January 21 , 2023 /


(Note: This blog is a follow up to this previous one, garygruber.com/broken

That piece focused on three systems, health care, education and politics.  The premise is that these systems are broken and dysfunctional, in need of more than being reformed. They need to be transformed into different systems that are more efficient, effective and economical. This piece has a number of references that provide information and details about other systems, thus it will be a longer read if you want some concrete examples and details.)



I wondered whether to use health care as two words or the one, healthcare.  The preference is to use healthcare as a one word noun when describing the system and two words when describing the practice and the process.


No system is perfect because it will not satisfy everyone nor will it solve all the problems inherent in any system.  A big part of the challenge is systemic change, defined here as change that reaches all or most parts of a system, thus affecting the general behavior of the entire system. However, systemic change is often difficult to envision, let alone encourage, because people generally find it easier to focus on the parts than on the systems that connect those pieces.  This seems to be the case in most efforts to change a system.  Different people have different priorities, different interests and tend to focus on those parts of a system that aren’t working rather than looking for places where things are working and building on those.


We have manufacturing, packaging and delivery systems that work well due to improved designs, technology, and logistics.  Those might have some clues for looking at how systems serving people might be designed differently, not merely upgraded but transformed to an entirely new system of delivery of services.  Think back to the advent of FEDEX in 1971 and how UPS, that started in 1907, and the USPS changed their systems to remain competitive. And then, Amazon.  For some other examples from other fields have a look at a TV program called Modern Marvels, formerly on the History channel. Look at the advent of EV’s.   Space travel.


There are many stories of incredible machines that continue to improve our lives and power the global economy. Adam Richman crisscrosses the country to discover how these incredible machines are made, what they do, and sometimes how what they do is make other machines! But for all of them, the ingenuity is something to applaud, and the process is a mesmerizing marvel. With exclusive access to the most well-known and beloved global industry titans, and the most promising up-and-coming small-town entrepreneurs, Richman pulls the curtain back on every step of the process. The machines found across America and the world tell the story of inspiration and innovation, they’re built to solve problems and elevate our lives and you’ll see them all on Modern Marvels: Machines.  So, why not find some clues there?


In the field of health care, there are four major healthcare models: the Beveridge model, the Bismarck model, national health insurance, and the out-of-pocket model. While each model is distinct in and of itself, most countries don’t adhere strictly to a single model; rather, most create their own hybrids that involve features of several.


The Beveridge model, developed in 1948 in the United Kingdom by Sir William Beveridge is based on a national health service where the government acts as the single payer. This removes competition in the market to keep costs low and standardize benefits. As the single-payer, the national health service controls what “in-network” providers can do and what they can charge.

You can see this model at work in the United Kingdom, Spain, New Zealand, Cuba, Hong Kong, and the Veterans Health Administration in the U.S.  And you can also see why this model has restrictions and limitations that are not popular and favored by many participants.

The Bismarck model (Otto Von Bismarck, end of 19th century) employers and employees are responsible for funding their health insurance system through “sickness funds” created by payroll deductions. Private insurance plans also cover every employed person, regardless of pre-existing conditions, and the plans aren’t profit-based.  Providers and hospitals are generally private, though insurers are public. In some instances, there is a single insurer (France, Korea). Other countries, like Germany and the Czech Republic, have multiple competing insurers. However, the government controls pricing.  The Bismarck model doesn’t provide universal health coverage. It requires employment for health insurance, so it allocates its resources to those who contribute financially.

The primary criticism of the Bismarck model is how to provide care for those who are unable to work or can’t afford contributions, including aging populations and the imbalance between retirees and employees.

The national health insurance model blends different aspects of both the Beveridge model and the Bismarck model. First, like the Beveridge model, the government acts as the single-payer for medical procedures. However, like the Bismarck model, providers are private.

This model is driven by private providers, but the payments come from a government-run insurance program that every citizen pays into. Essentially, the national health insurance model is universal insurance that doesn’t make a profit or deny claims.

Since there’s no need for marketing, no financial motive to deny claims, and no concern for profit, it’s cheaper and much simpler to navigate. This balance between private and public gives hospitals and providers more freedom without the frustrating complexity of insurance plans and policies.

The primary criticism of the national health insurance model is the potential for long waiting lists and delays in treatment, which are considered a serious health policy issue.   This model is used by Canada, Taiwan, and South Korea, and similar to Medicare in the United States.

