A comparison of healthcare service for international students in United States and United Kingdom: A perspective of institutional complexity

: As newcomers to the host country, international students face unique challenges when it comes to the healthcare service, such as the language barrier. The challenges lead to a low utilization rate of the healthcare service in the population of international student. This paper aims to find out the main reason behind the phenomenon and explore how to improve the health and welfare of the international students. A nested case study approach is used and the United States and the United Kingdom are the two countries for comparison. We found that benefiting from a simpler system, international students in the UK enjoy superior healthcare access compared to their counterparts in the US. It is recommended that UK and the US should prioritize comprehensive healthcare orientation programs, ensuring students are well-informed about accessing and navigating their respective systems.


Introduction
As the two largest destination countries in the world, the US and UK has attracted the largest number of overseas students in the world, and the number is increasing year by year.In 2021, over 0.6 million oversea students are in the UK 1 and over 1.2 million in the US in 2021 2 .And most universities are receiving more international student applications for the 2022/23 academic year 3 .More attention should be paid to this large population.International students usually face a set of challenges that can impact their overall well-being.These challenges include language barriers, cultural differences, financial difficulties, homesickness, academic challenges, and both mental and physical health.Of these challenges, the biggest obstacle for international students is to get used to a variety of unfamiliar institutions, such as the healthcare system.Considering the importance of healthcare system in daily life, the article will investigate how the complexity of healthcare system affects the healthcare service utilization.
Foreign students are not familiar with the new healthcare system so they need time to learn and understand the complex rules and procedures 4 .In particular, international students often struggle to utilize healthcare services in their host country due to the complexity of the healthcare system, language barriers, and the additional time and effort required to obtain information and adapt to the local healthcare system.As a result, some international students may delay seeking medical treatment or even avoid it altogether, which may worse the situation and can finally lead to increased medical costs.To support the health and well-being of international students, it is crucial to pay attention to their health status, willingness to seek medical care, and the convenience of accessing healthcare services.
Nevertheless, the easiness of healthcare services for international students varies across countries.The performances of healthcare systems vary widely depending on factors, such as the access to healthcare, coverage, costs and quality of care.For example, UK (public health service model) is believed to perform better than US (private health service model), in providing universal healthcare coverage for all citizens.Why do them perform differently?Which factor influence the quality of health services for foreign students?It is essential to examine the factors that influence the quality of healthcare services for international students and compare the experiences of international students in different healthcare systems.To address this issue, this article will focus on health service utilization of international students and varied states in different health systems.It aims to describe the challenges confronted by international students and the impact of health system setting on the quality of service.
The content of the article is as follows.First, review the literature on health problems and healthcare utilization of international students, and develop an analytical framework for case study.Second, describe the methodology and data; Third, compare the healthcare service that international students gain in UK and the US, the two countries that we choose for comparative case studies.Finally, based on the comparison, draw conclusions and provide policy recommendations to improve the quality of healthcare services for international students.

Health-related issues as to international student
There have already been many researches on mental health of international students.Those mental problems are homesickness, loneliness, culture shock, stress about linguistic, academic, interpersonal, and financial concerns, mental exhaustion and burnout, anxiety and depression 5 .For example, Han et al. (2013) illustrated that among 130 Chinese students at Yale University, 45% had symptoms of depression, and 29% had symptoms of anxiety 6 .Among 13,984 full-time students, 35% reported positive for at least one common lifetime disease and 31% reported positive for at least one 12-month disease 7 .
There is a growing body of research indicating that international students face a range of physical health problems as they adapt to life in a new country.For instance, they may experience injuries during exercise, contract illnesses like the flu, or even be involved in traffic accidents.Additionally, mental health problems can lead to physical symptoms such as fatigue, headaches, sleep problems, weakened immunity, and heightened susceptibility to other illnesses 8 .International students may also struggle with poor nutrition, lack of appetite, and gastrointestinal issues due to limited access to healthy food and cultural differences in available cuisine 9 .
Although there are many health issues, the willingness of international students to seek medical care is not high.Tang Charlotte et al. (2018) investigates challenges that international students face when accessing healthcare in their host countries and the alternative solutions they use to deal with challenges 4 .According to their findings international students encounter several difficulties in understanding healthcare services information, high healthcare treatment costs, unfamiliar and complex health practices, negative beliefs toward western medicine, and communication and language barrier.As a result, many international students must actively seek out information about healthcare services, take preventive measures to stay healthy, and rely on medicine from their home countries to deal with health problems.

