Editor’s Note: This post was written by the 2007-08 Commonwealth Fund Harkness Fellows. The lead authors are Andreas Gerber and Rhema Vaithianathan. Additional authors include Kalipso Chalkidou, Richard Gleave, Peter Hockey, Geraint Lewis, Ruth McDonald, Neil MacKinnon, Peter McNair, Claudia Sanmartin, and Stephanie Stock.

While policymakers in the U.S. have long recognized the benefits of looking overseas for useful lessons about health system reform, there now appears to be a wider interest in international comparisons.

As a group of Harkness Fellows in Health Care Policy and Practice from Australia, Canada, Germany, New Zealand, and the United Kingdom, we are aware that learning from other health care systems has great value, but it needs to be undertaken with care and sensitivity. We, too, are grappling with how exactly one learns lessons from systems that are very far from each other.

The New York Times recently wrote about the lessons to be learnt from Switzerland and the Netherlands and the results of the latest survey of international health care from the Commonwealth Fund. America’s Health Insurance Plans (AHIP) and Kaiser Permanente (KP) hosted presentations by executives from Swiss and Dutch insurance companies about how their health care systems deliver universal coverage through private insurance.


Switzerland´s health care system is a private insurance-based model offering universal coverage and therefore has certain features from which the U.S. could learn useful lessons. However, it has the following important shortcomings:

(1) Switzerland has the second most expensive health system in the world after the US (with 11.6% of gross domestic product spent on health, according to the Organization for Economic Cooperation and Development), but achieves only mediocre health outcomes (ranked 20th by the World Health Organization in 2000).

(2) Cost containment in the Swiss system has failed, with premiums having increased by 80% in real terms since 1996 when the system was first introduced, and by 51.5% from 1999 to 2006 alone.

(3) To achieve “universal coverage,” more than one-third of the Swiss population must rely on state subsidies.

(4) Premiums vary by more than 100% between Swiss counties (“cantons”) for identical coverage.

The Netherlands

The Netherlands only introduced universal private health insurance last year, so the effect of the reform on costs, risk selection, and the proportion of the population requiring state subsidies is not yet known. However, there are features of the Dutch system that are strikingly different from the U.S. health care system, so simply extrapolating the Dutch experience to the U.S. could lead to invalid conclusions, unless other changes, such as primary care reform, are also made in the U.S.

One of the pitfalls of intercountry exchanges of ideas on health system design is that all too often we hear only one side of the story, but if U.S. policymakers are keen to learn from health systems providing universal coverage, we suggest that they also look at other countries that achieve better health outcomes, with wider choice at lower cost.