The out-of-pocket model is the most common model in less-developed areas and countries where there aren’t enough financial resources to create a medical system like the three models above.

In this model, patients must pay for their procedures out of pocket. The reality is that the wealthy get professional medical care and the poor don’t, unless they can somehow come up with enough money to pay for it. Healthcare is still driven by income.  This model is used by rural areas in India, China, Africa, South America, and uninsured or underinsured populations in the U.S.



The descriptions of these models were published by Vera Whole Health who also published this article on Advanced Primary  Care:



Another article that is relevant to health care management is this one published in the Harvard Business Review in 2014 by Thomas Lee:






This is another case where it would behoove us to look beyond our borders to examples from other countries for national models and then look at some models delivering education within our own boundaries in the United States.  There are many.  Finland is regarded as having one of the best national systems and here is an article that describes 10 reasons why that is the case. If you think you don’t have time to read it now, save it for later.  It is worth a good read and think.




Other models I would suggest for consideration are a number of international schools with a refined, global awareness and a curriculum that is comprehensive, integrated, developmentally appropriate and performance based (not test score performance).  One example that comes to mind is the Singapore American School, one that continues to be on the growing, leading edge of an excellent, PreK-12 education.  https://www.sas.edu.sg/


There are other, similar, international schools throughout the world delivering first class, highly regarded learning experiences for their students.  Many of them are members of various international and regional organizations on different continents and they usually have their own web sites with details.


While being wary and suspicious about rankings in education, there are some states in the U.S. that seem to have better systems and results than others.  Part of this has to do with spending although there are numerous other variables at work in the ranking equations. Have a look at the rankings on the following list and see whether or not you agree or disagree with the results.




As for exemplary schools or groups of schools one has to delineate public versus private, the effects of compulsory schooling, too few vocational options and the effects of the one size fits all model which does not work.  Here are links to lists of some of the best public high schools in the U.S. a list of the best private high schools, and private K-12 schools.










Ironically, despite the United States having the best-surveyed education system on the globe, U.S students consistently score lower in math and science than students from many other countries. According to a Business Insider report in 2018, the U.S. ranked 38th in math scores and 24th in science. Discussions about why the United States’ education rankings have fallen by international standards over the past three decades frequently point out that government spending on education has failed to keep up with inflation.  Teachers in the U.S are overworked and underpaid leading to many leaving the profession and the Covid pandemic put additional pressure on teachers to reconsider whether or not to continue.  Thus, one big option for improvement, among others, is to increase compensation packages for teachers to be competitive with other highly educated and skilled professions.




A question that I posed to begin this section is how does one determine what is a good government and what other systems might be looked at for how they work?

One category that emerged in studying governments is political stability, meaning how power is achieved and used.   When we look at the rankings of countries according to political stability here are the results.  While the United States is 21st in political stability, it is ranked #4 overall.

Size and GDP are other factors:



Difference of opinion and methods of measuring how we go about deciding which governments better than others means it can seem almost impossible. However, many experts believe that there is a way to compare governmental systems in such a way that a comprehensive, reliable and in a way that a ranking can be produced. One such ranking is published by the Legatum Institute, based in the Unites Kingdom. From its methodology, it finds that Switzerland has the best government in the world.  It is also a small country that claims to be neutral.  Costa Rica is another interesting country in that it has no standing army, no significant military expenditure, a relatively good educational system, high level of employment and its leading export has shifted from fruit to medical technology.  However, only slightly over 5 million people living there while the U.S. contends with 339 million.  For more on Costa Rica, consider this:



It would appear that no matter how powerful or progressive or wealthy a nation may be, good governance plays an important role when considering how successful a nation is across the board. As a point in fact, although the United States currently claims to have one of the world’s largest economies, it only ranks 11th in both the Best Governance list and the Best Countries to Live In list.  Have a look at this list and then make up your own mind what you believe and why.




All of the above “OPTIONS FOR IMPROVEMENTS” are offered as examples where we might get some new ideas and suggestions.  There are no easy, quick or inexpensive solutions.  All have inherent challenges, take time and cost money.  What needs attention, and decisions, are priorities and then put some of the best minds and models in place to serve people and help make life better where we find it.




Please share your thoughts and opinions