Inclusion of immigrates in different healthcare system
Different countries have different healthcare system.The healthcare system can be broadly categorized into three types on the basis of three aspects of financing, provision and regulation 10 .The types are state healthcare systems, where state actors and institutions assume financing, provision and regulation; societal healthcare systems, where social actors are in charge of financing, provision and regulation; and private healthcare systems, where market actors play the most important role in the three dimension (See table 1).Böhm et al. made a more elaborated classification which included 10 types of healthcare system 11 , but the underlying logic of classification was consistent, which was also on the basis of regulation, financing and provision.Different healthcare systems provide services in different ways.The NHS in the UK is regarded as a typical state healthcare system, where the government ensures health insurance coverage for all citizens, regardless of their financial status.Immigrants are entitled to receive the same range of services as UK citizens, including primary care, emergency care, and hospital treatment.The NHS does not discriminate based on immigration status, and all individuals are encouraged to access care when needed.Additionally, the NHS offers interpretation and translation services to support communication with patients who may have limited proficiency in English.
Countries of Central and Eastern Europe (CEE) used to be the socialist healthcare system and then changed to social health insurance system 12 .Under that kind of system, the government owns and operates the health system, so the providers are employees in the government.
Unlike many other developed countries that have universal and free healthcare programs, the US healthcare system is a private type.Most Americans are served by a mixture of public and private healthcare systems 13 , but access to care can be limited for immigrants.While some immigrants can have access to healthcare through employer-sponsored plans or public programs such as Medicaid, others may be uninsured due to legal status or lack of affordable options 14 .Some states have implemented their own policies to expand coverage for immigrants, like Connecticut, which extended statefunded full Medicaid coverage to pregnant women and children from households with low incomes regardless of immigration status.Nevertheless, the overall landscape remains complex and varies widely depending on the individual's circumstances.Overall, the US healthcare system does not provide universal coverage, and immigrants may face significant challenges in accessing care.Although the health insurance in the United States is more selective, newcomers hold negative views on the insurance system in the United States.They regard the healthcare system in the US as an unpredictable and complicated one which is difficult to use, because in order to utilize the healthcare service, they need to learn a large amount information about the complex system 15 .

Healthcare utilization of international students
International students have a lower utilization rate of healthcare services compared to domestic students.The UK government's data revealed that uptake of the MenACWY vaccination was 45% in EU students and 29% in non-EU international students.Moreover, only 68% of international students knew how to access sexual health services, significantly lower than their domestic peers.Additionally, GP registration was found to be lower among international students, with 48% of unregistered students being unaware of how to access services 16 .Several studies have also indicated international students' mental health service utilization rate is similarly low 17 or even lower when compared to domestic students 18 .It was found that many factors hinder international students from utilizing healthcare services in their host countries.These factors include distrust of western medicine, language barriers, and knowledge gaps, which are commonly encountered by international students in both the UK and the US 4 .These challenges contribute to the lower healthcare utilization rate observed among international students compared to native English speakers.However, it is noteworthy that the healthcare service utilization rate of international students in the UK is higher than that in the US.According to the CPC-ONS-UUK Survey of Graduating International Students 2017 -Technical report, approximately 67.7% (1312 international students) utilized NHS services in the UK within the last 12 months while studying, including GP consultations, Accident and Emergency visits, and Contraception & sexual health services 19 .In contrast, one study focusing on Asian international graduate students in the US showed that only 6.9% of them utilized any mental health services, significantly lower than the rate of 45.2% among domestic graduate students 20 .The difference in the utilization rate of healthcare services between the two countries may be attributed to the distinctive health systems and their complexities.The health systems in the UK and the US differ significantly.As a result, international students experience varying degrees and types of difficulties when accessing services and seeking medical care.For example, international students in the UK expressed dissatisfaction with the long waiting time of GP appointments and automatic replies from medical centers 21 .In the US, international students often encounter challenges in understanding and utilizing healthcare insurance, along with concerns about the intimidating costs of health services 4 .

