ヘルスサイエンス・ヘルスケア Volume 19，No.1（2019）

ARTICLES

Medical Health Insurance Systems in Europe, USA,
Canada, and Australia
Yoriko Matsuoka，Kakuhiro Fukai
Fukai Institute of Health Science

Abstract： One of the goals of Universal Health Coverage is to create a healthcare system to provide thechance of equality in access of healthcare services for all people to enjoy the highest possible levelof health with no financial hardship. Aging population and slow economic growth areprompting
most developed nations to readjust their social security systems. The developed nations sharesome common challenges: how to fulfil the fair access to health care for all people with sufficientfinances and high quality.
This report focuses on the medical health insurance systems of seven nations in European countries, Canada, Australia, and USA. We summarize the characteristics and challenges of the publichealth insurance systems, based on research reports and government records in 1995 to 2019.
Some universal healthcare systems are based on government-funded or social insurance, others
are based on the need for people to purchase private health insurance. In the most developed
nations we picked up, especially the coverage for dental healthcare is partially covered or completely not covered in general, though dental treatments are often a high financial burden forpatients. There is potential for improvement so that wide range of people can receive the higher
quality of dental healthcare with no financial burden.
Key words : Universal Health Coverage, fair access, sufficient finances, high quality, cross-border

Introduction

preventive, curative, rehabilitative and palliative

Universal health coverage (UHC) is defined ashealth services they need, of sufficient quality toall people and communities can use the promotive,

be effective, while also ensuring that the use of
these services does not expose the user to financial hardship1）．This message has been repeatedly【著者連絡先】〒341-0003 埼玉県三郷市彦成3-86
深井歯科医院・深井保健科学研究所
松岡順子
TEL&FAX：048-957-3315
E-mail：yorikom@wg8.so-net.ne.jp
受付日：2019年7月1日 受理日：2019年8月30日

reinforce since the 1978 Declaration of Alma-Ata.
In 2005, the World Health Organization endorsed
UHC as a central goal and stated that health systems mustbe further developed in order toguarantee access to necessary services while providing protection against financial risk2， 3）． The
̶3̶

Medical Health Insurance Systems in Europe, USA, Canada, and Australia

definition of UHC embodies three related objec-

health services with national tax revenue. The

tives:

financial resources are 80% or more from tax, and1．Everyone who needs health services should

more than 18% from the partial contributions of

get them, not only those who can pay

National Health Service Premiums. The budget isenough;allocated in priority between medical security sys-

2．The quality of health services should be

tem and other public works. Management costs

good enough to improve the health of thosecan be reduced with nationwide collection of finan-

receiving services;

cial resources. This budget system is relatively
easy to control the entire healthcare cost8）．

3．People should be protected against financial1）

risk.

Except for medical emergency care, National

UHC can be understood as broad legal, rights-

Health Service is in the system that a patient see

based, social humanitarian, health economics anda pre-registered General Practitioner (GP), first.

4）

public concept ．

After that, if necessary, a GP introduces theWith acceleration of progress aging and slow

patient to see consultants in hospital. One percent

economic growth, the developed nations shareor more of national health expenditure occupies

some common challenges: how to fulfil the fair

private medical treatments with private insurance

access to health care for all people with sufficientand full amount of user charge5−8）． Per-capita

finances and high quality. This report is summa-

payment system is adopted that GPs receive therized the characteristics and tasks of the public

reimbursement of medical fees according to thehealth insurance systems of representative sevennumber of registered patients. The more regis-countries in Europe, USA, Canada, and Australia.

tered patients keep good health through preventive activities, the lower health service consump-

Medical health insurance systems

tion is needed. Since the surplus is the income of

Based on the financial resources, public medical

GPs, the preventive activities are willingly promot-

health insurance systems are mainly divided into

ed and incorporated into the healthcare systems8）．

three types: Tax Revenue Mode like United King-

General medical treatments are free of charge

dom, Sweden, Australia, and Canada in Table1;

for all residents who preregistered their own Gen-

Social Insurance Model financed from compulsive

eral Practitioner. One can basically see hospital

premiums like France and Germany in Table2;

consultants introduced by the General Practitioner

and the mixture of Tax Revenue Model and Social

with no charge.

