Universal health care

Universal health care results from a government mandated program to provide all citizens, and sometimes permanent residents, of a governmental region access to most types of health care regardless of ability to pay. Universal health care is provided in all but one of the developed countries, and in many developing countries across the globe. The United States is the only industrialized nation that does not guarantee access to health care as a right of citizenship.

In the 1880s, most Germans became covered under the mandatory health care system championed by Bismarck. The National Health Service (NHS) in the United Kingdom was the world's first universal health care system provided by government. It was established in 1948. The most comprehensive today is in France, and the second most is in Italy. Other examples are Medicare in Australia, established in the 1970s, and by the same name Medicare in Canada, established between 1966 and 1984. Universal health care contrasts to the systems like health care in the United States or South Africa, though South Africa is one of the many countries attempting health care reform.

Some government health care systems allow private practitioners to provide services, and some do not. In the U.K., doctors are allowed to provide services outside the government system; in Canada, some services are permitted and some are not.

Implementation


Universal health care is a broad concept and has been implemented in several ways. The common denominator for them all is that every resident of a geographic area — such as a country — is mandated to have guaranteed health care access at reasonable cost.

Most countries implement universal health care through legislation and taxation. Legislation directs what care must be provided, to whom, and on what basis. Usually some costs are borne by the patient but are heavily subsidised by direct taxation and compensated to the patient to some extent either directly by the government or by some form of compulsory insurance.

Europe
Most of Europe has publicly sponsored and regulated health care. Countries include Austria, Belgium, Bosnia, Bulgaria, Croatia, Czech Republic, Denmark, Finland, Estonia, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Malta, the Netherlands, Norway, Lichtenstein, Luxembourg, Poland, Portugal, Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland and the United Kingdom.

United Kingdom


The NHS is the world's largest centralized health service, and the world's third largest employer after the Chinese army and the Indian railways. It provides a very wide range of health services to virtually the entire population. Unlike most health systems, it does not bill its services to either its patients, an insurance fund or to the government. Even in-patient medicines, hospital supplies such as bandages and hip joints, as well hospital supplied meals and refreshments all are free to in-patients, and even outpatients receive free loans of medical aids such as crutches. This is a factor which reduces administration costs considerably over insurance based systems. It is entirely funded from general taxation. It was created in the aftermath of World War II, by Clement Attlee's Labour government, based on the proposals of the Beveridge Report, prepared in 1942. The structure of the NHS in England and Wales was established by the National Health Service Act 1946 (1946 Act). Governments since 1997 have spent more money on the NHS and UK spending on health is now closer to (but still below) the European average. The new money has reduced waiting times and modernised the infrastructure, and has improved the salaries of medical staff. The outsourcing of medical services and support to the private sector is a recent innovation. Hospitals may have both medical services (such as "surgicentres"), and non-medical services (such as catering) provided under long-term contracts by the private sector. Capital projects such as new hospitals have been privatized through the Private Finance Initiative, enabling the public sector borrowing requirement to be reduced.

See also Health care in the United Kingdom.

Americas
Argentina, Brazil, Costa Rica, Canada, Chile, Cuba and Uruguay all have public health care provided. Mexico is planning to launch its own universal health care network.

United States
The United States is the only wealthy, industrialized nation that does not have a universal health care system, and in part because of this, the World Health Organization ranked the U.S. at #37 in its 2000 international comparison of the health systems of member nations. The government covers a little over one-quarter of the population through health care programs for the elderly, disabled, military service families and veterans, children, and the poor. Federal law ensures public access to emergency services regardless of ability to pay. However, this unfunded mandate has contributed to a health care safety net that some analyses say is increasingly strained. Certain types of medical spending and particularly health insurance benefit from significant tax subsidies; in particular, employer-sponsored health insurance is a non-taxable benefit. In all, government spending accounted for 45.1% of total health spending in the U.S. in 2005.

