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+ "page_name": "Single-Payer Health Care: A Tale of 3 States \u2013 Third Way",
+ "page_url": "https://www.thirdway.org/report/single-payer-health-care-a-tale-of-3-states",
+ "page_snippet": "What do Vermont, the bluest of blue states, Colorado, a purple-trending blue state, and Massachusetts, home of an all-blue congressional delegation, have in common? They\u2019ve all failed at pursuing single-payer. States are the laboratories of democracy. Yet, single-payer initiatives have ...What do Vermont, the bluest of blue states, Colorado, a purple-trending blue state, and Massachusetts, home of an all-blue congressional delegation, have in common? They\u2019ve all failed at pursuing single-payer. States are the laboratories of democracy. Yet, single-payer initiatives have consistently failed. Bruce Japsen, \u201cColorado Rejects Single-Payer Healthcare Insurance.\u201d \u00b7 John Herrick, \u201cAsk the Indy: What\u2019s going on with universal health care in Colorado?\u201d The Colorado Independent, February 26, 2019. Accessed July 15, 2019. Available at: https://www.coloradoindependent.com/2019/02/26/ask-the-indy-universal-health-care-single-payer/ Single-payer advocates are right that universal coverage is fundamental to a successful health care system, economy, and country. However, as these states have shown, raising taxes to unprecedented levels and upending the entire health care system is not popular. So what is the alternative? The law mandated that nearly every resident of Massachusetts obtain a minimum level of insurance coverage, provided free and subsidized health care insurance for low-income residents, and mandated most employers to provide healthcare insurance. Many provisions of the law, such as the Massachusetts Health Connector, were used in the drafting of the ACA.",
+ "page_result": "Single-Payer Health Care: A Tale of 3 States \u2013 Third Way
What do Vermont, the bluest of blue states, Colorado, a purple-trending blue state, and Massachusetts, home of an all-blue congressional delegation, have in common? They\u2019ve all failed at pursuing single-payer.
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States are the laboratories of democracy. Yet, single-payer initiatives have consistently failed. These experiments demonstrate the challenges that single-payer faces\u2014ranging from high costs to opposition from core progressive constituencies. This report examines the single-payer experience in each of the three states. It also looks at what rose from the ashes after the efforts failed and what policymakers can learn.
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Plan Summaries
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Vermont, Colorado, and Massachusetts each took a different approach toward single-payer, as depicted in the chart below.1
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Vermont
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In 2011, Vermont State Senator Peter Shumlin became governor having campaigned on single-payer health care. The enactment of the ACA in the previous year made single-payer a seemingly realistic option because the law allowed states to establish innovative ways to finance and deliver health care. In his first year in office, Governor Shumlin took the state one step closer to single-payer by winning the enactment of legislation to create the nation\u2019s first single-payer system, called Green Mountain Care. His attempts to implement the law spanned his first two terms in office (Vermont governors serve two-year terms) during which he continued to campaign on single-payer right up to his election to a third term. Despite all the momentum, Shumlin could not overcome several major obstacles, and the single-payer experiment officially ended in late 2014.
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What were the obstacles and why did they prove immovable?
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\nEscalating costs. The initial estimate for Green Mountain Care was that it would save $1.6 billion over ten years. However, there were still numerous unknowns, such as what benefits patients would receive and their specific cost-sharing requirements.2 Once enacted, Governor Shumlin had until January 2013 to present a financing package to state lawmakers that would pay for the new single-payer health care system. However, that deadline came and went. Nonetheless, the governor pushed ahead without a plan to pay for the legislation. \u201cWe can move full speed ahead with what we need without knowing where the money\u2019s coming from,\u201d said the Governor\u2019s special counsel for health reform.3 Nearly a year later, the Governor announced he would release a new financing plan after the 2014 elections. The Governor\u2019s team ran 14 financing concepts that tried to create a fair balance between payroll taxes and income taxes. But, the computer models all showed that the only way to set taxes at rates as low as they wanted would be to give residents skimpier coverage that most insured Vermonters already had. \u201cWe were pretty shocked at the tax rates we were going to have to charge,\u201d Governor Shumlin recalled.4 After it was all said and done, Green Mountain Care would have cost $4.3 billion in its first year\u2014financed, in part, by $2.8 billion in new state tax revenue, or a 151% increase in total state taxes.5 Governor Shumlin\u2019s team estimated this cost would have swollen to over $5 billion in 2021. For context, the entire budget for the state of Vermont was $5.01 billion for 2012-2013. Officials in the state determined that an 11.5% state payroll tax and a 9.5% income tax would be necessary to pay for the new health care system. \u201cIn a word, enormous,\u201d is how Governor Shumlin described the tax hikes needed to fund single-payer.6 \u201cAs we completed the financing modeling,\u201d Shumlin lamented, \u201cit became clear that the risk of economic shock is too high to offer a plan I can responsibly support\u2026\u201d7 Despite being a small, progressive state, the government still could not figure out a way to make the numbers work.
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\nFragmented coalitions. Union members, community activists, disability rights advocates, and the Vermont Workers\u2019 Center (a group of single-payer supporters) all initially rallied to support the legislation. However, the new law unleashed a torrent of lobbying by these organizations trying to ensure the new law benefited their members before the new health care system was set to be implemented in 2017. single-payer advocates and unions pressed hard for generous benefits. Employers wanted coverage for out-of-state employees, while small businesses were terrified of huge tax increases. Large businesses pushed back strongly on the cost of the new plan.8 Self-insured companies lobbied against tax increases, as they resented the prospect of being taxed more to help others get coverage. These groups also failed to educate the public on the trade-offs a single-payer system would entail, including the huge tax increases. Governor Shumlin said that no one should be worse off under his plan, so he agreed the new system should cover out-of-state workers and 94% of Vermonters\u2019 health care costs, more than the most generous plan available on the marketplace today.9 He also agreed to consider a grace period for new taxes on small businesses, which would have reduced funding for the program by another $500 million. Still, these decisions made paying for the plan even harder. As a result, a few months before the decision about whether to move ahead, the Vermont public was divided over single-payer: 40% support, 39% opposed, and 21% undecided.10 Support had fallen from the initial level of 48% support, 36% opposed, and 16% undecided.11\n
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\nRegressive impact on families. Nearly all private employers, but particularly small businesses, would pay more under the new health plan. The taxes required to provide the coverage Governor Shumlin promised would have shifted costs onto employers, who could then shift those costs onto their employees. While many employees would receive better coverage under this new plan, other employees faced a new financial burden as these new costs would likely come out of their wages. For example, a worker making $20,000 at a small firm would be worse off under the new plan.12\n
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With single-payer dead in the state, Vermont switched gears and pursued an innovative delivery model that built on the ACA instead of replacing it. In October 2016, Governor Shumlin and the Green Mountain Care Board\u2014the board originally responsible for implementing single-payer\u2014released the first draft of the Vermont All-Payer Accountable Care Organization (ACO) Model, which pilots new payment models that coordinate physical health, mental health, and social services to help patients with the most complex needs. The new All-Payer ACO Model successfully builds on the existing health care infrastructure and state partners instead of trying to re-make the entire health system. Initial results from the study show that Medicaid beneficiaries are making greater use of primary care and behavioral health services, and those individuals deemed \u201chigh or rising risk\u201d had substantially fewer emergency department visits than before the program.13
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Colorado
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In 2016, Colorado residents voted on a citizen-initiated single-payer ballot initiative, Amendment 69. The ballot initiative would have amended the state constitution and created a taxpayer-funded, universal health plan for the state that would be operated by a 21-person elected board. This would have put all Colorado residents who currently receive private insurance onto ColoradoCare, while those with Medicare and Tricare would keep that insurance.14 ColoradoCare would cover 11 categories of health services, such as \u201cprescription drugs and medical equipment\u201d and \u201cpreventive and wellness services,\u201d with no deductibles or copayments for preventive and primary care services and some cost-sharing for other services. Despite being a progressive policy proposal, many Democrats and progressives opposed the measure. With close to 2 million votes, Amendment 69 was strongly defeated by nearly 60% (79% opposed, 21% in favor).15 Not one county in Colorado voted in favor of the initiative. 16 Even in some of the most liberal counties that voted in favor of Hillary Clinton by a large majority, the ballot initiative failed by at least 20%.17 This same failure was seen in other progressive states as well. California\u2019s ballot initiative garnered only 27% of the vote and Oregon\u2019s initiative saw only 20% in favor.18
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Why did the ballot initiative get defeated by such large margins?
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\nEscalating costs. The ballot initiative would have resulted in a $25 billion tax hike in the first year in order to fund the $36 billion health care program, which is nearly $10 billion larger than the 2017 budget for the entire state.19 Financing for the new health care system was a 10% tax on nonwage income and a 6.67% payroll tax on employers and 3.33% tax on employees.20 Even with these new taxes, the state would face a $7.8 billion deficit after ten years. Colorado voters hadn\u2019t passed a statewide tax hike for more than two decades, making the proposal a hard sell. Some voters worried that the price tag would make Colorado less attractive to new businesses and young workers.21 Voters were also concerned about the proposed tax authority the law would give to the new 21-member governing board. The board would have the ability to raise taxes with very little oversight. If health costs increased or the plan was more expensive than the models showed, the board would be forced to find a way to pay for it, primarily by raising taxes further. The law also had no way to ensure transparency on the board. One resident noted that it would be very easy for a donor to influence the makeup of the board and dictate the success of the new health care system.22 This unorthodox transfer of taxing power with no oversight gave many voters pause.
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\nFragmented coalitions. Amendment 69 was opposed by dozens of organizations across the political spectrum. Progressive think tanks, unions, the business community, and advocacy groups, came out against the measure because it was \u201ca poorly thought-through initiative.\u201d23 Women\u2019s health groups, including NARAL and Planned Parenthood, opposed the bill because it would remove access to abortion for the hundreds of thousands of women currently in private health plans that cover the procedure. Due to a 1984 Colorado law banning public funds from paying for abortions, the proposed bill would not be able to cover elective abortions for any woman in the state. As amendments can only address one issue, the ballot initiative could not make any changes to the existing abortion law.24 Moderate policymakers such as Governor John Hickenlooper, Senator Michael Bennet, and former Governor Bill Ritter all came out against the bill. This outcry led to citizens\u2019 negative perception of the bill. In an August 2016 poll, 27% supported and 65% opposed Amendment 69. Democrats were more favorable toward the measure, with 41% in support and 45% in opposition.25\n
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\nRegressive impact on families. A report by the left-leaning Colorado Fiscal Institute noted that while many low-income Hispanic families would pay less under ColoradoCare (not counting the employer side of the payroll tax), poor Medicaid enrollees would be faced with new taxes without new health benefits to offset them.26 Similar to the legislation in Vermont, low-income workers would disproportionately bear the burden of costs in a health care system financed on payroll taxes, while receiving coverage that would be no better than what they already had.
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While gubernatorial candidate Jared Polis called for a multi-state single-payer system on the campaign trail, after his election, he instead has focused on lowering health care costs for Coloradans.27 In April 2019, Governor Polis unveiled the Roadmap to Savings Coloradans Money on Health Care. The plan included passing a public option, a reinsurance program, a ban on surprise billing, expanding the primary care workforce, and increasing access to healthy food. His first action was to sign House Bill 1001, which requires financial transparency of hospitals.28
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Massachusetts
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Massachusetts has a longer, more complicated single-payer story, but the ending was the same. The state has debated the single-payer idea for three decades, with the first single-payer bill being introduced in 1986. Local, non-binding ballot initiatives in support of single-payer have been passed over 20 times.29 The state also has some of the strongest advocates for single-payer. Yet, despite the support from constituents and legislative interest, the bill has never gotten out of committee, let alone made it to the governor\u2019s desk. Furthermore, candidates who have run on a single-payer platform, such as the former acting administrator of the Centers for Medicare and Medicaid Services Donald Berwick, have not won elections.30 Despite public support, legislative action, and a strong progressive coalition, single-payer has never gotten off the ground. Why not?
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Similar to the other two states, the taxes necessary to fund a single-payer bill would be huge. MassCare, a Boston-based advocacy group, estimated that single-payer could be financed with a 10% capital gains tax on unearned income above $30,000, and a payroll tax of 7.5% for employers and 2.5% for employees.31 The state\u2019s fiscal 2019 budget totals $41.2 billion, which includes all the money used to pay for public services like fixing roads and funding schools. About 40% already goes toward public insurance programs. Adding $22.8 billion in health costs (the amount currently paid by private insurance) would increase the state budget by more than 50%.32
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John McDonough, a professor of public health at Harvard T.H. Chan School of Public Health said the biggest issue facing Medicare for all is related to cost. \u201cHow are you going to pay for it?\u201d he asked, rhetorically. \u201cThe level of taxation that would be required to replace private premiums would be seen as off the wall by most people.\u201d Furthermore, health care costs in Massachusetts have been increasing rapidly. In the last five years, health care costs grew 21%, increasing to $61.1 billion in 2017 compared to $50.5 billion in 2013. \u201cIt\u2019s almost impossible to find a revenue source that grows at the rate you would need to feed moderate cost growth in the health care system,\u201d said Anya Rader Wallack, a professor in the School of Public Health at Brown University in Rhode Island.33
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While single-payer has continued to stall for decades, the state has pushed forward on health care in a multitude of ways. Massachusetts passed a health care reform law in 2006 with the aim of providing health insurance to nearly all of its residents. The law mandated that nearly every resident of Massachusetts obtain a minimum level of insurance coverage, provided free and subsidized health care insurance for low-income residents, and mandated most employers to provide healthcare insurance. Many provisions of the law, such as the Massachusetts Health Connector, were used in the drafting of the ACA. 34 After the law\u2019s implementation, 97% of Massachusetts residents had health coverage compared to just over 90% nationally.35 The reform also improved health outcomes: the state saw reduced mortality for all residents. The mortality rate decreased even more among low-income households and those who were previously uninsured.36
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\n
Conclusion
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Single-payer advocates are right that universal coverage is fundamental to a successful health care system, economy, and country. However, as these states have shown, raising taxes to unprecedented levels and upending the entire health care system is not popular. So what is the alternative?
