Comparing Healthcare Systems: A Roleplay Debate

July 2, 2019

What healthcare system is best for the U.S.? Students work in teams to evaluate and debate different countries’ healthcare systems from the perspectives of a variety of stakeholders (including doctors, the wealthy, and people without insurance). Students must integrate data from a chart with information from text. This lesson works well as a followup to the Healthcare Roleplay and Scavenger Hunt lesson.

Medicaid checkup
https://www.flickr.com/photos/breadfortheworld/22295250392


Introduction


Explain to students that today they will divide into five different teams.  Each team will play the role of a different group with a particular perspective on healthcare – such as doctors, the wealthy, or people without insurance.  While playing the role assigned to their team, students will research and compare different countries’ healthcare systems from their group’s point of view. Then they will debate what changes might need to be made to the American healthcare system to improve it.

Once students are ready, divide them into five teams and give each team their team agenda (at the bottom of this lesson and also included in this handout). Tell students that they might not agree with some or all of their team’s agenda, but they get to pretend to believe it just for this debate.

Have each team read and discuss their agenda, come up with a personalized team name if they wish, and write the name on a sign.
 



Discuss in Teams


Give all teams the “Healthcare Systems Handout” comparing four countries’ healthcare systems (see the bottom of this lesson as well as the handout). You may wish to go over key vocabulary in advance (premium, deductible, subsidies, single-payer, etc.).

  • Ask students to read the handout and make notes about the reading and the chart to highlight what they like about each system.
  • In their teams, students should discuss together what kind of healthcare system is best according to the agenda of their roleplay team. Teams might choose an existing system described in the reading, or design a combination. If time permits, invite teams to do additional research on the different countries’ systems in order to develop their arguments further.
     

 

Roleplay Debate
 

As teams finish deciding which system they support, explain to the class that now the different teams will work together try to agree on an improved healthcare system for the U.S., using a fishbowl discussion format. (In a fishbowl, a small inner circle of students discuss an issue. Others from their team stand behind them and listen to the discussion.)

Invite each team to choose one member to send as a representative to the fishbowl.

Have each representative sit in the fishbowl behind their team sign, and have the rest of their team sit near their representative in support. At any point, team members can tap on the shoulder of their representative to switch out as the new team representative. No one outside the fishbowl should speak (though conferring in whispers between team members might be okay).
 

Begin the debate

Ask students: How should we improve the healthcare system in the U.S.?

Make sure to have a copy of the team agendas in front of you, so that if the teams begin arguing something that is obviously incongruent with their agenda, you can slip them a quick note to get them back on track.

Encourage a rapid exchange of participants in the fishbowl by inviting those who look eager to speak to tap into the debate. You may also call time-outs in order to allow teams to confer and plan arguments. Other than that, try to stay out of the debate.
 

Debrief the debate

  • End the debate with a round of applause to help everyone transition out of character.
  • Briefly discuss which team’s arguments were most convincing and why.

 


 

Closing

Ask students to share, in one sentence, one new realization they have about healthcare after today.

 



Extension Activities

Invite students to write individually, from their own perspective (not their role), what should happen to improve the healthcare system in the U.S.

To extend the learning, students might research what actions people are currently taking to improve the healthcare system, or which current political proposals come closest to their preferred system.

One resource for researching different healthcare political proposals is https://www.commonwealthfund.org/many-varieties-universal-coverage.

 

 


 

Healthcare Systems Handout

Also see this pdf version.

 

Group Agendas
 

  • Doctors: You got into medicine in order to help people, but now many of your patients can’t afford their medications and avoid going to the doctor because they  have to pay too much out of pocket – even if they have health insurance. You must see many patients in order to cover the cost of your office staff, who are responsible for billing and fighting with insurance companies to get them to pay for patients’ care. As a member of the medical profession, your priority is to have a healthcare system where doctors and hospitals still get paid a fair amount, but you also want to focus on caring for people, not worrying about billing.
     
  • Wealthy People: You represent the rich people of America who are able to get excellent care under the U.S.’s current healthcare system. You have high-quality private health insurance coverage and can easily cover out-of-pocket expenditures as needed. You ask the tough questions about what the changes everyone else is proposing will really mean. Your priority is to stop everyone else from doing anything too drastic, especially eliminating private health insurance—who knows what would happen! You advocate for a healthcare system that fixes a few of the problems of the current system, but without going too far. You want to make sure the system is responsible and doesn’t waste resources on people who don’t really need it.

     
  • Self-Employed People: You work for yourself or own your own small business. Before the Affordable Care Act (Obamacare), you often had a hard time affording insurance, and it’s still not be easy to pay for it.  However, Obamacare provides you with some subsidies to help you cover some of the cost. Your priority is to have a healthcare system where health coverage is affordable— but that could mean a lot of different things. You listen carefully to the arguments of the other groups and think about how their ideas would affect the financial bottom line for your business.

     
  • People Without Insurance: You represent all the people who still have a hard time getting insurance or care for whatever reason. Maybe you earn just enough money that you don’t qualify for Medicaid (the government-funded program for low-income people). Or maybe your job doesn’t offer insurance and you can’t afford to buy it on your own. Or, your job does offer insurance, but the premiums (monthly insurance payments) are so high, you can’t afford to pay for it. Your priority is to have a system where you get the healthcare you need without racking up medical bills that you can never pay.