Current estimates put U.S. health care spending at approximately 15% of GDP, the highest in the world. Despite this, only an estimated 84.2% of citizens have some form of health insurance coverage, either through their employer, purchased individually, or through government sources. In 2003, approximately 61 million adults, or 35 percent of individuals ages 19 to 64, had either no insurance, sporadic coverage, or insurance coverage that exposed them to high health care costs. Employers that do provide insurance, on average, spend between 4.6 and 8.7% of their payroll in health insurance premiums. The cost of health care premiums is rising much faster than the general rate of inflation or employee wages. Since 2001, premiums for family coverage have increased 78%, while inflation has risen 17% and wages have risen 19%, according to a 2007 study by the Kaiser Family Foundation.

In the absence of a national program, more localized efforts are under way. The Commonwealth of Massachusetts is implementing a near-universal health care system by mandating that residents purchase health insurance by July 1, 2007. The City of San Francisco is also undertaking a universal health care system for uninsured residents. California, Maine, Vermont and Hawaii are also considering or seeking to implement universal or near-universal systems.

Canada
In 1984, the Canada Health Act was passed, which prohibited user fees and extra billing by doctors. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."

The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises or private corporations. Most doctors do not receive an annual salary, but receive a fee per visit or service. About 30% of Canadians' health care is paid for by the private sector or individuals. This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and optometry. Many Canadians have private health insurance, often through their employers, that cover these expenses.

Canada is the only industrialized country that has outlawed private medical care for services covered by the public health plan. The government has exercised this monopsony power in an attempt to control costs. People cannot pay out of pocket for treatment and must wait their turn on waiting lists. However, in 2005, the Canadian Supreme Court ruled, in Chaoulli v. Quebec, that the provincial ban on private health insurance was unconstitutional. The ruling is expected to lead to greater privatization, thereby eroding the cost benefits of Canada's single payer system.

Asia and Africa
Australia, Brunei, India, Israel Japan, Malaysia, New Zealand, Saudi Arabia, South Korea, Seychelles, Sri Lanka, Taiwan and Thailand have universal health care.

Thailand
Thailand introduced universal coverage reforms in 2001, becoming one of only a handful of lower-middle income countries to achieve this. Means-tested health care for the poor was replaced by a new more comprehensive insurance scheme - originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card which allows them to access services in their health district, and - if necessary - to be referred for specialist treatment elsewhere. The Thai system is relatively unusual in having a single, central purchasing agency - the National Health Security Office - which channels funds to a large number of contracting units for primary care (CUPs) that co-ordinate services in local districts. The bulk of finance comes from public revenues, with funding allocated to CUPs annually on a population basis. All public hospitals and some private hospitals participate in the scheme. Although the reforms have received a good deal of critical comment, they have proved popular with poorer Thais, especially in rural areas, and appear likely to survive even after the 2006 military coup. The current Public Health Minister, Mongkol Na Songkhla, recently announced his intention to abolish the 30 baht co-payment and make the UC scheme free.

India
India has partial universal health care system run by the local governments. The "government hospitals", some of which are among the best hospitals in India, provide treatment free of cost, or at a nominal cost. Selected drugs are offered free of charge in some hospitals.

Australia


Medicare was introduced by the Whitlam Labor Government on 1 July 1975 through the Health Insurance Act 1973. The Australian Senate rejected the changes multiple times and they were passed only after a joint sitting after the 1974 double dissolution election. Yet Medicare has been supported by subsequent governments and became a key feature of Australia’s public policy landscape. The exact structure of Medicare, in terms of the size of the rebate to doctors and hospitals and the way it has administered, has varied over the years. The original Medicare program proposed a 1.35% levy (with low income exemptions) but these bills were rejected by the Senate, and so Medicare was originally funded from general taxation. In October 1976, the Fraser Government introduced a 2.5% levy. The program is now nominally funded by an income tax surcharge known as the Medicare levy, which is currently set at 1.5% with exemptions for low income earners. In practice the levy raises only a fraction of the money required to pay for the scheme. If the levy was to fully pay for the services provided under the medicare banner then it would need to be set at about 8%. There is an additional levy of 1.0%, known as the Medicare Levy Surcharge, for those on high annual incomes ($50,000) who do not have adequate levels of private hospital coverage. This is part of an effort by the current Coalition Federal Government to encourage people towards private health insurance.