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First, Congress needs to address the costs of health care. No one should go bankrupt from a hospital visit, and everyone should have access to care they can afford. But as Vermont learned, simply replacing premiums with taxes would require a huge payroll tax of between 10-25%. Further, the \u201ctaxes instead of premiums\u201d message has failed in states from Colorado, to California, to Vermont. For example, in California, 53% of likely voters back single-payer but support drops to just 41% when they are told it will require new taxes.
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Instead, let\u2019s expand on a technique from the ACA: cap out-of-pocket costs based on income no matter where the person gets insurance. This cap can be used in Medicare, Medicaid, and private insurance so that no middle-class person would pay more than 10% of their income on health care costs.
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Furthermore, the right coalitions must be in the room. Those coalitions need to be comprised of the people who use and pay for their health care. A massive coalition of consumers, unions, employers, small businesses, governors, and willing participants of the health care industry are needed to overcome opposition to change. The kernels of such a coalition are available through Consumers First, which is focused on realigning health care incentives to lower costs and improve quality.37
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Third, any health policy plan must avoid a regressive impact on low-income families. A consultant on the Vermont single-payer plan said, \u201cIf you can\u2019t do it in Vermont, with one private health plan and low uninsured rates, then the amount of disruption you would have nationally with winners and losers would be enormous.\u201d38 Some people in this country receive free or incredibly discounted care through Medicaid and the ACA exchanges. However, under a single-payer plan where taxes are increased upwards of 10%, they would bear an undue cost burden. Instead of making them worse off, Congress should focus on the millions of people who are eligible for free and discounted care and make sure they are enrolled through auto-enrollment or one-click simplified enrollment process. And all low- and middle-income families should receive protection from high costs based on their income.39
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Let\u2019s learn from the single-payer experiments in these states. With 29 million uninsured and tens of millions more worried about health care costs, the country does not have time to waste on policies that won\u2019t go anywhere. Instead, let\u2019s strengthen the ACA, control costs, build strong coalitions, and achieve universal coverage.
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+ "page_last_modified": ""
+ },
+ {
+ "page_name": "More States Are Proposing Single-Payer Health Care. Why Aren\u2019t ...",
+ "page_url": "https://fivethirtyeight.com/features/more-states-are-proposing-single-payer-health-care-why-arent-they-succeeding/",
+ "page_snippet": "The Democratic presidential primary might feel like a lifetime ago, but one important storyline in that race was health care \u2014 specifically single-payer health \u2026The exact scope of this law has been litigated for decades, but suffice it to say that it\u2019s successfully put the kibosh on many statewide health care reforms. Single-payer health insurance is particularly tricky as there\u2019s no way to get everyone onto the plan without first changing how private insurance works. Colorado and Nevada, for instance, successfully passed a public option in 2021, joining Washington, which passed one in 2019. Colorado\u2019s success in advancing a public option is particularly striking, given that almost 80 percent of people voted against its single-payer proposal in 2016. It\u2019s not clear yet how successful these state-run public option plans will be, but it is possible that a public option may prove more popular than single-payer. For starters, while single-payer health care is popular among Democrats, the public option still polls much better among Republicans and independents. The Democratic presidential primary might feel like a lifetime ago, but one important storyline in that race was health care \u2014 specifically single-payer health care, or the policy that the government should offer universal health insurance to everyone in the country.",
+ "page_result": "\n\n\n\t\n\t\n\t\t\t\n\n\t\t\n\t\t\n\t\t\t\t\n\t\t\n\t\t\nMore States Are Proposing Single-Payer Health Care. Why Aren\u2019t They Succeeding? | FiveThirtyEight\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n \n \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\t\t\n\t\t\t\n\t\n\t\n\n\n\nSkip to main content\n\n\n\t
\n\n\t\t\n\t\t\n\t\n\n\t\n\t\t\t\t\n\t\t\t\tTen single-payer bills were introduced last year by state legislators across the country.\t\t\t\t\t\t\t\t\t
The Democratic presidential primary might feel like a lifetime ago, but one important storyline in that race was health care \u2014 specifically single-payer health care, or the policy that the government should offer universal health insurance to everyone in the country. The nomination of now-President Biden, who opposed single-payer health care during the primary, has put single-payer health care on the backburner nationally. But that hasn\u2019t stopped the issue from impacting state legislators, who have introduced more single-payer health care bills in the last few years than ever before.
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Health care policy researchers Erin C. Fuse Brown and Elizabeth McCuskey tracked the number of unique single-payer bills introduced in state legislatures across the country from 2010 to 2019, finding a sharp uptick in bills introduced since 2017. During each of those three years, at least 10 single-payer proposals were introduced, according to Brown and McCuskey\u2019s research, for the first time since 2013. In total, state legislators proposed more single-payer bills from 2017 to 2019 than in the previous seven years combined. And for 2021, we\u2019ve identified 10 single-payer bills that legislators introduced across the country, from liberal states like California and Massachusetts to more conservative ones including Iowa and Ohio.1
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What do all these proposals have in common? They\u2019ve all universally failed. In fact, Vermont, the only state that managed to pass single-payer health care in 2011, ended up shelving its plan three years later.
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It makes sense why single-payer advocates have tried to take these fights to the states. States have traditionally been seen as the \u201claboratories of democracy,\u201d and some advocates of single-payer health care have argued that liberal states could provide unique opportunities to advance single-payer health care. But as I\u2019ll explain, passing single-payer health care at the state level is next to impossible, as states are particularly limited in how they can allocate federal and private health care funds. There is, however, evidence that Americans may have an appetite for a public option, or government-run health insurance that people can opt into at the state level. Three states (Colorado, Nevada and Washington) have already passed a public option. It\u2019s not single-payer health care reform, but it\u2019s possible that we might see more states adopt their own public-option reforms.
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One big reason single-payer proposals haven\u2019t caught on at the state level is because finding a reliable way to pay for such a program is challenging. Single-payer advocates originally envisioned a federal proposal that would cover all Americans under a more generous version of a preexisting program \u2014 that is, Medicare, but now for all. Doing this state-by-state would require each state to apply for waivers to divert federal funds used for Medicare, Medicaid and Affordable Care Act exchanges to be used for their own single-payer plans. And that\u2019s tricky because the Department of Health and Human Services has wide discretion to approve or deny states\u2019 requests, which makes any proposal highly dependent on the national political climate.
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This isn\u2019t just a theoretical debate either: Trump\u2019s administrator for the Centers for Medicare & Medicaid Services Seema Verma said in 2018 that she would deny waivers from states to create single-payer systems, while Biden\u2019s Health and Human Services Secretary Xavier Becerra has expressed more favorable sentiments. Almost all single-payer proposals depend on these waivers and states don\u2019t often have fallback plans for if this federal funding gets denied.
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Employer-sponsored health insurance plans, which cover 54 percent of Americans, are another hurdle for states trying to pass single-payer health care. Federal law largely prevents states from regulating employer-provided health insurance, so states can\u2019t just stop employers from offering their own health care benefits. The exact scope of this law has been litigated for decades, but suffice it to say that it\u2019s successfully put the kibosh on many statewide health care reforms. Single-payer health insurance is particularly tricky as there\u2019s no way to get everyone onto the plan without first changing how private insurance works. States have tried to address this through measures like increasing payroll taxes or restricting providers\u2019 ability to accept reimbursement from private insurance plans. But the more elaborate these mechanisms get, the more complicated it becomes to implement \u2014 and the more people that could slip through the cracks.
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Finally, another big financial barrier is that state governments have far less leeway than the federal government to increase budgetary spending. That means tax increases, which come with their own political challenges, are often necessary for states to secure the funding they need.
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Take California\u2019s single-payer proposal, which failed in late January. It would have required two-thirds of voters to pass a separate constitutional amendment to implement the necessary tax increases to pay for it. Concerns over tax increases also contributed to the demise of single-payer proposals in Colorado and Vermont. It\u2019s true that a recent analysis of New York\u2019s single-payer health care plan found that it would lower overall health care spending by 3 percent by 2031, but it would also require additional state tax revenue of $139 billion in 2022 \u2014 over 150 percent of the current state budget. Politicians facing the next election cycle may be leery of proposing short-term tax increases, even if the end result is long-term savings.
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All of this creates a daunting picture for statewide single-payer health care. But the failures of single-payer doesn\u2019t entirely close the door on health care reform, especially if these reforms are supplementing the existing system instead of entirely replacing it. Colorado and Nevada, for instance, successfully passed a public option in 2021, joining Washington, which passed one in 2019. Colorado\u2019s success in advancing a public option is particularly striking, given that almost 80 percent of people voted against its single-payer proposal in 2016.
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To be sure, though, efforts to implement a public option aren\u2019t without their own challenges. In 2021, during its first year of implementation, Washington state\u2019s public option struggled to enroll people and get health care providers to agree to lower payment rates. State lawmakers have tried to fix this problem by introducing legislation that would require more providers to participate and bring down premiums by increasing subsidies. Proponents have also cautioned that it might take years before the public option really gains a foothold with Washington state residents.
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It\u2019s not clear yet how successful these state-run public option plans will be, but it is possible that a public option may prove more popular than single-payer. For starters, while single-payer health care is popular among Democrats, the public option still polls much better among Republicans and independents. According to a Morning Consult/Politico poll from March 2021, the public option was roughly as popular as Medicare for All among Democrats \u2014 about 80 percent said they supported each. But support for the public option was much higher than support for Medicare for All among both Republicans and independents. Just 28 percent of Republicans and 50 percent of independents supported Medicare for All versus 56 percent of Republicans and 63 percent of independents who supported a public option.
Ultimately, any health care reforms would be easier to implement on a federal level than a patchwork, state-by-state approach. But Washington, Colorado and Nevada remain important tests of state governments\u2019 ability to implement a public option in lieu of action by the federal government. It\u2019s not single-payer, but it\u2019s still some of the most consequential health care reforms in decades \u2014 and a potential sign of where the debates over health care are heading.
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Footnotes
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To be sure, it\u2019s possible this tally includes repeats of past years\u2019 bills or bills that are not truly single-payer \u2014 Fuse Brown and McCuskey touch on some of the challenges of tracking this in their methodology \u2014 but the number of bills introduced last year shows that single-payer is still a popular legislative issue.
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Jean Yi is a former politics intern at FiveThirtyEight. @Jean_Yi_
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+ "page_last_modified": ""
+ },
+ {
+ "page_name": "Universal Health Coverage Globally | Commonwealth Fund",
+ "page_url": "https://www.commonwealthfund.org/international-health-policy-center/system-features/how-does-universal-health-coverage-work",
+ "page_snippet": "How does universal health coverage work? Which countries have implemented these policies successfully? Learn these answers and more in this article.A universal health care bill was initially introduced in Parliament in 1973 but failed three times to pass through the Senate. Because of these failed attempts, a new parliamentary election was called, a procedure known as double dissolution, to resolve the deadlock. The constitution of Brazil defines health as a universal right and a state responsibility. The Brazilian health system, known as SUS (Sistema \u00danico de Sa\u00fade), was conceived during the 1980s as part of the social movement aimed at Brazil\u2019s re-democratization. Canadian Medicare \u2014 Canada\u2019s universal, publicly funded health care system \u2014 was established through federal legislation originally passed in 1957 and in 1966. The Canada Health Act of 1984 replaces and consolidates the two previous acts and sets national standards for medically necessary hospital, diagnostic, and physician services. Universal access to health care underlies Denmark\u2019s Health Law, which sets out the government\u2019s obligation to promote population health and prevent and treat illness, suffering, and functional limitations; to ensure high-quality care and easy and equal access; and to promote service integration, choice, transparency, access to information, and short waiting times.",
+ "page_result": "\n\n \n \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n \n\n\n\nUniversal Health Coverage Globally | Commonwealth Fund\n \n\n\n\n\n \n \n \n \n \n \n \n \n \n \n
Our Scorecard ranks every state\u2019s health care system based on how well it provides high-quality, accessible, and equitable health care. Read the report to see health care rankings by state.
It took 10 years of political tension to establish Australia\u2019s universal public health insurance program, known as Medicare.
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A universal health care bill was initially introduced in Parliament in 1973 but failed three times to pass through the Senate. Because of these failed attempts, a new parliamentary election was called, a procedure known as double dissolution, to resolve the deadlock. The new Parliament passed the health care legislation in 1974, establishing free public hospital care and subsidized private care. However, following a change in government in 1975, access to free health care services was limited to retired persons who met stringent means tests.
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After another change of government in 1984, the current Medicare system was established. Medicare provides free public hospital care and substantial coverage for physician services and pharmaceuticals for Australian citizens, residents with permanent visas, and New Zealand citizens following their enrollment in the program and confirmation of identity. Restricted access is provided to citizens of certain other countries through formal agreements. Other visitors to Australia, as well as undocumented immigrants, do not have access to Medicare and are treated as private-pay patients, including those needing emergency services.
The constitution of Brazil defines health as a universal right and a state responsibility. The Brazilian health system, known as SUS (Sistema \u00danico de Sa\u00fade), was conceived during the 1980s as part of the social movement aimed at Brazil\u2019s re-democratization. SUS was officially created in 1988 by the new Brazilian constitution.
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Three principles underpin SUS:
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The universal right to comprehensive health care at all levels of complexity (primary, secondary, and tertiary).
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Decentralization with responsibilities given to the three levels of government: federal, state, and municipal.