Method and data
The article focuses on a comparative analysis between the US and the UK as case countries.To account for the significant differences in healthcare insurance plans among US universities, this article selects various types of universities for detailed analysis.In contrast, the healthcare service in the UK is provided through a unified system, eliminating the need for a classified discussion.The article compares the differences between the UK and the US in three key aspects, which are institution, complexity and performance, aiming to analyze how the complexity of healthcare systems (institutional settings) influences the effectiveness of medical services (See figure 1 and table 2).It's crucial to emphasize the importance of studying the "complexity" in healthcare systems.Complexity can significantly influence patients' ability to access and utilize medical services.For example, with varied choices and intricate reimbursement procedures, certain individuals might face challenges in getting the care they need.Moreover, complexity can amplify administrative costs and lead to inefficiencies.Therefore, understanding the complexity of healthcare systems is pivotal to comprehending their impact on the efficacy and equity of medical services.

Acquisition
ease or difficulty to register Utilization ease of use of the services

Reimbursement efficiency of claims and their reimbursement
Performanc e Utilization Rate Utilization rates of the two groups (domestic student and international students) Waiting time average time patients have to wait before receiving medical services.

Unexpected costs Unforeseen cost during the course of treatment
The article relies on various data sources, including public statistics from the British and American governments, reports from research institutions, and empirical research conducted by other scholars.These diverse data sources offer valuable information on aspects such as the complexity of healthcare systems and the medical access of international students.

UK healthcare system
In UK, residents access both physical and mental healthcare services through the National Health Service (NHS).The NHS is funded through a combination of employee contributions from wages and general government funding raised in the form of taxes.However, the availability of funding may fluctuate based on political and economic factors, necessitating NHS payment system that supports the delivery of improved healthcare within the available resources (see table 3).
Most medical services provided by the NHS are free at the point of use for the patient, but certain procedures may require additional payment.The NHS offers a wide range of services, including primary healthcare at General Practitioners (GPs), dental care, hospital and emergency treatment, family planning and sexual health services, mental health services, and more.People can access these services without any extra cost, except for some specialized NHS services like eye care, dental treatment, and prescriptions for medication.
The British public expresses great satisfaction with their country's health service system and holds it in high regard.A survey commissioned by the King's Fund and conducted by Ipsos reveals that support for the NHS and its founding principles remains robust.The majority of the public, about three-quarters (77%), firmly support maintaining the NHS in its current form, while a smaller proportion (23%) believe it may not be sustainable.This consistent level of support has persisted over nearly two decades 22 .

The complexity of UK healthcare system
The healthcare system in the UK is relatively straightforward and accessible for international students.
Although the NHS may be unfamiliar to many international students, the process of obtaining healthcare through it is simple, and the necessary knowledge is easily within their reach.
As for the acquisition of healthcare service, it's easy for international students in the UK to be qualified for the NHS.As for EU students, are eligible for free NHS treatment with a European Health Insurance Card (EHIC).As for Non-EEA international students, NHS covers foreigners who pay an extra cost called additional immigration healthcare surcharge (IHS) when they apply for visas.Only a small amount of information is required, such as checking their residence time in the UK.Full-time international students studying in the UK for a period longer than six months are eligible to use NHS services.For short stay, the international student should take out private health insurance.International students staying for six months or longer can pay a yearly fee of £470, granting them access to the same NHS services as domestic students.
As for the utilization of the healthcare service, one of the first tasks for international students upon arriving in the UK is to register with a GP practice.They can compare different GP practices based on location, facilities, services, and performance before choosing one that suits them best.
Ensuring that every citizen is served with free medical treatment is the main feature and advantage of NHS over other countries.The NHS protect the health and medical interests of the whole people.The free medical care system in the UK makes medical services accessible and equitable to everyone.Individuals can receive appropriate medical treatment without any financial burden, allowing for timely and comprehensive care.Additionally, the free medical care system in the UK reduces the financial burden of patients, enabling them to focus on their treatment and well-being instead of worrying about medical expenses.Patients can access the medical services they need promptly, leading to better care and improved overall health outcomes.