New Zealand
As with Australia, New Zealand's healthcare system is funded through general taxation.

Funding models
Universal health care in most countries has been achieved by a mixed model of funding, based on elements of compulsory safety net insurance for all (which may be levied on the individual and/or an employer), with special protections for the poor and disadvantaged (funded by taxation) with the option of private payments (either direct or via optional insurance) for services beyond that covered by the safety net.

Compulsory insurance
This is usually enforced via legislation. Sometimes there may be a choice of several funds providing a basic service (e.g. as in Germany) or sometimes just a single fund (as in Canada).

Taxation
Some countries (notably the UK) effectively have stripped away the pretence that there is insurance for the safety net and choose to fund health care directly from taxation.

Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation.

Single-payer
This term is used in the U.S. debate to describe a funding mechanism meeting the costs of medical care from a single fund. Although the fund holder is sometimes assumed to be the government allocating funding from taxation, its proponents do not rule out the possibility of some other mechanism. It is therefore as yet undetermined whether a future U.S. single-payer universal health care system would be funded from taxation, from compulsory insurance or a mixture of both.

Private insurance
In countries with universal coverage, private insurance is most often used as a supplement, covering what the core safety net service does not provide, Examples include elective cosmetic surgery and special comforts like private rooms. In some countries, people can use private insurance to obtain treatment more quickly than would otherwise be possible.

Where private insurance is predominant, such as in the U.S., medical (health) insurance is subject to the well-known economic problem of adverse selection which may also be referred to as a market failure. Adverse selection in insurance markets occurs because those providing insurance have limited information with which to estimate the health risks on which they may need to pay future claims. In simple terms, those with poor health are more likely to apply for insurance and more likely to need treatments requiring high insurance company payouts. Those with good health may find the cost of insurance too high for the perceived benefit, and some will remove themselves from the risk pool. This adverse selection concentrates the risk pool, thereby further raising costs. In practical terms, adverse selection means that private insurers have an economic incentive to 'weed out' bad risks in advance and provide medical insurance only to the most healthy. Among the potential solutions posited by economists are single payer systems as well as other methods of ensuring that health insurance is universal, such as by requiring all citizens to purchase insurance and limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.

Financial inputs and outcomes compared
The table below gives some indications of financial inputs and medical in a number of different countries, some of which have universal coverage and some of which do not. Interpreting data of this kind can be difficult because of other factors (e.g. genetic differences, diet) that are not controlled for.

Most all European systems are financed through a mix of public and private contributions. The majority of universal health care systems are funded primarily by tax revenue (e.g. Portugal ). Some nations, such as Germany, France and Japan employ a multi-payer system in which health care is funded by private and public contributions. In 2001 Canadians paid $2,163 per capita versus $4,887 U.S., according to the Los Angeles Times (also, see table above). According to Dr. Stephen Bezruchka, a senior lecturer in the School of Public Health at the University of Washington in Seattle, Canadians do better by every health care measure. According to a World Health Organization report published in 2003, life expectancy at birth in Canada is 79.8 years, versus 77.3 in the U.S.

A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency. One advantage of tying health care to local budgets is that that health care improvements and cost savings can be obtained by cross subsidy. For instance in Finland, type II diabetes patients can get discounted access to municipal owned sports facilities such as gyms and swimming pools, the discounts being rewarded to the community in the longer term because fitter patients will not need more expensive medical or personal care later in life. No entirely private health care system exists, although the reform bill in Massachusetts attempts to make private health care more affordable. Bill Frist argued in the New England Journal of Medicine that the free market will keep costs down, because individuals who have to pay for their own health care will make wiser decisions and not spend money on unneeded or inefficient care. A deregulated free market, Frist argues, will also encourage efficiency and innovation.