     
  • Very Sick People: You or your family need a lot of medical care, a lot more than most people, so you have a special perspective on how healthcare systems can break down. You live in fear that you will lose access to health insurance coverage for the medications or special treatments you need to survive. You want a healthcare system where nobody ever goes without care because of their health or finances. You care about making sure that doctors get to decide what gets paid for (not insurance companies), that people never lose their insurance, and no one ever goes without tests or treatment they need. 

 


 

Comparing Healthcare Systems

 

Instructions: Make notes on the handout about what you like about each country’s healthcare system. Which country’s system is best, according to your team’s agenda?

Healthcare systems in the U.S., Switzerland, Canada, and the U.K. are set up very differently in terms of who pays for the care and how care is provided. Broadly, the U.K. government pays for and runs all medical care; Canada pays for all medical care but does not run it; Switzerland requires all citizens to buy insurance but subsidizes the cost; and the U.S. uses a mishmash of all of the above.


The U.S. has many different systems to pay for healthcare.

  • About half of people have private insurance through jobs, while some buy private insurance themselves.
  • The Affordable Care Act (Obamacare) provides subsidies to help lower income  people purchase their own private insurance plans.
  • Many private insurance plans have high deductibles in addition to monthly premiums, forcing people to pay for care out of pocket until the deductible is met. Many people skip care because they can’t afford to pay this money.
  • About one-third of the population is on some kind of government health insurance plan, including Medicare (for people over 65 and the disabled), Medicaid (for low-income people), and military care.
  • Nine percent of the population is uninsured and must pay for care directly – or else go without care.
  • This complexity makes medical billing particularly expensive in the U.S.
  • Hospitals are privately run, except for those for military veterans (VA hospitals) which are run by the government.
  • U.S. medical care is the most technologically advanced and innovative in the world, and its doctors are the best paid.
  • But the U.S. leaves more people uninsured than any other industrialized country, and health outcomes (like infant mortality and longevity) are not as good.
  • The overall cost of U.S. healthcare is far higher than in any other country.

 

Switzerland requires everyone to buy private health insurance on healthcare exchanges (similar to the health exchanges under the U.S.’s Affordable Care Act).

  • Insurance companies are non-profit organizations but compete for customers.
  • Jobs do not provide insurance, and no one is allowed to go without insurance. As a result, the overall cost of private insurance goes down because the cost of medical care is spread over more people.
  • Thirty percent of people get subsidies based on their income to help them buy insurance.
  • Hospitals are privately run.
  • The government negotiates drug prices and regulates fees for medical services to control costs.
  • Swiss health outcomes are excellent, but costs are higher than many other countries (though still lower than in the U.S.).

 

In Canada, the government uses taxes to pay for health insurance for everyone.

  • This “single-payer” system (meaning that the government is the single payer of health insurance) greatly reduces costs for medical billing compared to Switzerland and the U.S. 
  • Everyone in the country has health insurance and can go to any doctor or clinic and get care.
  • Hospitals are privately owned, not run by the government.
  • Canadian health insurance covers basic care but does not cover things like prescriptions, dentistry, and vision care. Sixty percent of Canadians get private insurance, usually through their jobs, to cover those things.
  • Canadians have longer wait times to see doctors than many other countries, but when they have an urgent issue, they move to the top of the wait list.
  • Their health outcomes are better than in the U.S.
  • The country spends half what the U.S. spends on healthcare.

 

In the U.K., the National Health Service uses taxes to pay for almost all medical care (meaning it is single-payer) and also employs almost all doctors (meaning it is socialized).

  • All U.K. citizens are covered for any medically necessary care including free prescriptions, dentistry, and mental health care.
  • Copays are generally not required except for dentistry, and those are less than $15.
  • About 10 percent of Brits get private insurance, usually through their jobs, to cover medical care that their doctor decides is “elective” (optional). 
  • U.K. hospitals can be overcrowded and not as fancy as U.S. hospitals, without the latest tech.
  • But overall costs are among the lowest in the industrialized world, and health outcomes are better than in the U.S.

 


 

Costs, Access, and Health Data

 

 

U.S.

Switzerland

Canada

U.K.

Total cost (% of GDP)

17%

11%

11%

9%

Yearly cost per person

$9,086

$6,325

$4,569

$3,364

% who avoided medical care due to cost in past year

33%

22%

16%

7%

% who waited two months or more for specialist appointment

6%

9%

30%

19%

Infant deaths / 1000 births

6.1

3.9

4.8

3.8

Preventable deaths/100,000 people

112

55

78

85

Cost of medical billing as % of total hospital expenses

25%

Less than 25%

12%

12%-16%

Average doctor salary (adjusted for cost of living)

$161,000

$116,000

$107,000

$118,000

 

Sources:
ttps://international.commonwealthfund.org/
https://www.nytimes.com/2018/07/16/upshot/costs-health-care-us.html
https://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make/

 


 

Questions for Teams to Consider


Discuss these questions as your team considers which system to support:

  1. Should we work to make sure everyone has health insurance, or are there better ways to improve our system?
     
  2. Should a public health insurance plan be an option that people can buy into only if they don’t want to keep their current insurance, or should everyone automatically be enrolled in the public health plan covered by taxes? (Note that having everyone in one system saves bureaucracy and paperwork, which is one reason single-payer systems can cover everyone at less expense.) 
     
  3. Should people have to pay whenever they use medical care (through copays and deductibles) to make sure they only use what’s necessary, or should medical care always be free?
     
  4. Should hospitals be run by the government to control costs and quality directly, or privately to keep them competing on the free market?