Medical services encountered by international students in the UK
It is also found that newly arrived migrants tend to utilize healthcare services less frequently than the UK population 23 .Similarly, a study investigating the number of international students' GP visits in the last 12 months within one year revealed that 44% of students had not visited a GP during that period 19 .The specific challenges faced by international students, who predominantly come from non-English speaking countries, include language barriers and cultural differences, which act as significant barriers to healthcare utilization.It is difficult for them to describe their symptoms to the doctor clearly.Not only do doctors fail to correctly obtain their symptoms, but they also can't understand doctors' explanations and medical suggestions 21 .As a result, it increases the lack of sense of security and faith in doctors in the UK and make them feel humiliated.When they get ill, they just use medicines they bring from home such as special Chinese medicines 24 or wait until they return home.
However, the NHS is heavily understaffed and underfunded, which means long wait times for appointments 25 .Some international students may find themselves waiting for extended periods when they need medical services, which makes them painful and uncomfortable 21 .Also, automatic services in medical centers be difficult to operate, leaving students unsure of what steps to take next.
Although the healthcare system still has some deficiencies for international students, which affects their utilization of the NHS service, the overall health condition of international students in the UK appears to be satisfactory.In Jane's survey, the majority of international students rated their general health as very good or good (86.2%), with a smaller proportion considering it fair (12.0%), and only a small minority rating it as bad or very bad (1.8%) 19 .

US healthcare system
Unlike many other leading countries, the US healthcare system operates on a privately owned and free market system.In short, it means that hospitals and healthcare facilities are driven by profit motives.
The US medical system is not only complicated but also known for its high costs.For instance, a visit to a specialist doctor can cost around $400.A minor surgery at the local hospital may easily amount to thousands of dollars, including charges from the hospital, doctors, surgery, and follow-up care.Given these substantial expenses, having health insurance is crucial for international students during their time in the US.While the monthly health insurance fees can be costly, it provides essential protection against potential financial burdens resulting from medical care.International students in the US typically access healthcare through insurance.They pay a monthly premium for insurance coverage and then make payments when they utilize healthcare services.Without health insurance, seeking medical care could lead to owing thousands of dollars in medical expenses.Health insurance serves as a safeguard against such unexpected costs.Health insurance (Private or Federal insurances) covers the medical expenses of health care treatments of patients, provided by doctors or healthcare providers.Some health insurance plans also covers the prescription drugs.

The complexity of US healthcare system
The United States does not have a national healthcare system, instead there is a distributed, varied private insurance system.For international students, each university give them the flexibility to decide their insurance, although the laws at the national level and state level have some regulations on it.Most American universities provide school health insurance plans, but they are not compulsory.If the student can meet the waiver criteria, which means if student can obtain basic health service from the market, then they can choose other insurance.Universities that don't offer school-sponsored insurance plans require international students to select their insurance from the market.
As a result, international students must invest extra time in acquiring information about their school healthcare plans.They need to know if the university provides health insurance, whether it is compulsory, the waiver criteria, and the process of enrolling in the healthcare system.Additionally, they must familiarize themselves with the details of health insurance, including coverage, prices, and limitations 4 .The diverse information requires international students to prepare well in advance, even before departing their home country, to select the best insurance option for themselves.
In most cases, the healthcare insurance provided by universities is more expensive than that in the market, but both options are cheaper than the average cost of individual health insurance for an American ($6720 in 2023) 26 .For example, the University of California provides UC-ship for international students at $4,410 per year, Columbia University requires all international students enrollment in the Columbia Plan at $4,541 per year, while the Blue Sky 80CA in the market costs only $915 per year.Due to the high price, international students often prefer insurance from the market and need to waive the on-campus insurance.However, although most universities give them the freedom to waive, the fact is that some universities' waive criteria is so restrictive that students can't get through the application, which means the enrollment is mandatory.Some universities don't provide insurance so students have to choose commercial insurance in the market.The following comparison outlines the differences between the two types of insurance.
(1)Students with compulsory insurance Although the school's compulsory insurance is expensive, it offers superior services.For instance, Duke University is one of the schools mandating students to buy its insurance.It offers a Student Medical Insurance Plan (SMIP) for students.Students may waive the insurance if they does not hold an F1 or J1 visa, but almost all international students are on F1 and J1 visas, so they will be automatically enrolled in the Duke healthcare insurance plan.The annual cost of coverage for all eligible students for the 2023-2024 plan year is $3,282.12.The SMIP grants students access to medical care at the Duke Student Wellness Center and covers a wide range of healthcare services and offers lots of healthcare resources, including primary care, timely care, mental health service ,wellness promotion and nutrition resources.Although dental care is not covered, students can utilize the Basix Dental Savings Program, saving up to 50% on general dental care and 20% on specialty care.Although the annual premium can be a little steep, it will be well worth if international students get injured or ill.
(2) students with commercial insurance Due to the relatively high premiums of on-campus health insurance or the absence of insurance offerings by some universities, many international students choose to buy off-campus insurance.Ball State University is one of the universities that don't offer an international student health insurance plan, so students there will seek health insurance in the market.While this type of insurance may be cheaper than on-campus alternatives, it does come with certain drawbacks.For instance, Blue Sky 80CA costs only $915 per year, but the deductible and out-of pocket maximum is high, which are $500 and $7000 respectively.Premier 90 costs $1,488, but when you go to the emergency treatment in a non-crisis situation, the loss ratio is 0%.The medical services available to students vary depending on the insurance plan chosen, with generally higher premium plans providing more comprehensive medical services.
In summary, although on-campus health insurance may be more expensive, it often offers better services and coverage.Off-campus insurance can be more costeffective but may come with limitations and higher out-ofpocket expenses.International students need to carefully evaluate their options and consider their specific healthcare needs when choosing an insurance plan.