Insurance Model like America in Table3.

Prescription drugs in outpatient is fixed-rateshare per prescription. Eyesight test and a part of

１．Nations adopted healthcare systems based onlong-term treatments are full amount of user

the financial resources from tax

charge. People aged 60 years or more, less than 16

1−1．United Kingdom

years, low-income household, and pregnant are［Medical insurance system］

exempted from their payments5−8）．

National Health Service (NHS) established in1948 provides comprehensive health services［Dental insurance system］

including disease prevention, rehabilitation for all

There are three bands of fixed rate charges forpeople. Central government provides medical

all NHS dental treatments. As from April 2019, the̶4̶Table 1 Public Health Insurance Systems on Tax Revenue Model

ヘルスサイエンス・ヘルスケア Volume 19，No.1（2019）

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Medical Health Insurance Systems in Europe, USA, Canada, and Australia

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Table 2 Public Health Insurance Systems on Social Insurance Model

ヘルスサイエンス・ヘルスケア Volume 19，No.1（2019）̶7̶

Table 3 Public Health Insurance System on mixed model（both Social Inurance Model and Tax Revenue Model）
Medical Health Insurance Systems in Europe, USA, Canada, and Australia

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current dental charges in 2019 are as the following

20 for in-patient care in most county councils.

lists9）：Fixed visit copayment is set for out-patient care,Band 1 (£22.7)

according to first visit or not, age of patient, and：Examination, X-rays, scale and polish, preven-treatment destination. Fixed copayment per day istive treatments, adjusting false teeth, treating

set for in-patient care, according to age, income,sensitive cementum

and hospitalizations of patients. Prescription drugs

Band 2 (£62.10)

are not free, capped at 2,200 Krona per year. The：Treatments in Band 1 Plus restorations, root

government

coversexpenses

exceededthiscanal treatment, extractions, oral surgery, andamount. Pharmacies are connected with a central-

SRP

ized system that medical history of each patient isBand 3 (£269.3)

stored, available for all pharmacies5）．

：Treatments in Bands 1 and 2 plus crowns,

Health care is more likely to be given priority inbridges, dentures, inlays and onlays, orthodon-

local government with few other policies to com-

tic treatment and appliances

pete, compared with the state. Regional disparities

Urgent (£22.70)

and movement of the working population from

：Emergency treatment and relief of pain

rural areas to cities lead to regional disparities andTreatments such as veneers and braces areunfairness in healthcare resources. The government needs to rectify this problem8）．

only available on the NHS if there s a clinical needfor them (not for cosmetic reasons). Similarly,
other cosmetic treatments, such as teeth whiten-［Dental insurance system］

5−8，10）ing, are not available on the NHS．

Oral healthcare is the responsibility of county
government, though counties are not required to1−2．Sweden

provide the services themselves. Dental care is not［Medical insurance system］

included in the general health care system, but isSweden has a universal healthcare system, pri-partly subsidized by the government.

marily government-funded, decentralized by counDental care for children and adolescents5，10−14）

ty councils and municipal governments which areresponsible for providing services5，8，10，12）．Most

All dental care for children and adolescents is

healthcare is provided with a national social insur-

free of charge up to the age of 19. Some country

ance system. The Swedish healthcare system iscouncils have extended to include general dental

mainly financed through taxed levied by county

care for young people over 20. Care is provided oncouncils and municipalities and partial sharing ofa regular basis and is individually targeted. The

patients. County councils are political bodies, regu-

dental care up to the age of 19 includes dental

lating medical prices and level of services in each.

treatments with specific dentists. The dental care

Public coverage is extensive and small fees paid

is financed and provided through the counties car-by patients, capped at 1,100 Krona per year inried out either by dentists within the Public Den-

2017. Swedish residents do not have to pay moretal Service (PDS) or Private Practitioners (PP). The

than 300 Krona for each doctor visit with primary

most of dental care for children and adolescents iscare. Free for services is provided for residents

carried out within the PDS.