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Social participation in formulating and monitoring the implementation of health policies through federal, state, and municipal health councils.
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Since 1990, the incremental expansion of SUS has enabled substantial progress toward achieving universal health coverage.
Canadian Medicare \u2014 Canada\u2019s universal, publicly funded health care system \u2014 was established through federal legislation originally passed in 1957 and in 1966. The Canada Health Act of 1984 replaces and consolidates the two previous acts and sets national standards for medically necessary hospital, diagnostic, and physician services. To be eligible to receive full federal cash contributions for health care, each provincial and territorial (P/T) health insurance plan needs to comply with the five pillars of the Canada Health Act, which stipulate that it be:
China largely achieved universal insurance coverage in 2011 through three public insurance programs:
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Urban Employee Basic Medical Insurance, mandatory for urban residents with formal jobs, was launched in 1998.
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The voluntary Newly Cooperative Medical Scheme was offered to rural residents in 2003.
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The voluntary Urban Resident Basic Medical Insurance was launched in 2007 to cover urban residents without formal jobs, including children, the elderly, and the self-employed.
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\n\n
In 2016, China\u2019s central government, the State Council, announced that it would merge the Newly Cooperative Medical Scheme and Urban Resident Basic Medical Insurance to expand the risk pool and reduce administrative costs. This consolidation is still underway. The combined public insurance program is now called Urban-Rural Resident Basic Medical Insurance.
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Because China has a huge population, insurance coverage was increased gradually. In 2011, approximately 95 percent of the Chinese population was covered under one of the three medical insurances. Insurance coverage is not required in China.
All registered Danish residents are automatically enrolled in publicly financed health care, which is largely free at the point of use. Registered immigrants and asylum-seekers are also covered, while undocumented immigrants have access to acute-care services through a voluntary, privately funded initiative supported by the Danish Medical Association, the Danish Red Cross, and the Danish Refugee Council.
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Danes can choose from two public insurance options. Practically all Danes (98%) choose Group 1 coverage, under which general practitioners (GPs) act as gatekeepers and patients need a referral to see specialists, except for a few specialties. The remaining 2 percent of Danes choose Group 2 coverage, which allows access to specialists without a referral, although copayments apply. Under both insurance options, access to hospitals requires a referral.
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Universal access to health care underlies Denmark\u2019s Health Law, which sets out the government\u2019s obligation to promote population health and prevent and treat illness, suffering, and functional limitations; to ensure high-quality care and easy and equal access; and to promote service integration, choice, transparency, access to information, and short waiting times.
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Universal coverage developed gradually, starting in the latter part of the 1800s with nongovernmental insurance, known as sickness funds, covering primary care and user charges for hospital care. In 1973, the current universal public coverage system was founded through legislative reform.
Health coverage in England has been universal since the creation of the National Health Service (NHS) in 1948. The NHS was set up under the National Health Service Act of 1946, based on the recommendations of a report to Parliament by Sir William Beveridge in 1942. The Beveridge Report outlined free health care as one aspect of wider welfare reform designed to eliminate unemployment, poverty, and illness, and to improve education. Under the 1946 Act, the Minister of Health had a duty to provide a comprehensive, free health service, replacing voluntary insurance and out-of-pocket payments.
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Currently, all those \u201cordinarily resident\u201d in England are automatically entitled to NHS care, still largely free at the point of use, as are nonresidents with a European Health Insurance Card. For other people, such as non-European visitors or undocumented immigrants, only treatment in an emergency department and for certain infectious diseases is free. Rights for those eligible for NHS care are summarized in the NHS Constitution; they include the right to access care without discrimination and within certain time limits for certain categories, such as emergency and planned hospital care.
Universal coverage was achieved over seven decades by extending statutory health insurance (SHI) to all employees (in 1945), retirees (in 1945), the self-employed (in 1966), and the unemployed (in 2000). In 2000, the Couverture maladie universelle (Universal Health Coverage), or CMU, was created for residents not eligible for SHI, although the program required yearly renewals and entitlement changes whenever a beneficiary\u2019s professional or family situation changed. After the implementation of CMU, fewer than 1 percent of residents were left without baseline coverage.
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In January 2016, SHI eligibility was universally granted under the Protection universelle maladie(Universal Health Protection law), or PUMa, to fill in the few remaining coverage gaps. The law also replaced and simplified the existing system by providing systematic coverage to all French residents. It merged coverage for persons previously covered by the Universal Health Coverageand immigrants covered by the state-sponsored health insurance.
Chancellor Otto von Bismarck's Health Insurance Act of 1883 established the first social health insurance system in the world. At the beginning, health insurance coverage was restricted to blue-collar workers. In 1885, 10 percent of the population was insured and entitled to cash benefits in case of illness (50% of wages for a maximum of 13 weeks), death, or childbirth. While initially limited, coverage gradually expanded. The final step toward universal health coverage occurred in 2007, when health insurance, either statutory or private, was mandated for all citizens and permanent residents. Today\u2019s system provides coverage for the entire population, along with a generous benefit package.
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Health insurance is provided by two subsystems: statutory health insurance (SHI), consisting of competing, not-for-profit, nongovernmental health insurance plans known as sickness funds; and private health insurance.
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Long-term care services are covered separately under Germany\u2019s mandatory, statutory long-term care insurance (LTCI).
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Unlike those in many other countries, sickness funds and private health insurers, as well as long-term care insurers, use the same providers. In other words, hospitals and physicians treat all patients regardless of whether they have SHI or private insurance.
The constitution of India obliges the government to ensure the \u201cright to health\u201d for all. Each state is required to provide free universal access to health care services. However, health care in India has been chronically underfunded.
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Historically, there have been several government-funded health insurance schemes intended to improve coverage for specific population groups, with variations across states. One important scheme aimed at reducing financial catastrophe and vulnerability for lower-income populations is the National Health Insurance Program (Rashtriya Swasthya Bima Yojana, or RSBY), launched in 2008. As of 2016, some 41 million families were enrolled in RSBY. However, evidence indicates that the scheme has not significantly reduced out-of-pocket spending. It is now being subsumed under the PM-JAY.
\n\n
With ineffective public insurance schemes and the low uptake of commercial insurance, only around 37 percent of the population were covered by any form of health coverage in 2017\u20132018. Further systemic barriers to access include long wait times in hospitals, the perceived low quality of public health services, and substantial workforce and infrastructure shortfalls.
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In March 2018, the central government approved the implementation of PM-JAY. This flagship public health initiative has been internationally recognized as a significant step toward achieving universal coverage in India. The initiative offers hospital coverage for the 40 percent of the country\u2019s population that is poor or low-income. The other important initiative is to bolster preventive and promotive health care services by revamping existing primary health facilities into Health and Wellness Centres.
Since 1995, Israel\u2019s National Health Insurance (NHI) law has ensured universal coverage for citizens and permanent residents. As the law states, \"Health insurance\u2026shall be based on principles of justice, equality and mutual assistance.\" Under this commitment, every resident is entitled to health care services.
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Residents are free to choose one of four competing nonprofit health plans that must cover anyone who applies. Every resident has a right to receive all services included in the benefit basket that is mandated by the government, subject to medical discretion. While residents also have the right to receive services at a reasonable quality level, within a reasonable period of time, and at a reasonable distance from their home, no formal definition of \u201creasonable\u201d exists, and there is no penalty for health plans that fail to comply.
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Some populations are excluded: soldiers, who receive health care directly from the army; inmates, who receive care from the Israel Prison Service; documented and undocumented foreign workers, whom employers are required to enroll in private insurance programs; and undocumented migrants, temporary residents, and tourists.
Universal coverage is provided through Italy\u2019s National Health Service (Servizio sanitario nazionale, or SSN), established through legislation in 1978. The SSN automatically covers all citizens and legal foreign residents. Since 1998, undocumented immigrants have had access to urgent and essential services. Temporary visitors are responsible for the costs of any health services they receive.
Japan\u2019s statutory health insurance system (SHIS) covers 98.3 percent of the population, while the separate Public Social Assistance Program, for impoverished people, covers the remaining 1.7 percent. Citizens and resident noncitizens are required to enroll in an SHIS plan; undocumented immigrants and visitors are not covered.
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The SHIS consists of two types of mandatory insurance:
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employment-based plans, which cover about 59 percent of the population
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residence-based insurance plans, which include Citizen Health Insurance plans for nonemployed individuals age 74 and under (27% of the population) and Health Insurance for the Elderly plans, which automatically cover all adults age 75 and older (12.7% of the population).
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Each of Japan\u2019s 47 prefectures, or regions, has its own residence-based insurance plan, and there are more than 1,400 employment-based plans.
In the Netherlands, a national health insurance program was first rolled out in 1941, reflecting the German Bismarck model of public and private health insurers. Around 63 percent of the population was covered by public health insurance, while the more affluent could opt for private insurance or choose to remain uninsured.
\n\n
At the turn of the century, concerns over inefficiencies and long waiting lists provided momentum for market-oriented reform based on the managed competition model proposed by American economist Alain C. Enthoven. The 2006 Health Insurance Act merged the traditional public and private insurance markets into one universal social health insurance program underpinned by private insurance and mandatory coverage.
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All residents (and nonresidents who pay Dutch income tax) must purchase statutory health insurance from private insurers. Adults choose a policy on an individual basis (no family coverage), and children under 18 are then automatically covered. Insurers are required to accept all applicants, and enrollees have the right to change their insurer each year.
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The uninsured are fined, and their insurance premiums may be levied directly from income. People who conscientiously object to insurance can opt out by making mandatory contributions into a health savings account. Active members of the armed forces (who are covered by the Ministry of Defense) are exempt.
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Undocumented immigrants cannot purchase health insurance and have to pay for most treatments out-of-pocket (excluding acute care, obstetric services, and long-term care). However, some mechanisms are in place to reimburse costs that undocumented immigrants are unable to pay. Political asylum\u2013seekers fall under a separate, limited insurance plan. Permanent residents living in the Netherlands for more than three months are obliged to purchase private insurance. Short-term visitors are required to purchase insurance for the duration of their visit if they are not covered through their home country.
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Since 2011, the number of uninsured in the Netherlands has steadily declined. At the end of 2016, 23,000 people (less than 0.2% of the population) remained uninsured.
Beginning with the 1938 Social Security Act, a consensus developed in New Zealand that government has a fundamental role in providing for the population\u2019s health care needs. Not long after that law\u2019s passage, the government achieved its goal of universal health coverage. No citizen can be denied treatment in public hospitals, and all citizens have insurance through government-funded, universally accessible health services. In practice, however, coverage varies by income, need, location, and type of service.
Norway has universal health and social insurance coverage, known as the National Insurance Scheme (NIS), or Folketrygd. It is currently regulated by the 1997 National Insurance Act and the 1999 Patient Rights Act.
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The establishment of universal coverage has a long history in Norway. Political and social movements began advocating for universal social and health care insurance around 1900. The Act of Health Insurance, covering employees as well as their families, came into force in 1909. Membership was mandatory for low-income employees; others could opt in. The coverage was twofold: health care and guaranteed basic income in case of income loss due to ill health. In 1956, the system was converted into a universal and mandatory right for all citizens.
Singapore\u2019s health care financing system is underpinned by the belief that all stakeholders share responsibility for attaining sustainable universal health coverage. Singapore has a multipayer health care financing framework, where a single treatment episode might be covered by multiple schemes and payers, often overlapping. The system, known as the 3Ms, comprises the following programs:
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MediShield Life, a universal basic health care insurance, is mandatory for citizens and permanent residents and provides lifelong protection against large hospital bills and select costly outpatient treatments. It was launched in 2015 to replace MediShield, an opt-out catastrophic illness insurance scheme.
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MediSave, a national medical savings scheme, helps cover out-of-pocket payments. Personal and employer salary contributions (8%\u201310.5%, depending on age) to MediSave accounts are mandatory for all working citizens and permanent residents. These tax-exempt, interest-bearing (currently 4% to 5%) accounts can be used to pay for family members\u2019 health care expenses.
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MediFund is the government\u2019s safety net for needy Singaporeans who cannot cover their out-of-pocket expenses, even with MediSave.
The Health and Medical Services Act states that Sweden\u2019s health system must cover all legal residents. Coverage is universal and automatic. Emergency coverage is provided to all patients from the European Union, European Economic Area countries, and nine other countries with which Sweden has bilateral agreements. Asylum-seeking and undocumented children have the right to health care services, as do children who are permanent residents. Adult asylum-seekers and undocumented adults have the right to receive care that cannot be deferred, such as maternity care.
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Three basic principles apply to all health care in Sweden:
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Human dignity: All human beings have an equal entitlement to dignity and have the same rights regardless of their status in the community.
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Need and solidarity: Those in greatest need take precedence in being treated.
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Cost-effectiveness: When a choice has to be made, there should be a reasonable balance between costs and benefits, with costs measured in relation to improvement in health and quality of life.
Historically, health insurance in Switzerland had been provided by many small private insurers. After several attempts to introduce a system of universal coverage, the federal government adopted the Health Insurance Law in 1994, based on a private insurance model. The law\u2019s objectives were to:
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strengthen equality by introducing universal coverage and subsidies for low-income households
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expand the benefit basket and ensure high standards of health services
\n\t
contain the growing costs of the health system.
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Since going into effect in 1996, health insurance coverage is close to 100 percent. Citizens are legally required to purchase insurance, and the cantons ensure compliance. Insurance policies typically apply to individuals, and separate coverage must be purchased for dependents. New residents must purchase a policy within three months of arriving in Switzerland, and coverage applies retroactively to the arrival date. Temporary nonresident visitors pay for care themselves and claim expenses from any insurance coverage they hold in their home countries. The absence of mandatory health insurance for undocumented immigrants remains an unsolved problem.
