.
General Accounting Office 1994).Japanese health-care follows much the same
private, multi-payer model as in Germany, with
health-care provided to all citizens through 5,000