aged under 20 for out-patient care and aged 18 to̶9̶Medical Health Insurance Systems in Europe, USA, Canada, and Australia

Dental care for adults5，10−14）［Dental insurance system］

Dental care for adults is provided by dentists

Patients must pay full amount of charge for den-from both PDS and PP. Adults pay almost fulltal care services including orthodontics, unlessamount of dental charge by themselves. Social

they hold a Health Care card, which may entitle

insurance system covers parts of the service costs

them to subsidized access15）．

and reimburses the patient for the majority of dental care, regardless of the dental care which is pro-

1−4．Canada

vided within the PDS or the PP.

［Medical insurance system］

A dental care voucher or dental grant of €15 isMedical healthcare in Canada is delivered

given to population aged 30 to 74 every year. For

through the provincial and territorial systems of

those aged 20 to 29 and 75 or older, the total is at

public burden funded by tax for all eligible resi-

the price of €30 per year. Not all kinds of dental

dents with medical services including in-patientcare are reimbursable. It is prioritized for preven-and out-patient care called Medicare5， 21−25）． It

tive care and disease treatment. The grant can beprovides coverage for 70 percent of healthcare

saved for two years.

needs. The remaining 30 percent is patients

self-

payment services such as prescription drugs,
1−3．Australia

optometry, and rehabilitation.

［Medical insurance system］
Australia has a universal health care system［Dental insurance system］

with primary care and General Practitioners simi-

Dental care is almost completely private pay-lar to UK, mainly funded by Medicare since 1984.

ments with 60 percent of employment-based insur-

Healthcare is delivered by both government andance and with 35 percent of self-payments, notprivatebycovered by public medical insurance guided the．It is mainly funded by the govern-

Canada Health Act of 1984. Dental care and regu-

ment at national, state and local government levels

lar checkups are highly relied on the affordability

as well as private health insurance. Medicare isof people to pay those fees5，23−25）．

companies

which

are

covered15−20）

Medicarefunded by a Medicare levy which is a 2% levy on
inhabitants

taxable income over a certain income.

２．Nations adopted healthcare systems based on

Higher income earners pay 1-1.5% additional levy

the financial resources from social insurance

called a Medicare Levy Surcharge if they do not

2−1．France

have private insurance. As for exceptions, resi-［Medical insurance system］

dents with certain medical conditions, foreign resi-

Health care in France is provided as a national

dents, low-income earners exempt from paying the

responsibility. The French health care system has

levy.

been one of universal health care from 2000, pro-

The federal government-administered Medicare

viding two fundamental rights for access to care: ainsurance scheme covers the majority of costs ofright to health insurance for anyone in stable andprimary health services. It covers a part of out-

regular, and a right for the most disadvantaged, topatient care, full amount of charge for in-patienta free coverage, with exemption from fee.

care.

The finance in the French health care system isa Social insurance model which premiums are̶ 10 ̶

ヘルスサイエンス・ヘルスケア Volume 19，No.1（2019）

based on income in Tabe2 5， 10， 26）． The French

Orthodontics is not covered under the state sys-

health care system is funded in part by compulso-tem. Basic dentistry including consultations, cavi-ry health contributions levied on all salaries, paidties, and tooth extraction is covered by the state,by employers and employees, in part by central

but more complex or cosmetic treatments such as

government funding. The state has been increas-

teeth whitening and a tooth implant are usually

ingly involved in controlling health expenditures

pricier. The state will not give any money back forcovered by statutory health insurance, financed bythese non-essential or infrequent treatments.

employer and employee payroll taxes, general

Patients will have to shoulder the costs them-social contribution, earmarked taxes levied on

selves or take out private insurance. Although,tobacco and alcohol, and state subsidies.

dental prostheses will be fully reimbursed starting

All legal residents compulsory join the systems

in 2021 under the system.

according to each occupation as statutory system,

Children are offered free dental check-ups every

where Caisse is set as a management system ofthree years between the ages of 6 and 18. You will

health insurance of occupations:

receive a letter from the Caisse Primaire d Assur-

１．Systems for employees include general sys-

ance Maladie, which entitles your children to their

tem which is registered by 92% of all

regular examination. Take the letter to the dentist,

nations including workers and the retired inand you will not be charged for the consultation5，commerce and industry. Others are civil

10）．

servant system, local public official system,and special system such as Paris Travel

2−2．Germany

Bureau, sailors, and solders.