Taiwan's NHI system was implemented in 1995. Before then, Taiwan had had more than 10 public insurance schemes, each covering a particular group, such as government employees, farmers, and low-income households. These programs covered 59 percent of the population.
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In 1986, Taiwan's government proposed moving to a universal NHI program. The planning process involved studying health insurance systems abroad, borrowing parts from systems of other countries and adapting them to suit Taiwan's national conditions. On the recommendation of former government adviser Uwe Reinhardt, the late Princeton University economist, Taiwan's government established a single-payer system, which merged Taiwan's then-existing public insurance schemes. Reinhardt's recommendation was based on three principles:
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Equity in both access and benefits
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Effective and egalitarian cost control
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Administrative simplicity to help the public understand the system.
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The NHI Act became law in July 1994 and implemented rapidly in 1995. NHI is a government-run social health insurance program that provides equitable medical and health care services to all in case of illness, injury, and childbirth. Enrollment in NHI is mandatory for all citizens and for foreigners legally residing in Taiwan for longer than six months. Virtually all residents are enrolled.
The United States does not have universal health insurance coverage. Nearly 92 percent of the population was estimated to have coverage in 2018, leaving 27.5 million people, or 8.5 percent of the population, uninsured. Movement toward securing the right to health care has been incremental.
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Employer-sponsored health insurance was introduced during the 1920s. It gained popularity after World War II when the government imposed wage controls and declared fringe benefits, such as health insurance, tax-exempt. In 2018, about 55 percent of the population was covered under employer-sponsored insurance.
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In 1965, the first public insurance programs, Medicare and Medicaid, were enacted through the Social Security Act, and others followed.
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Medicare. Medicare ensures a universal right to health care for persons age 65 and older. Eligible populations and the range of benefits covered have gradually expanded. In 1972, individuals under age 65 with long-term disabilities or end-stage renal disease became eligible.
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All beneficiaries are entitled to traditional Medicare, a fee-for-service program that provides hospital insurance (Part A) and medical insurance (Part B). Since 1973, beneficiaries have had the option to receive their coverage through either traditional Medicare or Medicare Advantage (Part C), under which people enroll in a private health maintenance organization (HMO) or managed care organization.
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In 2003, Part D, a voluntary outpatient prescription drug coverage option provided through private carriers, was added to Medicare coverage.
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Medicaid. The Medicaid program first gave states the option to receive federal matching funding for providing health care services to low-income families, the blind, and individuals with disabilities. Coverage was gradually made mandatory for low-income pregnant women and infants, and later for children up to age 18.
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Today, Medicaid covers 17.9 percent of Americans. As it is a state-administered, means-tested program, eligibility criteria vary by state. Individuals need to apply for Medicaid coverage and to re-enroll and recertify annually. As of 2019, more than two-thirds of Medicaid beneficiaries were enrolled in managed care organizations.
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Children\u2019s Health Insurance Program. In 1997, the Children\u2019s Health Insurance Program, or CHIP, was created as a public, state-administered program for children in low-income families that earn too much to qualify for Medicaid but that are unlikely to be able to afford private insurance. Today, the program covers 9.6 million children.5 In some states, it operates as an extension of Medicaid; in other states, it is a separate program.
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Affordable Care Act. In 2010, the passage of the Patient Protection and Affordable Care Act, or ACA, represented the largest expansion to date of the government\u2019s role in financing and regulating health care. Components of the law\u2019s major coverage expansions, implemented in 2014, included:
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requiring most Americans to obtain health insurance or pay a penalty (the penalty was later removed)
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extending coverage for young people by allowing them to remain on their parents\u2019 private plans until age 26
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opening health insurance marketplaces, or exchanges, which offer premium subsidies to lower- and middle-income individuals
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expanding Medicaid eligibility with the help of federal subsidies (in states that chose this option).
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The ACA resulted in an estimated 20 million gaining coverage, reducing the share of uninsured adults aged 19 to 64 from 20 percent in 2010 to 12 percent in 2018.
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+ "page_last_modified": " Tue, 12 Mar 2024 21:59:24 GMT"
+ },
+ {
+ "page_name": "List of countries with universal health care - Wikipedia",
+ "page_url": "https://en.wikipedia.org/wiki/List_of_countries_with_universal_health_care",
+ "page_snippet": "Singapore has "one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes," according to an analysis by global consulting firm Watson Wyatt. Singapore's system uses a combination of compulsory savings ...Singapore has \"one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes,\" according to an analysis by global consulting firm Watson Wyatt. Singapore's system uses a combination of compulsory savings from payroll deductions (funded by both employers and workers) a nationalized health insurance plan, and government subsidies, as well as \"actively regulating the supply and prices of healthcare services in the country\" to keep costs in check; the specific features have been described as potentially a \"very difficult system to replicate in many other countries.\" Achieving this level of equality guaranteed basic healthcare regardless of fund affiliation, which was one of the principal aims of the law. An appeals process handles rejection of treatments and procedures by the funds and evaluates cases that fall outside the \"basket\" of services or prescription formulary. The law is generally considered a success, and Israeli citizens enjoy a high standard of medical care comparatively, with more competition in the country's health care, and with order having brought to what was once a somewhat disorganized system\u2014the law nevertheless has its critics. The government may provide universal health insurance in the form of a social insurance plan that is affordable by all citizens, such as in the case of Germany and Taiwan, although private insurance may provide supplemental coverage to the public health plan. In twenty-five European countries, universal healthcare entails a government-regulated network of private insurance companies. Algeria operates a public healthcare system. It is a universal healthcare system as well. A network of hospitals, clinics, and dispensaries provide treatment to the population, with the Social Security system funding health services, although many people must still cover part of their costs due to the rates paid by the Social Security system remaining unchanged since 1987. Morocco does not have universal health care. It is currently building a system which was slated to cover the entire population by the end of 2022. The country operates a public health sector run by the government that operates 85% of the country's hospital beds. It deals mainly with the poor and rural populations, who cannot afford private healthcare.",
+ "page_result": "\n\n\n\nList of countries with universal health care - Wikipedia\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nJump to content\n
\n\nGovernment-guaranteed health care for all citizens of a country, sometimes called universal health care, is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at broadly extending access to health care and setting minimum standards. Most implement universal health care through legislation, regulation, and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis.\n
The logistics of such health care systems vary by country. Some programs are paid for entirely out of tax revenues. In others, tax revenues are used either to fund insurance for the very poor or for those needing long-term chronic care. In some cases such as the UK, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care. Alternatively, much of the provision of care can be contracted from the private sector, as in the case of Canada and France. In some instances, such as in Italy and Spain, both these realities may exist at the same time. The government may provide universal health insurance in the form of a social insurance plan that is affordable by all citizens, such as in the case of Germany and Taiwan, although private insurance may provide supplemental coverage to the public health plan. In twenty-five European countries, universal healthcare entails a government-regulated network of private insurance companies.[1][2]\n
Algeria operates a public healthcare system. It is a universal healthcare system as well. A network of hospitals, clinics, and dispensaries provide treatment to the population, with the Social Security system funding health services, although many people must still cover part of their costs due to the rates paid by the Social Security system remaining unchanged since 1987. The poor are generally entitled to taxpayer funded health services, while the wealthy pay for treatment according to a sliding scale.[3][4]\n
Botswana established a free healthcare system that operates a system of public medical centers, with 98% of health facilities in the country run by the government.[citation needed] All citizens are entitled to be treated in taxpayer funded facilities, though a nominal fee of ~70 BWP (~US$6.60) is typically charged for public health services except for sexual reproductive health services and antiretroviral therapy services, which are free.[5]\n
Burkina Faso provides universal healthcare to citizens through a system called Universal Health Insurance (AMU)\u2014administered by two bodies, one for civilians and the other for the armed forces.[6]\n
Morocco does not have universal health care. It is currently building a system which was slated to cover the entire population by the end of 2022.[8] The country operates a public health sector run by the government that operates 85% of the country's hospital beds. It deals mainly with the poor and rural populations, who cannot afford private healthcare. In addition, a non-profit health sector operated by the National Social Security Fund covers 16% of the population. Private medical care is available for those who can afford it.[9]\n
Rwanda operates a system of universal health insurance through the Ministry of Health called Mutuelle de Sant\u00e9 (Mutual Health), a system of community-based insurance where people pay premiums based on their income level into local health insurance funds, with the wealthiest paying the highest premiums and required to cover a small percentage of their medical expenses, while those at the lowest income levels are exempt from paying premiums and can still utilize the services of their local health fund. In 2012, this system insured all but 4% of the population.[10]\n
Tunisia operates a public healthcare system under the National Health Insurance Fund (Caisse Nationale d'Assurance Maladie). All Tunisian citizens and residents can receive treatment in state-run hospitals and clinics for a very low co-pay, while people with the lowest income are able to apply for an exemption from co-pays.[11]\n
The Royal Government of Bhutan maintains a policy of free and universal access to primary health care. As hospital facilities in the country are limited, patients with diseases that cannot be treated in Bhutan, such as cancer, are normally referred to hospitals in India for treatment. Such referral treatment is also carried out at the cost of the Royal Government.[12]\n
As of 2017, more than 97% of people in China are covered by one of three categories of public health insurance. From most generous to least generous, they are the: \n
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Urban Employee Basic Medical Insurance (UEBMI, \u804c\u5de5\u533b\u4fdd)
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Urban Resident Basic Medical Insurance (URBMI, \u5c45\u6c11\u533b\u4fdd)
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New Cooperative Medical Service (NCMS, \u65b0\u519c\u5408)
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The UEBMI is funded by 6-12% by employers and 2% by employees; the URBMI entirely by local governments, and it covers students, the unemployed, and the retired; and the NCMS by the central government. In 2016, the government announced plans to merge NCMS with URBMI. China also has five private health insurance companies for supplementary care: the three largest are Ping An, PICC, and China Life.\n[13] For the public plans, the list of covered procedures is limited, and copayment is common. The proportion of out-of-pocket costs depends on profession and location: for example, workers in urban Shanghai might have 85% of their medical costs covered up to $740,000 while workers in rural Guiyang are reimbursed for 65% of their medical costs up to $29,000 annually.[14]\n
Immediately after the Chinese Communist Revolution in 1949, the state both directly operated all hospitals and clinics. The government paid for healthcare services, and life expectancy improved greatly, although the services provided were basic. State-provided health insurance varied by area: the Cooperative Medical System (CMS) covered rural areas, while the Government Insurance Scheme (GIS) and Labor Insurance Scheme (LIS) covered residents of urban areas.[15] After the Chinese economic reform in 1978, the state reduced spending on hospitals and allowed them to charge patients for profit. The state, however, did not stop paying for certain healthcare services like mandatory vaccination.[14]\n
From the high point of privatization of healthcare in the 1990s,[15] China has been reforming with universal health care as a goal in the 21st century, as part of the \"moderately prosperous society\" plan. The New Rural Co-operative Medical Care System (NRCMCS) from 2005, aimed at the rural poor, sets the annual cost of medical coverage at 50 yuan (US$7) per person. As of September 2007, around 80% of the whole rural population of China had signed up (about 685 million people). For patients who go to a small hospital or clinic in their local town, the scheme covers from 70 to 80% of their bill; patients at a county provider get 60% of their cost covered; and in a large modern city hospital, the scheme covers about 30% of the bill.[16]\n
At the end of 2008, the government published its reform plan clarifying government's responsibility by saying that it would play a dominant role in providing public health and basic medical service. The plan listed public health, rural areas, city community health services and basic medical insurance as four key areas for government investment. It also promised to tighten government control over medical fees in public hospitals and to set up a \"basic medicine system\" to cover drug costs.[17][18] China's \"Law on Promotion of Basic Medical and Health Care\", effective June 2020, asserts that Chinese citizens have a positive right to healthcare, regardless of cost. Additional laws are expected to specify what this right will mean in practice.[citation needed]\n
Hong Kong has early health education, professional health services, and well-developed health care and medication system. The life expectancy is 84 for females and 78 for males,[19] which is the second highest in the world, and 2.94 infant mortality rate, the fourth lowest in the world.[20][21]\n
There are two medical schools in Hong Kong, and several schools offering courses in traditional Chinese medicine. The Hospital Authority is a statutory body that operates and manages all public hospitals. Hong Kong has high standards of medical practice. It has contributed to the development of liver transplantation, being the first in the world to carry out an adult to adult live donor liver transplant in 1993.[22]\n
At the federal level, a national health insurance program was launched in 2018 by the Government of India, called Ayushman Bharat. This aimed to cover the bottom 50% (500 million people) of the country's population working in the unorganized sector (enterprises having less than 10 employees) and offers them free treatment at both public and private hospitals.[23] For people working in the organized sector (enterprises with more than 10 employees) and earning a monthly salary of up to Rs 21000 are covered by the social insurance scheme of Employees' State Insurance which entirely funds their healthcare (along with pension and unemployment benefits), both in public and private hospitals.[24][25] People earning more than that amount are provided health insurance coverage by their employers through the many public or private insurance companies. As of 2020, 300 million Indians are covered by insurance bought from one of the public or private insurance companies by their employers as group or individual plans.[26] Unemployed people without coverage are covered by the various state insurance schemes if they do not have the means to pay for it.[27]\nIn 2019, the total net government spending on healthcare was $36 billion or 1.23% of its GDP.[28]\nAn outpatient card at AIIMS costs a one-time fee of 10 rupees (around 20 cents U.S.) and thereafter outpatient medical advice is free. In-hospital treatment costs is extremely minimal and depends on the financial condition of the patient and the facilities utilized, but are usually much less than in the private sector. For instance, a patient is waived treatment costs if their income is below the poverty line. However, getting treatment at high quality government hospitals is very tough due to the high number of people needing healthcare and the lack of sufficient facilities.\n
Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These hospitals provide treatment free of cost. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses.[29] Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals).[citation needed]. In urban cities and towns like Delhi, there are neighbourhood health clinics called Mohalla Clinics which offer completely free treatment, testing and drugs.[30]\n
The Indian government has launched Ayushyaman Bharat Yojana (AB-NHPM), which will provide all Indian citizens with insurance coverage for serious illnesses, and free drugs and diagnostic treatments.[31]\n
Indonesia is currently building a universal healthcare system with its Jaminan Kesehatan Nasional (JKN) scheme, managed by BPJS Kesehatan, which covers a range of treatments from public providers as well as private providers that opt to participate. The scheme is funded by premiums from the employed. The formally employed pay a premium worth 5% of their salary, with 1% paid by the employee and 4% paid by the employer, while informal workers and the self-employed must pay a fixed monthly premium. As of April 2018, 75% of the population was covered by JKN.[32]\n
While the country has a number of government-owned hospitals, about 63% are privately owned.[33] Indonesia also operates a three-tier community health system. The Ministry of Health oversees a network of Puskesmas, or community health centers, followed by health sub-centers and village-level integrated posts.[34]\n
Israel has a system of universal healthcare as set out by the 1995 National Health Insurance Law. The state is responsible for providing health services to all residents of the country, who can register with one of the four national health service funds. To be eligible, a citizen must pay a health insurance tax. Coverage includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, preventive dental care for children, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.[35]\n
In Israel, the National Health Insurance Law is the legal framework that enables and facilitates basic, compulsory universal health care. Promoted by health ministerHaim Ramon in the early 1990s,[36] the Knesset put the law into effect on January 1, 1995\u2014basing it on recommendations from a National Committee of Inquiry headed by Shoshana Netanyahu, which examined restructuring the health care system in Israel in the late 1980s. Prior to the law's passage, over 90% of the population was already covered by voluntarily belonging to one of four nationwide, not-for-profit sickness funds. These operated some of their own medical facilities, funded in part by employers and the government, and in part by the insured via levies that varied according to income. However, there were three problems associated with this arrangement. First, membership in the largest fund, Clalit, required one to belong to the Histadrut labor organization, even if a person did not want to (or could not) have such an affiliation, and other funds restricted entry to new members based on age, pre-existing conditions, or other factors. Second, different funds provided different levels of benefit coverage or services to their members. Lastly, some of the population, albeit a small percentage, had no health insurance.\n
Before the law went into effect, all the funds collected premiums directly from members. However, upon passage of the law, a new progressive national health insurance tax was levied through Bituah Leumi (Israel's social security agency), which then re-distributes the proceeds to the sickness funds based on their membership and its demographic makeup. This ensured that all citizens would now have health coverage. While membership in one of the funds now became compulsory for all, free choice was introduced into movement of members between funds (a change is allowed once every six months), effectively making the various sickness funds compete equally for members among the populace. Annually, a committee appointed by the ministry of health publishes a \"basket\" or uniform package of medical services and prescription formulary that all funds must provide as a minimum to all members. Achieving this level of equality guaranteed basic healthcare regardless of fund affiliation, which was one of the principal aims of the law. An appeals process handles rejection of treatments and procedures by the funds and evaluates cases that fall outside the \"basket\" of services or prescription formulary.\n
The law is generally considered a success, and Israeli citizens enjoy a high standard of medical care comparatively, with more competition in the country's health care, and with order having brought to what was once a somewhat disorganized system\u2014the law nevertheless has its critics. First among the criticisms is that the \"basket\" may not provide enough coverage. To partly address this, the health funds began offering \"supplementary\" insurance to cover certain additional services not in the basket. However, since this insurance is optional (though rather modestly priced, costing the equivalent of about US$10 to $35 a month depending on age and coverage for an adult in 2019), critics argue that it goes against the spirit of the new law, which stressed equality of healthcare for all citizens. Another criticism is that, to provide universal coverage to all, the tax income base amount (the maximum amount of yearly earnings that are subject to the tax) was set rather high, causing many high-income taxpayers to see the amount they pay for their health premiums (now health tax) skyrocket. Finally, some complain about the constantly rising costs of copayments for certain services.\n
All residents of Japan are required by the law to have health insurance coverage. People without insurance from employers can participate in a national health insurance programme, administered by local governments. Patients are free to select physicians or facilities of their choice and cannot be denied coverage. Hospitals, by law, must be run as non-profit and be managed by physicians.\n
Malaysia has achieved universal health coverage. It has made remarkable progress in improving health outcomes over the past seven decades. At the time of Independence, the number of infant deaths was 75.5 per 1,000 live births. This has since fallen by more than 90 percent to 6.7 deaths per 1,000 live births in 2016. Maternal mortality which refers to the death of a woman caused by her pregnancy, during and after delivery, has also decreased by 89% between 1963 and 2013.[37]\n
Aasandha is the national healthcare insurance scheme of the Maldives. It provides taxpayer-funded medical assistance to all Maldivian citizens. National Social Protection Agency of Maldives was formed under the National Social Health Insurance Act on August 27, 2008. It is mandated to administer the National Social Health Insurance Scheme and by an executive order under the same act mandated to conduct social protection programs identified by the government of Maldives. NSPA is also the responsible agency to regulate and conduct Social Protection programs under the Social Protection Act.\n
Some of Pakistan's provinces have universal healthcare coverage. The Government of Khyber Pakhtunkhwa launched a \"universal health insurance programme\" known as the \"Sehat Insaf Card\" to provide free healthcare for the residence of KPK, where families would be covered up to Rs. 10 lakh (US$3,500) for treatment.[38] This was further expanded to the Punjab province of Pakistan, in December 2021, to cover more than 31 million families. Prime Minister Imran Khan announced that an additional Rs. 440 billion (US$1.5 billion) would be spent to cover the entire province.[39]\n
Filipinos are covered under the National Health Insurance Program (NHIP) of the Philippine government-owned Philippine Health Insurance Corporation or PhilHealth. Under the Universal Health Care Law of 2019, all Filipinos were automatically enrolled in the NHIP.[40]\n
The Government of Saudi Arabia provides free universal health coverage for all citizens. Non-citizens are required by law to have private insurance paid for by their employer.\n
Singapore has a universal health care system where government ensures affordability, largely through compulsory savings and price controls, while the private sector provides most care. Overall spending on health care amounts to only 3% of annual GDP. Of that, 66% comes from private sources.[41] Singapore currently has the second lowest infant mortality rate in the world and among the highest life expectancies from birth, according to the World Health Organization.[42] Singapore has \"one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes,\" according to an analysis by global consulting firm Watson Wyatt.[43] Singapore's system uses a combination of compulsory savings from payroll deductions (funded by both employers and workers) a nationalized health insurance plan, and government subsidies, as well as \"actively regulating the supply and prices of healthcare services in the country\" to keep costs in check; the specific features have been described as potentially a \"very difficult system to replicate in many other countries.\" Many Singaporeans also have supplemental private health insurance (often provided by employers) for services not covered by the government's programs.[43]\n
North Korea claims to provide universal health care with a national medical service and health insurance system.[44] It claims that health services are offered for free.[44]: 7\u20138 However, this claim has been contrasted by North Korean defectors, who claim that patients must in fact pay for health services, that the upper classes have access to a higher standard of healthcare than ordinary ones do, and that \"how much money a patient has determines whether they live or die\".[45]\n
The current health care system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan that centralizes the disbursement of health care dollars. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[47] NHI is mainly financed through premiums based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers.[citation needed]\n
NHI delivers universal coverage offered by a government-run insurer. The working population pays premiums split with their employers, others pay a flat rate with government help and the poor or veterans are fully subsidized.[48]\n
Under this model, citizens have free range to choose hospitals and physicians without using a gatekeeper and do not have to worry about waiting lists. NHI offers a comprehensive benefit package that covers preventive medical services, prescription drugs, dental services, Chinese medicine, home nurse visits and many more. Since NHI, the previously uninsured have increased their usage of medical services. Most preventive services are free such as annual checkups and maternal and child care. Regular office visits have co-payments as low as US$5 per visit. Co-payments are fixed and unvaried by the person's income.[49]\n
Thailand introduced universal coverage reforms in 2001, becoming one of only a handful of lower-middle income countries to do so at the time. Means-tested health care for low income households was replaced by a new and 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 that they use to access services in their health district, and, if necessary, get referrals for specialist treatment elsewhere. The bulk of finance comes from public revenues, with funding allocated to Contracting Units for Primary Care annually on a population basis. According to the WHO, 65% of Thailand's health care expenditure in 2004 came from the government, and 35% was from private sources.[41] Although the reforms have received a good deal of critical comment, they have proved popular with poorer Thais, especially in rural areas, and survived the change of government after the 2006 military coup. The then Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the UC scheme free. It is not yet clear whether the scheme will be modified further under the coalition government that came to power in January 2008.[50][51][52]\n
In 2016, Thailand became the first country in Asia to eliminate HIV transmission from mother to child, owing to its robust public healthcare system.[53]\n
The United Arab Emirates has enacted federal legislation that requires universal healthcare nationals and mandatory health insurance for expatriates, but this legislation has not yet been implemented across the entire country. [54]\n
Almost all European countries have healthcare available for all citizens. Most European countries have systems of competing private health insurance companies, along with government regulation and subsidies for citizens who cannot afford health insurance premiums.[55] Countries with universal healthcare include Austria, Belarus,[56] Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Italy, Latvia, Lithuania, Luxembourg, Macedonia, Malta, Moldova,[57] Norway, Poland, Portugal,[58] Romania, Russia, Serbia, Spain, Sweden, Switzerland, Ukraine,[59] and the United Kingdom.[60]\n
Armenia operates a mandatory social health insurance system. The majority of the population is enrolled in the Compulsory Health Insurance Fund, which is funded through payroll taxes and contributions from employers and employees.\n
Healthcare in Austria is universal for residents of Austria as well as those from other EU countries.[61] Austria has a two-tier payment system in which many individuals receive basic publicly funded care; they also have the option to purchase supplementary private health insurance.\n
Healthcare in Belgium is composed of three parts. Firstly there is a primarily publicly funded healthcare and social security service run by the federal government, which organises and regulates healthcare; independent private/public practitioners, university/semi-private hospitals and care institutions. There are a few (commercially run for-profit) private hospitals.[62] Secondly is the insurance coverage provided for patients. Finally, industry coverage covers the production and distribution of healthcare products for research and development. The primary aspect of this research is done in universities and hospitals.\n
Healthcare in Bulgaria is mixed. Some services are private, like dental care, and some services are run publicly by NHIF.[63] Because 15% of the population is uninsured and cannot access most health services, it does not currently qualify as having universal healthcare.[64]\n
Croatia has a universal health care system that provides medical services and is coordinated by the Ministry of Health. The population is covered by a basic health insurance plan provided by statute and by optional insurance. It is administered by the Croatian Health Insurance Fund. In 2012, annual compulsory healthcare related expenditures reached 21.0 billion kunas (c. 2.8 billion euro). There are hundreds of healthcare institutions in Croatia, including 79 hospitals and clinics with 25,285 beds, caring for more than 760 thousand patients per year, 5,792 private practice offices and 79 emergency medical service units.\n
A universal national health system, known as GESY, was implemented in Cyprus in June 2019. The new system aims to provide affordable and effective medical care to all people residing permanently in Cyprus. As of June 2022, 917,000 Cypriots have registered[5][clarification needed] with a general practitioner through the GESY system, which is roughly the current population of the Republic of Cyprus.\n
Czech Republic has a universal public health system paid largely from taxation. Private health care systems do co-exist freely alongside public ones, sometimes offering better quality or faster service. Almost all medical services are covered by health insurance and insurance companies, though certain services such as prescription drugs or vision and dental care are only covered partially.\n
Denmark has a universal public health system paid largely from taxation with local municipalities delivering health care services in the same way as other Scandinavian countries. Primary care is provided by a general practitioner service run by private doctors contracting with the local regions with payment on a mixed per capita and fee for service basis. Most hospitals are run by the regions (only 1% of hospital beds are in the private sector).\n
Estonia's health care system is based on compulsory insurance based on solidarity funding and on universal access to services provided by private service providers. \n
In Finland, public medical services at clinics and hospitals are run by the municipalities (local government) and are funded 76% by taxation, 20% by patients through access charges, and 4% by others. Private provision is mainly in the primary care sector. There are a few private hospitals.[65] The main hospitals are either municipally owned (funded from local taxes) or run by the medical teaching universities (funded jointly by the municipalities and the national government). According to a survey published by the European Commission in 2000, Finland's is in the top 4 of EU countries in terms of satisfaction with their hospital care system: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[66] Finnish health care expenditures are below the European average.[67] The private medical sector accounts for about 14 percent of total health care spending. Only 8% of doctors choose to work in private practice, and some of these also choose to do some work in the public sector.[citation needed]\n
Taxation funding is partly local and partly nationally based. The national social insurance institution KELA reimburses part of patients prescription costs and makes a contribution towards private medical costs (including dentistry) if they choose to be treated in the private sector rather than the public sector. Patient access charges are subject to annual caps. For example, GP visits cost \u20ac11 per visit with annual \u20ac33 cap; hospital outpatient treatment \u20ac22 per visit; a hospital stay, including food, medical care and medicines \u20ac26 per 24 hours, or \u20ac12 if in a psychiatric hospital. After a patient has spent \u20ac683 per year on public medical services, all further treatment in that year is covered (although the required initial deductible is reviewed annually, so it may vary). There is a separate reimbursement system for prescribed medicine: after paying \u20ac578 per year, the remaining bought medicine will have a maximum price of \u20ac2.50 per purchase.[68]\n
Finland has a highly decentralized three-level public system of health care and alongside this, a much smaller private health care system.[69]\nOverall, the municipalities (funded by taxation, local and national) meet about two thirds of all medical care costs, with the remaining one third paid by the national insurance system (nationally funded), and by private finance (either employer-funded or met by patients themselves).[69]\nPrivate inpatient care forms about 3\u20134% of all inpatient care.[69] In 1999 only 17 per cent of total funding for health care came from insurance, comprising 14.9% statutory (government) insurance and 2.1% private health insurance. Eyeglasses are not publicly subsidized at all, although dentistry is available as a municipal service or can be obtained privately with partial reimbursement from the state.[69]\n
