This past Thursday, the United States Supreme Court upheld the constitutionality of the Affordable Care Act, which I believe is the first step towards universal health care coverage. While learning more about the ruling, I thought I should take some time to learn what some of the other nations that share our world are doing in regards to universal health care coverage.
A story in the Washington Post shows that many nations, both wealthy and developing, have adopted or are adopting different forms of universal health care coverage.
Among the countries mentioned in the article as Singapore, South Korea, Colombia, India, China, India, South Africa, Rwanda and Thailand as nations that have adopted or are adopting forms of universal health care coverage.
The Washington Post article cites great progress in Brazil:
Then there’s Brazil, where half the population had no health coverage in 1988. Now, more than 75 percent of the country’s people rely exclusively on the government system for their health-care coverage,. according to a 2010 World Health Organization bulletin. Inadequate funds and staffing shortages have plagued the system from the start, but still, “infant mortality has decreased from 46 per 1000 live births in 1990 to 18 per 1000 live births in 2008,” the WHO wrote.
In the previously mentioned article by Yanzhoung Hang in Yale Global Online, the writer notes that many nations have adopted universal health care coverage.
World Momentum Builds for Universal Health Coverage
YaleGlobal, 9 March 2012
This new wave of universal health coverage, or UHC, has touched nearly 100 countries, all studying how to institute government-funded programs of health care. This concept is taking off in populous countries and traditionally UHC “blind spots,” such as Indonesia, China, India and South Africa. Combined, these four countries account for 40 percent of the world’s population. Unlike the US, emerging economies are not buying the argument that health care is largely the responsibility of individuals and businesses, with a public provision relegated to special interests, including the elderly, veterans and the indigent.
In India, a national health-insurance scheme geared towards increasing access for the poor, known as RSBY, started rolling in April 2008. So far it has enabled 100 million to have cashless, paperless, portable access to inpatient health care provided by more than 8,000 public and private hospitals across the country. The country’s Planning Commission is considering a report from a high-level expert group, calling for provision of easily accessible and affordable health care to all Indians by 2022.
Similar dynamics are observed in China, which announced plans to pump $124 billion into its health sector in January 2009, in a bid to achieve “safe, effective, convenient and affordable” health care by 2020. By the end of 2011, 95 percent of the Chinese citizens have already been covered by some form of health insurance. While UHC programs and initiatives vary across countries, the government political and financial support allows the cost burden of health care to be shared widely and evenly, health care services to be better utilized, and the health status of individuals to steadily improve.
If all goes well, most of the world’s population will have access to affordable basic health care in one decade – a true milestone in human history in view of the fact that 1 billion people today lack access and 150 million people face catastrophic costs each year because of direct payments for health care.
More than three decades ago, French philosopher and social theorist Michel Foucault reminded us that the principle aim of political rule was to “improve the condition of the population, to increase its wealth, its longevity, and its health.”
Population health and well-being are issues of governance. No matter how imperfect many existing UHC schemes may be, they constitute a global movement worth sustaining.
This graph that ran with the article gives some idea of the total cost of health care in some selected countries from the Yale Global article.
In Israel, citizens have a form of public health care that evolved from health maintenance organizations. While the system is not perfect, and its supporters see additional areas of reform, it has still achieved several remarkable results.
A recent article in the Forward examines Israel's health care system in comparison to that of the United States of America.
Israel's Health Care Outpaces U.S.
Provides Universal Coverage and Better Outcomes, Experts Say
By Nathan Guttman and Nathan Jeffay
Published June 28, 2012, issue of July 06, 2012.
The heated debate over health care reform, reignited by the Supreme Court’s decision to uphold President Barack Obama’s plan, has drawn attention, once again, to the issue of government involvement in health care management and the effectiveness of a system based on universal coverage.
For Israel, this is a Rubicon crossed long ago. Despite the country’s mania for most things American, when it comes to health care, Israel chose a system based more on the European model. The government’s role is central as both funder and regulator. Yet, going by many indexes of health outcomes, the result in terms of quality of care is often better — and definitely cheaper than in the U.S. Under the Israeli system, the percentage of the country’s gross domestic product going to health care is less than half that of the United States. And coverage is universal.
Stephen Reingold has observed both systems from up close. He is a pediatrician who practiced medicine in New Jersey before moving to Israel in 2009, where he now sees patients in Modi’in.
“One of the first things I noticed in the emergency room was that we only got severe cases,” Reingold recalled of the time he spent at an Israeli children’s hospital. The reason, he later learned, was that “hey, people here have a doctor to go to” and therefore do not end up in the hospital for minor problems, even if they are poor.
Access to doctors on a regular basis is one of the advantages that the universal health care system offers in Israel. It is commonly referred to as a “socialist” health care system, as opposed to the “private” system in the United States, but as a 2010 study comparing the two approaches demonstrated, these descriptions do not reflect their true nature, since both Israel and the United States have a mix of private and public health care.
The Israeli health care system has seen success both in terms of controlling costs and providing high quality care.