［Medical insurance system］

２．Systems for non-employees include selfemployed and priests.

Germany has a universal health care system
paid for by a combination of statutory health insur-

Insurance benefits are based on reimbursement,

ance (Gesetzliche Krankenversicherung) and pri-

except for hospitalization which is directly paid tovatemedical institutions. The out-of-pocket paymentssicherung), dating back to the 1880s5， 10， 27−30）． It

healthinsurance(Private

Krankenver-for patients are basically composed of 70% out-

is a basically legal obligation for the whole popula-patient care, 80% in-patient care, and 65% generaltion living in Germany to have public or private

medical drugs. In many cases, the most of user

health insurance. Statutory health insurance ischarge is covered by benevolent association andbased on the worker s salary, covering majority ofmutual benefit association. The remainder is apeople. Salaried workers and employees with afinal self-payment.

yearly income below 60,750 Euros (2019) 27） areautomatically enrolled into one of 130 public non-

［Dental insurance system］

profitsick funds

at common rates for all

Citizens can claim 70% of the fee back from themembers. The employer pays 7.3%, half of thestate, if they are covered by the French Social

contribution, and the employee pays 7.3% of the

Security called Carte Vital. Normally. Patients willother half. Self-employed workers must pay all

charge full amount for treatments at once, andcontribution themselves.

then, 70% of most dental treatments for adults andSalaried workers and employees with a yearly

100% of them for children will be reimbursed.

income above 60,750 Euros (2019), students and̶ 11 ̶

Medical Health Insurance Systems in Europe, USA, Canada, and Australia

civil servants, and self-employed workers with nolow-income person, children and their families who

compulsory enrollment into public health insur-

meet certain eligibility requirements. In this manu-

ance can opt for private health insurance, charging

script, we describe these three types as publicrisk-related contributions.

health insurance system.

［Dental insurance system］［Medical insurance system］

Dental fees, both inside and outside sick funds

Health insurance in the US includes private

and insurance based care, are regulated. The sickinsurance, and social insurance programs such as

funds provide full reimbursement for surgical den-

Medicare as well as social welfare programs liketal treatment and necessary orthodontist care for

Medicaid and the Children s Health Insurance Pro-

persons aged less than 18. Persons under 18 years

gram (CHIP) in Table 3 5， 38−40）． Public healthof age are also eligible to receive certain prophy-

insurance coverage provide the primary source of

lactic treatments with free of charge. Traditional-

coverage for most seniors, and low-income chil-ly, public health insurance has imposed few cost-dren and their families who meet certain eligibility

sharing mainly for pharmaceuticals and dental

requirements.

care. In 2004, co-payments were introduced for

Medicare provides health insurance for seniors

adults aged 18 years or more to visit physicians

aged 65 and over and totally or permanently dis-and dentists. Dental treatments exceeding the pre-ability individuals, and people with end stage renal

defined range of necessary care and dental pros-disease and ALS. Medicare requires considerable

theses make co-payments of the insured person.

cost-sharing and 90 percent of Medicare enrollees

Those co-payments will be reduced for persons tohave some kind of supplemental health insurance.

keep healthy teeth.