Politics
Because most developed and many developing countries already have systems for universal health care that have been in place for many years, universal health care per se is not a matter of political debate. However, health care systems throughout the world face sustainability challenges that may require far-reaching changes in national policy. Over the last decade, health spending has been accelerating as a percent of Gross Domestic Product (GDP) among Organisation for Economic Co-operation and Development (OECD) countries. Many industrialized countries have aging populations, with resulting increases in health care utilization, while others face rapid population growth. One recent study, by global consulting firm PriceWaterhouseCoopers, projected that global health care spending would triple in real dollars by 2020, consuming 21% of GDP in the U.S. and 16% of GDP in other OECD countries.

United States
Whether a government mandated system of universal health care should be implemented in the U.S. remains a hotly debated political topic. Those in favor of universal health care, such as the non-partisan Institute of Medicine of the National Academies, which has called for the U.S. to implement universal health care by 2010, argue that the current rate of uninsurance creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality. American have a lower average life expectancy than those in other industrialized nations with universal health care, such as Australia, the United Kingdom, Canada, and Sweden. Infant mortality rates also remain higher in the U.S., despite declines in recent decades, and are higher than the average of the European Union.

Critics of this argument note that there is very little correlation between life expectancy and infant mortality with the quality of health care, due to such factors as alternate causality and variations in the way countries collect their statistical data. In fact, the U.S. led the world in life expectancy twenty years ago with virtually the same health system. Rather, many analysts attribute the lower life expectancy to the astronomical surge in obesity rates.

Opponents of government mandates or programs for universal health care, including conservative think tanks such as The Cato Institute, argue that people should be free to opt out of health insurance and that government programs would require higher taxes, increase utilization, and reduce health care quality. Opponents also claim that the absence of a market mechanism may slow innovation in treatment and research, and lead to rationing of care through waiting lists. Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.

Debate
Common arguments forwarded by supporters of universal health care systems include:
 * Health care is a basic human right  or entitlement.
 * Ensuring the health of all citizens benefits a nation economically.
 * Coverage should be provided to all citizens regardless of ability to pay.
 * About 60% of the U.S. health care system is already publicly financed when federal and state taxes, property taxes and tax subsidies are included A universal healthcare system would merely replace private/employer spending with taxes. Total spending would go down for individuals and employers.
 * A single payer system could save $286 billion a year in overhead and paperwork. Administrative costs in the U.S. health care system are substantially higher than those in other countries and than in the public sector in the US: one estimate put the total administrative costs at 24 percent of U.S. health care spending.
 * For-profit healthcare has been shown to have higher expenses and worse results.
 * Several studies have shown a majority of taxpayers and citizens across the political divide would prefer a universal healthcare system over the current U.S. system
 * Health care is increasingly unaffordable for businesses and individuals.
 * Universal health care would provide for uninsured adults who may forgo treatment needed for chronic health conditions.
 * Providing access to medical treatment to those who cannot afford it reduces the severity of epidemics by reducing the number of disease carriers.
 * Wastefulness and inefficiency in the delivery of health care would be reduced.
 * America spends a far higher percentage of GDP on health care than any other country but has worse ratings on such criteria as quality of care, efficiency of care, access to care, safe care, equity, right care and wait times, according to the Commonwealth Fund.
 * A universal system would align incentives for investment in long term health-care productivity, preventive care, and better management of chronic conditions.
 * By reducing paperwork a universal system would allow doctors to spend more time with patients, thereby increasing physician productivity.
 * Patients would be encouraged to seek preventive care, enabling problems to be detected and treated earlier.
 * A centralized national database would make diagnosis and treatment easier for doctors.
 * Universal health care could act as a subsidy to business, at no cost thereto. (Indeed, the Big Three of U.S. car manufacturers cite health-care provision as a reason for their ongoing financial travails.  The cost of health insurance to U.S. car manufacturers adds between USD 900 and USD 1,400 to each car made in the U.S.A.)
 * The profit motive adversely affects the cost and quality of health care. If managed care programs and their concomitant provider networks are abolished, then doctors would no longer be guaranteed patients solely on the basis of their membership in a provider group and regardless of the quality of care they provide. Theoretically, quality of care would increase as true competition for patients is restored.
 * The profit motive adversely affects the motives of healthcare. Because of medical underwriting, which is designed to mitigate risk for insurance providers, applicants with pre-existing conditions, some of them minor, are denied coverage or prevented from obtaining health insurance at a reasonable cost. Health insurance companies have greater profits if fewer medical procedures are actually performed, so agents are pressured to deny necessary and sometimes life-saving procedures to help the bottom line.
 * According to an estimate by Dr. Marcia Angell roughly 50% of healthcare dollars are spent on healthcare, the rest go to various middlemen and intermediaries. A streamlined, non-profit, universal system would increase the efficiency with which is money spent on healthcare.