The percentage of total health expenditure financed by taxation in Finland (78%)[70] is above the OECD average and similar to the levels seen in Germany (77%) and France (80%) but below the level seen in the UK (87%). The quality of service in Finnish health care, as measured by patient satisfaction, is excellent. According to a survey published by the European Commission in 2000, Finland has one of the highest ratings of patient satisfaction with their hospital care system in the EU: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[71]\n
There are caps on total medical expenses that are met out-of-pocket for drugs and hospital treatments. The National Insurance system pays all necessary costs over these caps. Public spending on health care in 2006 was 13.6 billion euros (equivalent to US$338 per person per month). The increase over 2005 at 8.2 per cent was below the OECD average of 9 percent. Household budgets directly met 18.7 per cent of all health care costs.[72]\n
France has a system of health care largely financed by government through a system of national health insurance. Nonetheless, not all medical care is paid for by the state, with only 70% of initial GP care covered and anywhere between 35% and 100% of prescription medication covered. It is consistently ranked as one of the best in the world.[73]\n
In 2013, Georgia adopted a universal health care system. Healthcare in Georgia is provided by a universal health care system under which the state funds medical treatment in a mainly privatized system of medical facilities. In 2013, the enactment of a universal health care program triggered universal coverage of government-sponsored medical care of the population and improving access to health care services. Responsibility for purchasing publicly financed health services lies with the Social Service Agency (SSA).[74][75] However, according to the UN, due to the high out-of-pocket costs that patients incur, Georgia has not yet achieved universal healthcare.[76]\n
Germany has the world's oldest national social health insurance system,[77][78][79] with origins dating back to Otto von Bismarck's Sickness Insurance Law of 1883.[80][81] The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Employers pay for half of their employees' health insurance contributions, while self-employed workers pay the entire contribution themselves.[82] Approximately 90% of the population is covered by a statutory health insurance plan, which provides a standardized level of coverage through any one of approximately 100 public sickness funds.[82][83] The rest are covered by private health insurance. Private health insurance is only accessible to self-employed workers, high-income employees and Beamte. The contributions for public insurance is determined according to income, while the contributions for private health insurance are determined according to age and health condition.[82]\n
Purchasing basic health insurance is mandatory for all persons residing in Germany if not employed. Historically, the level of provider reimbursement for specific services is determined through negotiations between regional physician's associations and sickness funds. Since 1976 the government has convened an annual commission, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries.[84] The commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. In 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. Although reimbursement of providers is on a fee-for-service basis, the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. Capitated care, such as that provided by U.S. health maintenance organizations, has been considered as a cost containment mechanism but would require consent of regional medical associations, and has not materialized.[85]\n
Copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).[86][87] The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[88]\n
The Greek healthcare system provides high quality medical services to insured citizens and is coordinated by the Ministry for Health and Social Solidarity. Public health services are provided by the National Healthcare Service, or ESY (Greek: \u0395\u03b8\u03bd\u03b9\u03ba\u03cc \u03a3\u03cd\u03c3\u03c4\u03b7\u03bc\u03b1 \u03a5\u03b3\u03b5\u03af\u03b1\u03c2, \u0395\u03a3\u03a5). In 2010 there were 35,000 hospital beds and 131 hospitals in the country.\n
The Greek healthcare system has received high rankings by the World Health Organization, ranked 14th in the overall assessment and 11th in quality of service in a 2000 report by the WHO. However, it must be noted that the entire financial system collapsed in 2007\u20132008. The data listed above is from 2000.\n
Iceland has a universal public health system paid largely from taxation with local municipalities delivering health care services in the same way as the Scandinavian countries. Iceland's entire population has equal access to health care services.[citation needed][89]\n
The public health care system in Ireland is governed by the Health Act 2004,[90] which established a new body to be responsible for providing health and personal social services to everyone living in Ireland \u2013 the Health Service Executive. The new national health service came into being officially on January 1, 2005; however, the new structures are currently[when?] in the process of being established as the reform program continues[citation needed]. In addition to the public-sector, there is a large private health care market.\n
In Ireland, 37% of the population have a means-tested medical card that gives the holder access to tax-funded GP care and requires \u20ac2.00 for each prescription drug.[91] The standard charge for Irish and EU citizens who attend the A&E in hospitals is \u20ac100. This is free of charge if referred by a GP.[92] For all other residents who do not have a medical card, the average price for an appointment with a family doctor GP is \u20ac50 or \u20ac70 for an emergency appointment with a Caredoc GP.[93] Ireland is currently in the process of establishing a universal healthcare system based on compulsory private health insurance, with competition managed by the government. These reforms are known as Sl\u00e1intecare and are scheduled to be completed by 2030.[94]\n
Italy has a public health care service for all the residents called \"Servizio Sanitario Nazionale\" or SSN (National Health Service). It is publicly run and funded mostly by taxation. Some services require variable co-pays, while other services (such as emergency medicine and a general doctor) are free. There is also a small parallel private health care system, especially in the field of dentistry and optometry.\n
Healthcare in Latvia is universal for citizens of Latvia. The healthcare system in Latvia operates as a universal program that is primarily funded through government taxation.[95] It bears similarities to the National Health Service (NHS) in UK and employs a purchaser-provider split (PPS). Following several reforms, a National Health Service (NHS) type system, known as Nacion\u0101lais vesel\u012bbas dienests (NVD) in Latvian, was established in 2011.[96]\n
The NVD controls the implementation of healthcare policies while the Ministry of Health develops policies and oversees the system. Healthcare services are available for free for citizens of Latvia. The country's Ministry of Health manages its healthcare system through a combination of social insurance institutional body, legislative healthcare provision financed by taxes and numerous public and private providers.[97]\n
Despite near-universal population coverage provided by the NVD established in 2011, there are challenges to equitable access with issues around geographical distribution of health professionals, user charges and long waiting lists. The publicly funded health benefits package is limited in scope and only covers a predetermined set of services.[98][99]\n
The public healthcare system in Lithuania ensures free healthcare for almost all its citizens. This state-funded healthcare is available to long-term residents and expats too. \n
Luxembourg provides universal health care coverage to all residents (Luxembourgers and foreigners) by the National Health Insurance (CNS - Caisse nationale de sant\u00e9 (French) or National Gesondheetskeess (Luxembourgish)). It is funded by mandatory contributions of employers and the workforce, and by government subsidies for insuring jobseekers, the poor, and for financing medical infrastructure. The nation also has mandatory public long-term care insurance.[100][101]\n
The Netherlands has a dual-level system. All primary and curative care (family doctors, hospitals, and clinics) is financed from private compulsory insurance. Long-term care for the elderly, the dying, the long-term mentally ill etc. is covered by social insurance funded by public spending. According to the WHO, the health care system in the Netherlands was 62% government-funded and 38% privately funded as of 2004.[41]\n
Insurance companies must offer a core universal insurance package for universal primary, curative care, including the cost of all prescription medicines. They must do this at a fixed price for all. People pay the same premium whether young or old, healthy or sick. It is illegal in The Netherlands for insurers to refuse an application for health insurance, to impose special conditions (e.g., exclusions, deductibles, co-pays etc.), or refuse to fund treatments that a doctor has determined are medically necessary. The system is 50% financed from payroll taxes paid by employers to a fund controlled by the Health regulator. The government contributes an additional 5% to the regulator's fund. The remaining 45% is collected as premiums paid by the insured directly to the insurance company. Some employers negotiate bulk deals with health insurers and some even pay the employees' premiums as an employment benefit. The regulator has sight of the claims made by policyholders and therefore can redistribute the funds its holds on the basis of relative claims made by policy holders. Thus insurers with high payouts receive more from the regulator than those with low payouts. Insurance companies have no incentive to deter high-cost individuals from taking insurance and are compensated if they have to pay out more than might be expected. Insurance companies compete with each other on price for the 45% direct premium part of the funding and try to negotiate deals with hospitals to keep costs low. The competition regulator is charged with checking for abuse of dominant market positions and the creation of cartels that act against consumer interests. An insurance regulator ensures that all basic policies have identical coverage rules so that no person is medically disadvantaged by his or her choice of insurer.\n
Hospitals in the Netherlands are also regulated and inspected but are mostly privately run and not-for-profit, as are many of the insurance companies. Patients can choose where they want to be treated, and have access to information on the internet about the performance and waiting times at each hospital. Patients dissatisfied with their insurer and choice of hospital can cancel at any time but must make a new agreement with another insurer.\n
Insurance companies can offer additional services at an extra cost over and above the universal system laid down by the regulator, e.g., for dental care. The standard monthly premium for health care paid by individual adults is about \u20ac100 per month. Persons with low incomes can get assistance from the government if they cannot afford these payments. Children under 18 are insured by the system at no additional cost to them or their families because the insurance company receives the cost of this from the regulator's fund. There is a fixed yearly deductible of \u20ac385 for each adult person, excluding first visits for diagnosis to general physicians.\n
Norway has a universal public health system paid largely from taxation in the same way as other Scandinavian countries. The Norwegian health care system is government-funded and heavily decentralized. The health care system in Norway is financed primarily through taxes levied by county councils and municipalities. Dental care is included for children until 18 years old, and is covered for adults for some ailments.[102]\n
Norway regularly comes top or close to the top of worldwide healthcare rankings.\n
The country inherited a large health infrastructure after independence in 1991 with good well-distributed public health services. Private hospitals were opened and primary care was privatised. Subsequently, both public and private providers have been integrated into one social insurance-funded model managed by the Health Insurance Fund of North Macedonia. The public hospital sector is seen as inefficient and is unpopular with both patients and professional staff. 90% of the population is within 30 minutes of a health service.\n
Expenditure on healthcare was $851 per head in 2014, 6.5% of GDP.\n
According to the Euro health consumer index the Macedonian health system made the most remarkable advance of any country in the history of their Index, from 27th to 16th place in 2014, because by implementing a real-time e-Booking system they reduced waiting lists so significantly. From July 2013, any GP can make a booking at any specialist or heavy diagnostic equipment in the country in real-time while the patient is present. They rated Macedonia 16th in Europe in 2015.\n
The Doctor's Chamber of Macedonia complains that there is a discrepancy between the available funds and the quality of service expected, that facilities are not used efficiently, equipment is outdated and staff are not used effectively.\n
Portugal's National Healthcare Service, known nationally as Servi\u00e7o Nacional de Sa\u00fade (SNS), is a universal and free healthcare service provided nationwide since 1979 and available to both Portuguese and foreign residents. In 2014, Portugal SNS ranked 13th best healthcare service in Europe.[103] The National Medical Emergency Institute (INEM) is the main emergency medical service and can be activated by calling 112.\n
According to Article 34 of the Constitution of Romania, the state is obliged \"to guarantee the protection of healthcare\". Romania has a fully universal healthcare system, which covers medical check-ups, surgical interventions, and any postoperative medical care, as well as free or subsidized medicine for a range of diseases. The state is also obliged to fund public hospitals and clinics. Dental care is not funded by the state, although there are public dental clinics in some hospitals, which treat patients free of charge.\n
In the former Soviet Union, the preferred term was \"socialist medicine\"; the Russian language has no term to distinguish between \"socialist\" and \"socialized\" (other than \"public\", Rus: obshchestvenniy/\u043e\u0431\u0449\u0435\u0441\u0442\u0432\u0435\u043d\u043d\u044b\u0439, sometimes \"collectivized\" or \"nationalized\", Rus: obobshchestvlenniy/\u043e\u0431\u043e\u0431\u0449\u0435\u0441\u0442\u0432\u043b\u0435\u043d\u043d\u044b\u0439).[104][105]\n
Russia in Soviet times (between 1917 and 1991) had a totally socialist model of health care with a centralized, integrated, hierarchically organised government providing free health care to all citizens. Quality of care and access to medications was not equal however and was dependent on the social status of patient. The best care was provided for nomenklatura and their family members, who had been segregated from the rest of population facilities, such as Kremlin hospital.[106] Initially successful at combating infectious diseases, the effectiveness of the socialized model declined with underinvestment. Despite a doubling in the number of hospital beds and doctors per capita between 1950 and 1980, the quality of care began to decline by the early 1980s and medical care and health outcomes were below western standards.\n
The new mixed economy Russia has switched to a mixed model of health care with private financing and provision running alongside state financing and provision. The OECD reported that unfortunately, none of this has worked out as planned and the reforms have in many respects made the system worse.[107][needs update] The population's health has deteriorated on virtually every measure. The resulting system is overly complex and very inefficient. It has little in common with the model envisaged by the reformers. Although there are more than 300 private insurers and numerous public ones in the market, real competition for patients is rare leaving most patients with little or no effective choice of insurer, and in many places, no choice of health care provider either. The insurance companies have failed to develop as active, informed purchasers of health care services. Most are passive intermediaries, making money by simply channelling funds from regional OMS funds to healthcare providers.\n
Article 41 of the Constitution of the Russian Federation confirms a citizen's right to state healthcare and medical assistance free of charge.[108] This is achieved through state compulsory medical insurance (OMS), which is funded by an obligatory medical insurance payroll tax and government subsidies.[109][110] It is worth mentioning that Russian citizens never pay taxes for themselves and often don't even know how much taxes they pay, because tax payment process is maintained by companies they are working on.[111] Introduction in 1993 reform of new free market providers in addition to the state-run institutions intended to promote both efficiency and patient choice. A purchaser-provider split helps facilitate the restructuring of care, as resources would migrate to where there was greatest demand, reduce the excess capacity in the hospital sector and stimulate the development of primary care. Russian Prime Minister Vladimir Putin announced a new large-scale health care reform in 2011 and pledged to allocate more than 300 billion rubles ($10 billion) in the next few years to improve health care in the country. As of 2020 the health insurance tax (called deposition to an OMS fund) is 5.1%.[112]\n
The Constitution of the Republic of Serbia states that it is the right of every citizen to seek medical assistance free of charge.[113] This is achieved by mutual contribution to the Compulsory Social Healthcare Fund of RZZO (Republi\u010dki Zavod za Zdravstveno Osiguranje or National Health Insurance Institution). The amount of contribution depends on the amount of money the person is making.\n
Spain provides a public universal health care system for all citizens and, under certain conditions, also non-citizens. Healthcare is free except for co-payments for some products and services; it is mostly paid from the Social Security budget. Adult dental care is not covered but for basic extractions or problems that could result in serious stomatological conditions.\n