Medicaid is a social welfare or social protection

Before seeking general care from the statutory

program which provide to people who cannot

health system, the patient must have a voucher

afford health coverage, instituted in 1965. It isfrom the sick fund. This voucher is both a certifi-

funded jointly by the federal government and thecate to demonstrate entitlement to care and thestates, and administered at the states. CHIP is adentist s claim form for reimbursement of the fee-

federal-state partnership to serve health insurance

for-service10）．

for certain children and their families who do not
qualify for Medicaid but cannot afford to enroll pri-

３．The Nation adopted healthcare system based

vate insurance31−37）．

on the financial resources from both tax andsocial insurance［Dental insurance system］

USA

Original Medicare (Part A and B) typically does

Traditionally, there is no public medical healthnot cover routine dental care such as dental

insurance system targeted for all residents in theexams, cleanings, fillings, crowns, bridges, and den-

US where the main medical security has been tra-tures38）．

ditionally covered with private insurance. Public

Some exceptions are the cases of the medical

health insurance coverage provides the primaryreconstruction of the jaw due to the suffering ansource of coverage for the only specific age andaccident in damage to the jaw, having a disease

persons: most seniors aged 65 years or more, andinvolving the jaw, and a tooth extraction directly

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ヘルスサイエンス・ヘルスケア Volume 19，No.1（2019）

caused by the disease. Medicare Advantage Plan,

cumstances.

private insurers, includes everything that Original
Medicare covers and covers additional dental cov-

Discussion

erage such as:

Tax-based financing system is relatively easy to・Cleanings

control the entire healthcare cost in healthcare

・Examssystem like UK8，41）．While, quality and inefficien-

・X-rayscies of health services are always problems such・Diagnostic services

as long waiting time of treatments and hospitaliza-

・Restorative services (fillings)

tion. In spite of dental treatments which need・Root canal treatment

large financial burden for patients, generally, it is・Periodontal disease treatment

partially covered with public dental health insur-

・Extractions

ance or almost full amount of direct payments for・Crowns, bridges, implants, and dentures

patients in most developed nations we picked up.

In spite of Medicaid dental benefits, the cover-Due to a shortage of dentists in public healthcare

age is limited and includes only essential ser-services, long waiting time and financial burden to39，40）

vices．Children under the age of 21 are pro-dental treatments motivates for patients to move

vided as part of Medicaid s Early Periodic Screen-

and receive cross-border health care in foreigning, Diagnosis and Treatment (EPSDT) program.

countries8， 42）． Problems relating the free move-

Under this program, children receive periodic oral

ment of patients and healthcare professionals with-evaluations, routine preventive dental care every

in EU member states need to deal with across

six months, restorative, and emergency dental

borders8）． It is necessary to discuss topics ofcare.

healthcare systems not only for one country as

The Medicaid Orthodontic Benefits for children
under 21 years old with severe physically handi-

well as the entire EU member states or global
scale.

capping malocclusions. The coverage is limited to

It is difficult to control the increasing medical

three years of treatment and one year of retention

costs because of fee-for-service system in social

care.

insurance model based on the financial resources

Medicaid dental coverage for adults over thefrom compulsory premiums like France. The

age of 21 or more varies the type of services

increase in medical expenses are compensated foraccording to the minimum standard set each fed-

the increase in health insurance premiums. Thiseral government39）． Major covering services are

has a negative effect on the national economy

preventive dental care such as checkups, oral

itself, such as a declining in purchase motivation of

exams, cleaning, bitewing X-rays, and sealants;

people8，43）．

restorative services, crowns, dentures, orthodontic

While there is a nation where public healthbraces to treat an accidental injury, TMJ, or sleep

insurance coverage provide the primary source of

apnea; root canal treatments and oral surgery;coverage for the only specific age and persons:dental work for the cases medically necessary

most seniors aged 65 years or more, and low-

across the country. Medicaid rarely covers dental

income children and their families who meet cer-

implant costs in full. Medicaid does not cover cos-tain eligibility requirements like USA. It would

metic dental procedures for adults under any cir-need to adjust and enlarge the range of application

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Medical Health Insurance Systems in Europe, USA, Canada, and Australia

for public healthcare system which all people
receive the fair access to health care with sufficient finances and high quality.
Conclusion
In the most developed nations we picked up,
especially the public health coverage for dental
treatments partially covered or completely notcovered in most cases, though dental treatments
are often a high financial burden for patients. USA
is a country where public health insurance coverage provide the primary source of coverage forthe only specific age and persons. There is potential for improvement so that wide range of people
can receive the higher quality of health care withless financial burden within the public health insurance.
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