Israel spends slightly less than 8% of its GDP to achieve universal health care coverage, compared with 17.4% of the GDP in America for a system that leaves more than 40 million residents — one out of every eight residents — uninsured.
Moreover, under many criteria, Israeli citizens appear to be getting better care for their lower expenditures. Israel has an infant mortality rate that is only 57% of that in the United States, and a life expectancy from birth of 82 years, compared with 78 years in the United States. Its mortality rate due to heart disease is only half that of America’s. Many other indicators having to do with specific diseases are similarly favorable or, at worst, roughly equal.
“I think that America can learn a lot from the Israeli system. The quality is high, and the outcomes are good,” said Orly Manor, dean of the Hadassah-Hebrew University Braun School of Public Health
The following graphic created by Kurt Hoffman for the Forward, summarizes some of the differences in health care in the two countries.
While the information on Israel's health system may be news to man Americans, more people in the U.S. are familiar with the Canadian health care system, where the current system began with reforms in different provinces. The article, Canadian Federalism and Public Health Care: The Evolution of Federal-Provincial Relations
provides many details on the history of Canadian health care.
The present health care system began with the Saskatchewan Hospitalization Act under Premier Tommy Douglas in 1946. The act had the province assume responsibility for hospital payments. Alberta and British Columbia followed up in 1949.
A short eight years later, the Canadian federal government passed the Hospital Insurance and Diagnostic Services Act, which provided half the cost of provincial hospital services. By 1961, agreements were in place with the provinces to provide hospital care coverage across the country. In 1962, Saskatchewan instituted universal health care for physician services performed outside of hospitals. Doctors could practice outside the system.
In 1966, Canada passed the Medical Care Act, which committed the government to share costs with all the provinces. I suspect that the US will see an evolving system of medical care, with different programs in different states. Vermont and California are looking at exemptions to allow them to pursue a form of single payer coverage.
For information on the Canadian Health Care system, I recommend the following links: Canada’s Health Care System: An Overview of Public and Private Participation
and Canadian Health Care
No health care system, like any other thing designed by human beings, is perfect. However, countries can continue to address the problems in their systems. In the previously mentioned article in the Forward, there are concerns in Israel about a need for more specialists, and a concern about inequalities in the system. (All but 20 percent of the Israeli public – the poorest citizens – pay for extra coverage.) There is a realization of the need to make some changes, and concerns where there system may be going. However, I think that the awareness of the problems in the system are leading people to search for solutions.
Ehud Kokia, director general of Hadassah Medical Organization, which runs some of Israel’s largest and most prestigious hospitals, also sees trouble ahead. “The system is underfunded, and the only way to fix it is by having the government add more money,” he said. Health care funding needs to fight for its place on the government agenda against other urgent needs such as security and defense, he said.
Stav Shaffir, one of the leaders of Israel’s social protest movement, said one of the protest movement’s demands in this summer’s demonstrations is that “we get our health care system back.” She stated that otherwise, they are “afraid that the Israeli system of health care will become the American system.”
In the end, I suspect that we will see a lot of different programs at the state level in the U.S. However, we can learn from other countries. We may well see a world in the next few decades where the majority of its people have guaranteed access to health care. Somehow, I think that Franklin Delano Roosevelt, whose Four Freedoms Speech
called for a world where all had freedom of speech and expression, freedom of worship, freedom from want, and freedom from fear, would be glad to see such a world.
In the future days, which we seek to make secure, we look forward to a world founded upon four essential human freedoms. The first is freedom of speech and expression—everywhere in the world. The second is freedom of every person to worship God in his own way—everywhere in the world. The third is freedom from want—which, translated into world terms, means economic understandings which will secure to every nation a healthy peacetime life for its inhabitants—everywhere in the world. The fourth is freedom from fear—which, translated into world terms, means a world-wide reduction of armaments to such a point and in such a thorough fashion that no nation will be in a position to commit an act of physical aggression against any neighbor—anywhere in the world. That is no vision of a distant millennium. It is a definite basis for a kind of world attainable in our own time and generation. That kind of world is the very antithesis of the so-called new order of tyranny which the dictators seek to create with the crash of a bomb.—Franklin D. Roosevelt, State of the Union Address to the Congress, January 6, 1941
These concepts were later integrated into the Universal Declaration on Human Rights, a UN treaty that is now international law. (It may shock some in this country, but as the U.S. ratified this treaty, we are bound by it. Yet I have heard some who argue that the only rights we have are life, liberty and the pursuit of happiness. Very often these persons seem to have a very narrow and rigid view of theses rights. I would argue that a person who is hungry, insecure in his home and health is truly not free. It is up to us to insure that we will build a world where all can live with dignity – something that universal health care helps build. There is an old Talmudic saying about making the world a better place, attributed to one Rabbi Tarfon:
"It is not incumbent upon you to complete the work, but neither are you at liberty to desist from it.
The Affordable Care Act, although it has many good provisions, is imperfect and even its staunchest defenders see room for improvement. It is up to us to do the work of improving our health care system, both in terms of quality of care and access to care, as part of our larger task of making this a better nation and a better world. I can think of no better tasks nor a better way to pursue our lives for our generation, or any generation.