Medical services encountered by international students in the US
It is found that international students in the US prefer to go back to their home country for healthcare service during breaks 15 .Their preferences are influenced by various personal concerns, such as distrust of certain health services, fear of privacy breaches, language barriers, cultural differences and discrimination.Consequently, they develop negative beliefs towards Western medicine and place greater trust in doctors and medications from their hometowns 4 .
Due to the complexity of private insurance healthcare system in the US, international students encounter difficulties in seeking a desirable health insurance plan.International students find it difficult and frustrating to understand the health-related information.The information available on the university website and pamphlets regarding school-sponsored plans is often insufficient, unclear, or confusing.Additionally, staff at the International Center lack training to provide advice on health insurance, leaving students without practical help or clarification.Moreover, the unfamiliarity of foreign students, particularly Asian students, with the US healthcare system and the intricate insurance terms and terminology poses further difficulty in understanding these aspects at their language level 4 .
Accessing medical treatment is also cumbersome for international students.For instance, scheduling appointments can be challenging as doctors often have early off hours, unlike in their home countries where they can visit hospitals without appointments.The US insurance system mandates them to choose from a certain network of doctors only, and requires referrals from their primary care physician before visiting a specialist, but in their home countries, unlike in their home countries where they have more flexibility in choosing doctors 4 .
After receiving the medical treatment, international students may experience high out-of-pocket costs depending on different insurances they choose, because the insurance doesn't cover everything and the insurance company pays only a certain amount.It makes them unwilling to see a doctor next time in order to avoid unexpected medical bills.Moreover, the reimbursement process can be cumbersome.International students need to submit the claim for reimbursement in time after the medical treatment ends.Commercial insurance typically allows for direct reimbursement of most medical expenses at the hospital, while insurance provided by the school requires students to submit various reimbursement documents, such as drug receipts, laboratory reports, and doctor's prescriptions, and fill in application forms for insurance company audit.Being unfamiliar with the insurance company's rules can make the reimbursement process difficult, affecting international students' enthusiasm for seeking medical treatment.