Common arguments forwarded by opponents of universal health care systems include:
 * Health care is not a right.
 * Providing health care is not the responsibility of government.
 * Universal heath care would result in increased wait times, which could result in unnecessary deaths.
 * Poorer quality of care.
 * Unequal access and health disparities still exist in universal health care systems.
 * Universal health care would reduce efficiency because of more bureaucratic oversight and more paperwork, which could lead to fewer doctor-patient visits. Advocates of this argument claim that the performance of administrative duties by doctors results from medical centralization and over-regulation, and may reduce charitable provision of medical services by doctors.
 * Profit motives, competition, and individual ingenuity lead to greater cost control and effectiveness.
 * By law, uninsured citizens receive emergency care regardless of ability to pay. The health care safety net, which includes free medical clinics, charity care, and nonprofits and government-run community hospitals provides necessary care to the uninsured.
 * Government-mandated procedures would reduce doctor flexibility.
 * Healthy people who take care of themselves should not have to pay for the burden of those who smoke, are obese, etc.
 * Loss of private practice options and possible reduced pay would dissuade many would-be doctors from pursuing the profession.
 * Likely loss of insurance industry jobs and business closure in the private sector.
 * Universal health care would eliminate the right to privacy between doctors and patients.
 * Empirical evidence on single payer-insurance programs demonstrates that the cost exceeds the expectations of advocates.
 * Universal health care systems, in an effort to control costs by gaining or enforcing monopsony power, sometimes outlaw medical care paid for by private, individual funds.

Support

 * American Medical Student Association (AMSA) - Statement supporting universal health care
 * California OneCareNow Campaign
 * Connecticut Coalition for Universal Health Care
 * Health Care for All—California
 * Physicians for a National Health Program
 * Sicko - Official site
 * Universal Health Care Action Network (UHCAN)
 * Universal Health Care / National Health Insurance

Oppose

 * British, Canadian Experience Shows Folly of Socialized Medicine, Analyst Says. Press release, Heritage Foundation. Sept. 29, 2000.
 * Capitalism Magazine
 * Dead Meat On The Fence's short film about Canada's socialized healthcare system.
 * The Heartland Institutes' Health Care Issue Suite
 * The Problems with Socialized Health Care from Mark Valenti's Liberty Page

Neutral

 * BalancedPolitics.org - "Should the Government Provide Free Universal Health Care for All Americans?"
 * Hidden costs, value lost: uninsurance in America. Institute of Medicine Committee on the Consequences of Uninsurance. Washington, DC: National Academies Press, 2003.
 * World Health Organization. Assesses The World's Health Systems," Press Release, WHO/44, June 21, 2000.