Irrespective of the nationality and insurance situation of the patient, the public system always treats medical emergencies until achieving the best possible outcome. If not covered by the Spanish Social Security (i.e., a visiting foreigner), the provider later negotiates payment with the patient or the patient's insurer. If actually unable to pay, it is covered by Social Security on humanitarian grounds unless the patient purposely traveled to Spain to get free healthcare. Obvious unexpected emergencies such as accidental injuries or sudden illness are customarily covered, but those that could be reasonably expected (e.g., arising from a chronic condition or from avoidable risk-taking) are studied on a case-per-case basis.\n
According to the World Economic Forum and to Bloomberg, Spain has the most efficient health system in Europe, and also ranks at the top worldwide along with Hong Kong, Japan and Singapore.[114][115]\n
Private health insurance is available for those who prefer it, and recommended for visitors not covered by the Spanish Social Security or a foreign public or private insurer with overseas coverage.\n
Sweden has a universal public health care system paid for through taxation. The Swedish public and private health care systems are funded through taxes levied by the county councils. Government-paid dental care is accessible to those under 23 years old.\n
Sweden also has a smaller private health care sector, mainly in larger cities or as centers for preventive health care financed by employers.\n
In recent years the health care system of Sweden has been heavily criticized for not providing the same quality of health care to all Swedish citizens.[116][117][118][119] This was especially brought to light during the COVID-19 pandemic as Swedish media and public health researchers pointed out that Swedish citizens of other ethnicities than Swedish and people living in working class areas were dying from COVID-19 at a significantly higher rate than the rest of the population.[120][121][122]\n
Purchasing basic health insurance is mandatory for all persons residing in Switzerland (within three months of taking up residence or being born in the country).[123] Healthcare in Switzerland is universally available and is regulated by the Federal Health Insurance Act of 1994. Supplemental insurance plans are optional. Insurers are required to offer insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans.[124]\n
Turkey achieved universal health coverage in 2003.[125]\n
The Government's Health Transformation Program of 2003 established a common benefit package that covers primary and preventive care, ambulatory and inpatient care, laboratory services, rehabilitation and follow-up services, pharmaceuticals and medical aids and appliances.[125] Payroll taxes of 12.5% of a person's gross income (5% by the employee and 7.5% by the employer) fund 97%[126] of the program. The government provides for the remaining 3% of the cost.[127]\n
Each of the countries of the United Kingdom has a National Health Service that provides public healthcare to all UK permanent residents that was originally designed to be free at the point of need and paid for from general taxation; but changes included introducing charging for prescription medicines and dentistry (those below 16 and those on certain benefits may still get free treatment). However, since health is now a devolved matter, considerable differences are developing between the systems in each of the countries for example Northern Ireland, Scotland and Wales abolished prescription charges.[128] Private healthcare companies are free to operate alongside the public system.\n
The NHS Constitution for England documents, at a high level, the objectives of the NHS, the legal rights and responsibilities of the various parties (patients, staff, NHS trust boards), and the guiding principles that govern the service.[129] The NHS constitution makes it clear that it provides a comprehensive service, available to all irrespective of age, gender, disability, race, sexual orientation, religion, or belief; that access to NHS services is based on clinical need and not an individual's ability to pay; and that care is never refused on unreasonable grounds. Patient choice in terms of doctor, care, treatments, and place of treatment is an important aspect of the NHS's ambition, and in some cases patients can elect for treatment in other European countries at the NHS's expense. Waiting times are low, with most people able to see their primary care doctor on the same day or the following day.[130] Only 36.1% of hospital admissions are from a waiting list, with the remainder being either emergencies admitted immediately or else pre-booked admissions or the like (e.g., child birth).[131] One of the main goals of care management is to ensure that patients do not experience a delay of more than 18 weeks from initial hospital referral to final treatment, inclusive of time for all associated investigative tests and consultations.[132] In 2009, two-thirds of patients were treated in under 12 weeks.[133]\n
Though centrally funded, the NHS is not managed by a large central bureaucracy. Responsibility is divided among geographical areas through strategic health authorities. Management is distributed even more locally through primary care trusts, hospital trusts\u2014and increasingly to NHS foundation trusts that provide even more decentralized services within the NHS framework, with more decisions left to local people, patients, and staff. The central government office\u2014the Department of Health\u2014is not involved in day-to-day decision making in either the Strategic Health Authorities or the individual local trusts (primarily health, hospital, or ambulance) or the national specialist trusts such as NHS Blood and Transplant. It does lay down general guidelines they must follow. Local trusts are accountable to their local populations, whilst government ministers are accountable to Parliament for the service overall.[citation needed]\n
The NHS provides, among other things, primary care, in-patient care, long-term healthcare, psychiatric care and treatments, ophthalmology, and dentistry. All treatment is taxpayer-funded with the exception of certain charges for prescriptions, dentistry and ophthalmology (which themselves are free to children, certain students in full-time education, the elderly, the unemployed and those on low incomes). Around 89 percent of NHS prescriptions are obtained free of charge, mostly for children, pensioners, and pregnant women. Others pay a flat rate of \u00a39.00, and others may cap their annual charges by purchasing an NHS Prescription Prepayment Certificate. Private health care has continued parallel to the NHS, paid for largely by private insurance. Private insurance accounts for only 4 percent of health expenditure and covers little more than a tenth of the population.[134] Private insurers in the UK only cover acute care from specialists. They do not cover generalist consultations, pre-existing conditions, medical emergencies, organ transplants, chronic conditions such as diabetes, or conditions such as pregnancy or HIV.[135]\n
Most NHS general practitioners are private doctors who contract to provide NHS services, but most hospitals are publicly owned and run through NHS trusts. A few NHS medical services (such as \"surgicentres\") are sub-contracted to private providers[136] as are some non-medical services (such as catering). Some capital projects such as new hospitals have been funded through the Private Finance Initiative, enabling investment without (in the short term) increasing the public sector borrowing requirement, because long-term contractually obligated PFI spending commitments are not counted as government liabilities.[citation needed]\n
NHS Scotland, created by the National Health Service (Scotland) Act 1947, was also launched on July 5, 1948, although it has always been a separate organization. Since devolution, NHS Scotland has followed the policies and priorities of the Scottish Government, including the phasing out of all prescription charges by 2011. Prescriptions are now free in Scotland for all citizens.\n
NHS Wales was originally formed as part of the same NHS structure created by the National Health Service Act 1946 but powers over the NHS in Wales came under the Secretary of State for Wales in 1969,[137] in turn being transferred under devolution to what is now the Welsh Government.\n
The medical care system in the Channel Islands is very similar to that of the UK in that many of the doctors and nurses have been trained from the UK health perspective.\n
There is universal health care for residents of Jersey.[139]\n
Healthcare in Guernsey and Alderney is charged for[140] with all primary care provided for on a private basis.[141][142]\n
There is no universal healthcare for residents of Sark.\n
The Bahamas approved the National Health Insurance Act in August 2016. The legislation establishes a universal health coverage system that begins with universal coverage of primary health care services, and later expands to include a wide set of benefits that includes all specialized care. The system allows for universal coverage of a basic benefits package and for voluntary insurance to be purchased as a top-up policy to cover services or amenities that are not included in the government plan.[143]\n
In 1984, the Canada Health Act was passed, which prohibited extra billing by doctors on patients while at the same time billing the public insurance system. 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.\"[144]\n
The system is for the most part publicly funded, yet most of the services are provided by private enterprises or private corporations,[citation needed] although most hospitals are public. Most doctors do not receive an annual salary, but receive a fee per visit or service.[145] About 29% of Canadians' health care is paid for by the private sector or individuals.[146] This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry, physiotherapy and vision care.[147] Many Canadians have private health insurance, often through their employers, that cover these expenses.[148]\n
The Canada Health Act of 1984 \"does not directly bar private delivery or private insurance for publicly insured services,\" but provides financial disincentives for doing so. \"Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed,\" according to a report in the New England Journal of Medicine.[149][150] The legality of the ban was considered in a decision of the Supreme Court of Canada, which ruled in Chaoulli v. Quebec that \"the prohibition on obtaining private health insurance, while it might be constitutional in circumstances where health care services are reasonable as to both quality and timeliness, is not constitutional where the public system fails to deliver reasonable services.\" The appellant contended that waiting times in Quebec violated a right to life and security in the Quebec Charter of Human Rights and Freedoms. The Court agreed, but acknowledged the importance and validity of the Canada Health Act, and at least four of the seven judges explicitly recognized the right of governments to enact laws and policies that favour the public over the private system and preserve the integrity of the public system.\n
Universal healthcare and pensions are run by the Caja Costarricense de Seguro Social (CCSS). In 1941, Costa Rica established Caja Costarricense de Seguro Social (CCSS), a social security insurance system for wage-earning workers. In 1961, coverage was expanded to include workers' dependents and from 1961 to 1975, a series of expansions extended coverage for primary care and outpatient and inpatient specialized services to people in rural areas, the low-income population, and certain vulnerable populations. Further expansions during the late 1970s extended insurance coverage to farmers, peasants, and independent contract workers. Additionally, CCSS mandates free health service provision to mothers, children, indigenous people, the elderly, and people living with disabilities, regardless of insurance coverage. By 2000, 82 percent of the population was eligible for CCSS, which has continued to expand in the ensuing period. By covering all population groups through the same system, Costa Rica has avoided social insurance stratification and inequity common in many other countries in the region.[151]\n
CCSS is funded by a 15 percent payroll tax, as well as payments from retiree pensions [6]. Taxes on luxury goods, alcohol, soda, and imported products also help to cover poor households who do otherwise pay into the system. All CCSS funds are merged into a single pool, which is managed by the central financial administration of CCSS. In 1973, the Ministry of Health decided to move away from direct service provision and adopt a steering role. Responsibility for the provision of most care was transferred to the CCSS, although the Ministry retained responsibility for disease control, food and drug regulation, environmental sanitation, child nutrition, and primary care for the poor. Through the CCSS, health care is now essentially free to nearly all Costa Ricans. Private health care is also widely available and INS offers private health insurance plans to supplement CCSS insurance.[152]\n
The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of all its citizens. There are no private hospitals or clinics as all health services are government-run. All healthcare in Cuba is free to Cuban residents.[153] The present Minister for Public Health is Roberto Morales Ojeda. The Cuban government sends doctors and other medical personnel overseas as part of medical missions. These missions are mainly in Latin America, Africa, and Oceania and have had substantial positive impacts on the local populations served. Cuba also brings medical students and patients to Cuba for training and treatment respectively.\n
Public health care became universal healthcare on January 1, 2020,[154] mandated by the new President Andr\u00e9s Manuel L\u00f3pez Obrador and approved by Congress. It is completely free for Mexican citizens who do not have health insurance. Mexico's new universal healthcare, administered by the Instituto de Salud para el Bienestar (Institute of Health for Welfare, INSABI), includes free consultations with family doctors and specialists, free medications, free surgeries, free dental and vision[citation needed]. As of 2020, public health care is provided to all Mexican citizens as guaranteed via Article 4 of the Constitution. Public care is now fully subsidized by the federal government. All Mexican citizens are eligible for subsidized health care regardless of their work status via a system of health care facilities operating under the federal Secretariat of Health (formerly the Secretaria de Salubridad y Asistencia, or SSA) agency.\n
Employed citizens and their dependents, however, are further eligible to use the health care program administered and operated by the Instituto Mexicano del Seguro Social (IMSS) (English: Mexican Social Security Institute). The IMSS health care program is a tripartite system funded equally by the employee, its private employer, and the federal government. The IMSS does not provide service to employees of the public sector. Employees in the public sector are serviced by the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) (English: Institute for Social Security and Services for State Workers), which attends to the health and social care needs of government employees. This includes local, state, and federal government employees. The government of the states in Mexico also provide health services independently of those services provided by the federal government programs. In most states, the state government has established free or subsidized healthcare for all their citizens.\n
In 2006, the Mexican government created the Health Insurance for a New Generation also known as \"life insurance for babies\".[155][156][157] On May 28, 2009, Universal Care Coverage for Pregnant Women was introduced.[158] In a 2020 expansion of health care coverage, all Mexicans are now covered.\n
A universal health care system is used in Trinidad and Tobago and is the primary form of health care available in the country. It is used by the majority of the population seeking medical assistance, as it is free for all citizens. Responsibility for the provision of healthcare services in Trinidad and Tobago was devolved from the Ministry of Health to Regional Health Authorities under the Regional Health Authorities Act No. 5 in 1994.\n
Health care is provided through a combination of employer and labor union-sponsored plans (Obras Sociales), government insurance plans, public hospitals and clinics and through private health insurance plans. It costs almost 10% of GDP and is available to anyone regardless of ideology, beliefs, race or nationality.\n
The universal health care system was adopted in Brazil in 1988 after the end of the military dictatorship. However, universal health care was available many years before, in some cities, once the 27th amendment to the 1969 Constitution imposed the duty of applying 6% of their income in healthcare on the municipalities.[160]\nThe Brazilian universal health care is called SUS (Sistema \u00danico de Sa\u00fade), which covers all treatments, surgeries and medications for all resident and non-resident individuals within Brazilian jurisdiction, regardless of ethnicity, nationality, or visa - including tourists, passengers in transit and refugees.\n
Health care in Chile is provided by the government (via public corporation FONASA, National Healthcare Fund) and by private insurers (via ISAPRE, Previsional Healthcare Institutions). All workers and pensioners are mandated to pay 7% of their income for health care insurance (the poorest pensioners are exempt from this payment but medications are expensive and pensioners have to pay). Workers who choose not to join an Isapre, are automatically covered by Fonasa. Fonasa also covers unemployed people receiving unemployment benefits, uninsured pregnant women, insured worker's dependant family, people with mental or physical disabilities and people who are considered poor or indigent.\n
Fonasa costs vary depending on income, disability or age. Attention at public health facilities via Fonasa is free for low-income earners, people with mental or physical disabilities and people over the age of 60. Others pay 10% or 20% of the costs, depending on income and the number of dependants. Fonasa beneficiaries may also seek attention in the private sector, for a designated fee.\n
Additionally, exist the GES Plan (Explicit Guarantees in Healthcare Plan), that consists of a defined number of high-morbility and mortality diseases (currently 85) that have special mandatory attention guarantees for all people, both Isapre and Fonasa affiliates, in relation to:\n
\n
Access: Universal access to treatment if required. Individuals will be able to get attention from a provider near their place of residence.