Comparing healthcare service utilization in UK and US
International students often encounter difficulties when living in different countries due to their unfamiliarity with the local medical systems, resulting in a low utilization rate of healthcare services.For instance, they should learn the process of registering with a GP surgery in the UK and understand various insurance models in the US.In addition, communication and language barriers make international students afraid of misunderstanding.It is difficult for foreigner to express their symptoms accurately to doctors, potentially leading to misdiagnosis or inappropriate treatment and fostering distrust in Western medicine.Most international students come from non-western cultures which may hold different views about the causes and medical treatments of illness, so they trust doctors and technology in their home countries instead of the host country.For example, the Chinese medicine uses traditional and unique medicine and therapies like herbal medicine, acupuncture, scraping and cupping.These treatments are not used in western medicine, so when some Chinese students get ill, they tend to use traditional Chinese medicine they brought from home or delay seeking medical care until they return home.Such delays can pose potential risks to public health, particularly in cases of infectious diseases like COVID-19 27 .
The complexity of healthcare systems in the UK and the US significantly impacts international students' willingness to seek medical treatment and their utilization of medical resources in these countries (see table 4).In order to fully benefit from the host country's medical services, it is crucial for international students to know the information of service acquisition, medical treatment, and reimbursement.The UK's National Health Service (NHS) offers a simpler and more straightforward system in these respects compared to the complex private insurance system in the US.
In terms of service acquisition, the UK's universal and equal healthcare system requires less information from international students.They only need to pay the Immigration Health Surcharge (IHS) with their visa application according to their visa type, then they can enjoy the same health services as local residents.In contrast, US international students first need to know whether their school provides healthcare insurance plan and whether they can choose off-campus insurance.Comparing coverage, price, and services to select the most suitable insurance option can be challenging, making the US healthcare system less user-friendly for international students.Compared with the UK, the more complex healthcare system is hard to be accepted and used by international students.
In terms of service utilization, most healthcare services in the UK are provided free of charge through the NHS.International students using NHS-covered healthcare services do not have to pay any additional fees.However, certain services like eye care, dental treatment, and prescriptions may incur additional charges.In the US, the cost of healthcare services depends on the insurance coverage held by international students.If international students choose inappropriate healthcare insurance, the cost might be prohibitively high.When they encounter huge medical expenses, they are likely to end up paying out-of-pocket for medical service and face economic difficulties.
In terms of the reimbursement, international students in the UK generally do not need to make payments or seek reimbursements for most NHS services, such as diagnostic tests, hospital treatments and GP consultations .In contrast, after the medical treatment, the reimbursement process in the US is more complex and different from what international students might be accustomed to in their home countries.Students need to submit reimbursement claims after the medical treatment concludes.For commercial insurance, most medical expenses can be reimbursed directly at the hospital.However, insurance provided by the school often requires students to provide detailed medical receipts and reimbursement documents and then undergo an application process for insurance company audit.The unfamiliarity with insurance company rules can make reimbursement challenging.The cumbersome reimbursement affects the enthusiasm of international students for medical treatment.

Conclusion
The article highlights the challenges international students face in navigating the host country's complex healthcare system.Language barriers, system intricacies, and as a result the preference to seek medical care back home, which often lead to delayed treatments, resulting in worsening health.Addressing these barriers is crucial for both their mental and physical well-being.The article underscores the challenges international students face when navigating the host country's complex healthcare system.Our research indicates that variations of institutional complexity in medical systems significantly influence the healthcare-seeking behaviors of these students.
Benefiting from a simpler system, international students in the UK enjoy superior healthcare access compared to their counterparts in the US.In detail, The UK's National Health Service (NHS) is renowned for providing free healthcare services to its residents, including international students.While this is commendable, one of the persistent challenges the NHS faces is the lengthy waiting times for consultations, largely due to the high demand.Conversely, the US boasts a broad spectrum of healthcare services.However, its complexity, especially regarding acquisition, utilization, and reimbursement, often proves daunting for international students.
To bridge the healthcare gaps in both systems, a few systemic solutions can be considered.Universities in both the UK and the US should prioritize comprehensive healthcare orientation programs, ensuring students are well-informed about accessing and navigating their respective systems.Specifically, in the US, detailed workshops on understanding health insurance can be pivotal.This should encompass aspects like choosing the right plan, understanding reimbursement processes, and more.Furthermore, appointing dedicated healthcare liaison officers can offer students personalized assistance, from booking appointments to understanding medical paperwork.Another avenue worth exploring is telehealth services.Given the wait times in the UK and the intricacies in the US, telehealth can offer prompt consultations and medical advice, eliminating the need for physical appointments.Collaborative health plans, especially for students oscillating between the UK and the US, can be invaluable, utilizing the strengths of both systems.Lastly, training medical staff near universities in cultural sensitivities and multilingual services can further bridge the communication gap, ensuring a holistic healthcare experience for all international students.

Table 1 .
A typology of healthcare systems

Table 3 .
A comparison of the structure and financing mechanisms of healthcare system in the UK and the US

Table 4 .
A comparison of of healthcare system and international students' utilization in the UK and the US