\n
Opportunity: Opportune waiting times, there is a maximum pre-established time limit to get initial and post-diagnosis attention.
\n
Financial protection: Law-fixed maximum price with low copayments to providers (maximum copayment of 20% of the cost), the payment cannot be an obstacle to attention. The total cost must not exceed one monthly income for the family in a year.
\n
Best possible quality of service: Attention only in accredited public or private Health centers, that follow technical requirement standards that will be established based on medical evidence.
\n
The treatment protocols and number of diseases included are evaluated every 3 years by the authorities.\n
In 1993 a reform transformed the health care system in Colombia, trying to provide a better, sustainable, health care system and to reach every Colombian citizen.\n
Peru does not currently have universal health care, as only about 80% of the population is insured.\n
On April 10, 2009, the Government of Peru published the Law on Health Insurance to enable all Peruvians to access quality health services, and contribute to regulating the financing and supervision of these services. The law enables all population to access diverse health services to prevent illnesses, and promote and rehabilitate people, under a Health Basic Plan (PEAS).[161][162]\n
On April 2, 2010, President Alan Garcia Perez signed a supreme ordinance approving the regulations for the framework law on Universal Health Insurance, which seeks to provide access to quality health care for all Peruvian citizens.\n
Peru's Universal Health Insurance law aims to increase access to timely and quality health care services, emphasizes maternal and child health promotion, and provides the poor with protection from financial ruin due to illness.[163]\n
The regulation states that membership of the Universal Health Insurance (AUS for its Spanish acronym) is compulsory for the entire population living in the country. To that end, the Ministry of Health will approve, by supreme ordinance, the mechanisms leading to compulsory membership, as well as escalation and implementation.[164]\n
The National Basic Health Insurance Law, introduced in 2014, provides access to a basic package of primary, secondary, and tertiary care services for citizens. It repeals the Healthcare Tariffs Law from 2005.\n
Australia and New Zealand both have universal health care. Hospitalisation is free for permanent residents in both nations. In addition, Australia grants primary care coverage, while in New Zealand general practice and prescriptions are subsidised only.\n
In Australia, Medibank\u2014as it was then known\u2014was introduced, by the Whitlam Labor government on July 1, 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. However, Medibank was supported by the subsequent FraserCoalition (Australia) government and became a key feature of Australia's public policy landscape. The exact structure of Medibank/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 Medibank program proposed a 1.35% levy (with low-income exemptions) but these bills were rejected by the Senate, so Medibank was funded from general taxation. In 1976, the Fraser Government introduced a 2.5% levy and split Medibank in two: a universal scheme called Medibank Public and a government-owned private health insurance company, Medibank Private.\n
In 1984, Medibank Public was renamed Medicare by the Hawke Labor government, which also changed the funding model, to an income tax surcharge, known as the Medicare Levy, which was set at 1.5%, with exemptions for low-income earners.[165] The Howard Coalition government introduced an additional levy of 1.0%, known as the Medicare Levy Surcharge, for those on high annual incomes ($70,000) who do not have adequate levels of private hospital coverage.[166] This was part of an effort by the Coalition to encourage take-up of private health insurance. According to WHO, government funding covered 67.5% of Australia's health care expenditures in 2004; private sources covered the remaining 32.5% of expenditures.[41]\n
As of 2019, the Medicare levy is 2% of taxable income,[167] with a Medicare levy surcharge, for those on high income who do not have appropriate private patient hospital cover (1% for singles on $90,000 pa and families on $180,000 pa, rising to 1.5% for higher incomes).[168]\n
In addition to Medicare, there is a separate Pharmaceutical Benefits Scheme, funded by the federal government, which substantially subsidises a range of prescription medications.\n
As with Australia, New Zealand's healthcare system is funded through general taxation according to the Social Security Act 1938. However, aside from hospitalisation, there are user charges for prescriptions (introduced in February 1985, (this ended in mid 2023 when funded drugs became free under prescription)) and partial subsidisation of general practitioner visits with additional provision for those on low or modest incomes known as Community Service Cards (introduced on February 1, 1992) to target healthcare based on income.[169][170][171] These changes were part of broader controversial policies introduced by the Fourth National Government between 1991 and 1993 and effectively ended largely free provision of primary healthcare. According to the WHO, government sources covered 77.4% of New Zealand's health care costs in 2004; private expenditures covered the remaining 22.6%.\n
Historic attempts to bring general practitioner care into government ownership have been largely unfulfilled.\n
There are twenty district health boards as of 2019 whose task is ensuring the provision of health and disability services to populations within a defined geographical area and are partially elected while the remainder is appointed by New Zealand's Minister of Health.[172] This system of management came into being on January 1, 2001, abolishing the much controversial Crown Health Enterprises regime which had replaced Area Health Boards previously.\n
^ abYip, Winnie; Hsiao, William (March 2008). \"The Chinese Health System At A Crossroads\". Health Affairs. 27 (2): 460\u20138. doi:10.1377/hlthaff.27.2.460. PMID18332503.\n
\n
^Carrin G, Ron A, Hui Y, et al. (April 1999). \"The reform of the rural cooperative medical system in the People's Republic of China: interim experience in 14 pilot counties\". Soc Sci Med. 48 (7): 961\u201372. doi:10.1016/S0277-9536(98)00396-7. PMID10192562.\n
^ abLibrary of Congress \u2013 Federal Research Division (2007). \"Country Profile: North Korea\"(PDF). Library of Congress \u2013 Federal Research Division. Retrieved September 6, 2010.\n
^Jui-Fen Rachel Lu; William C. Hsiao (2003). \"Does Universal Health Insurance Make Health Care Unaffordable? Lessons From Taiwan\". Health Affairs. 22 (3): 77\u201388. doi:10.1377/hlthaff.22.3.77. PMID12757274.\n
\n
^G20 Health Care: \"Health Care Systems and Health Market Reform in the G20 Countries.\" Prepared for the World Economic Forum by Ernst & Young. January 3, 2006.\n
^Hughes D, Leethongdee S (2007). \"Universal coverage in the land of smiles: lessons from Thailand's 30 baht health reforms\". Health Affairs. 26 (4): 999\u20131008. doi:10.1377/hlthaff.26.4.999. PMID17630443.\n
^Portugal: Bentes M, Dias CM, Sakellarides C, Bankauskaite V. Health Care Systems in Transition: Portugal. WHO are Regional Offices for Europe on behalf of the European Observatory on Health Systems and Policies, 2004.\n
^Corens, Dirk (2007). \"Belgium, health system review\"(PDF). Health Systems in Transition. European Observatory on Health Systems and Policies. 9 (2).\n
^Bump, Jesse B. (October 19, 2010). \"The long road to universal health coverage. A century of lessons for development strategy\"(PDF). Seattle: PATH. Retrieved March 11, 2013. Carrin and James have identified 1988\u2014105 years after Bismarck's first sickness fund laws\u2014as the date Germany achieved universal health coverage through this series of extensions to minimum benefit packages and expansions of the enrolled population. B\u00e4rnighausen and Sauerborn have quantified this long-term progressive increase in the proportion of the German population covered by public and private insurance. Their graph is reproduced below as Figure 1: German Population Enrolled in Health Insurance (%) 1885\u20131995.\n
^Leichter, Howard M. (1979). A comparative approach to policy analysis: health care policy in four nations. Cambridge: Cambridge University Press. p. 121. ISBN978-0-521-22648-6. The Sickness Insurance Law (1883). Eligibility. The Sickness Insurance Law came into effect in December 1884. It provided for compulsory participation by all industrial wage earners (i.e., manual laborers) in factories, ironworks, mines, shipbuilding yards, and similar workplaces.\n
^Kirkman-Liff BL (1990). \"Physician Payment and Cost-Containment Strategies in West Germany: Suggestions for Medicare Reform\". Journal of Health Care Politics, Policy and Law. 15 (1): 69\u201399. doi:10.1215/03616878-15-1-69. PMID2108202.\n
^ abTatar, M., S. Mollahaliloglu, B. Sahin, S. Aydin, A. Maresso and C. Hern\u00e1ndez-Quevedo (2011), \"Turkey: Health System Review\", Health Systems in Transition, Vol. 13, No. 6, pp. 1-186.\n
\n
^Borowitz, M. and H. Kluge (forthcoming), \"Pay for Performance in Health Care: Implications for Health System Efficiency and Accountability\", WHO and the European Observatory on Health Systems and Policies Publishers.\n
\n
^Sulku, S. and D. Bernard (2009), \"Financial Burden of Health Care Expenditures in Turkey: 2002-2003\", Agency for Healthcare Research and Quality Working Paper, No. 09004, Rockville, United States.\n
^The OECD Health Project (2004). Private Health Insurance In OECD Countries. Organisation for Economic Co-operation and Development. ISBN978-92-64-00668-3.\n
\n\n\n\n",
+ "page_last_modified": " Mon, 11 Mar 2024 14:48:43 GMT"
+ },
+ {
+ "page_name": "The Precarious Path to Universal Health Coverage",
+ "page_url": "https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/health-matters-in-elections/the-precarious-path-to-universal-health-coverage/",
+ "page_snippet": "Ironies and contradictions abound with a goal of universal health care coverage called Medicare for All. As COVID-19 has exposed a need for health care in the United States to change, the 2020 election results will shape the future of medical care policy.What the candidates\u2014and a majority of the American people\u2014really want is medical care for all. I will lay out the most important real barriers to achieving the goal of universal health care coverage in the United States and conclude with some predictions about what may happen to Medicare for All after the 2020 election. For example, in May 2020, 63 percent of the public said they favored federal action to achieve \u201cuniversal health coverage,\u201d but only 49 percent in the same poll favored \u201ca single payer national health plan.\u201d The partisan divide over health care reform has dramatically widened. Creating medical care for all Americans is a policy choice, not a legal matter. Decades of litigation provide solid constitutional support for alternative ways to achieve universal health care. The tax and spend power of Congress is the foundation for traditional Medicare. The constitutional basis for a universal health coverage policy will almost certainly remain even if the Supreme Court declares the current ACA unconstitutional next year, based on the theory that the individual mandate was central to the whole scheme (California v. Texas).",
+ "page_result": "\n\n\n \n\n\n\nThe Precarious Path to Universal Health Coverage\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n \n \n \n\n\n\n\n\n\n\n\n\n \n\n \n\n \n\n \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n \n\n\n\n\n\n\n \n\n\n
Medicare for All became the rallying point for health care reform early in the 2020 election, often without details as to how it could be provided and paid for. When Elizabeth Warren got specific, it sank her campaign. What the candidates\u2014and a majority of the American people\u2014really want is medical care for all. I will lay out the most important real barriers to achieving the goal of universal health care coverage in the United States and conclude with some predictions about what may happen to Medicare for All after the 2020 election.
What the candidates\u2014and a majority of the American people\u2014really want is medical care\r\nfor all.
\n
SENATE DEMOCRATS ON WIKIMEDIA
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The ironies and contradictions abound when we call the goal Medicare for All. Medicare, the government-run, single-payer national insurance program for everyone over 65 is massively popular. But public support for Medicare for All falls when it is described as a single-payer insurance program. Most Americans would like to lower their out-of-pocket medical expenses\u2014traditional Medicare has a 20 percent copayment for all physician visits, diagnostic tests, and equipment. Typical Medicare recipients spend about 14 percent of their income on medical care by the time they are in their mid-70s, some of it for supplemental private insurance to pay for what traditional Medicare doesn\u2019t cover.
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A majority of Americans support additional federal efforts to help people get access to medical care. However, the level of that support changes depending on the words used to describe it as a policy choice. For example, in May 2020, 63 percent of the public said they favored federal action to achieve \u201cuniversal health coverage,\u201d but only 49 percent in the same poll favored \u201ca single payer national health plan.\u201d The partisan divide over health care reform has dramatically widened. In 2006, 72 percent of Republicans told pollsters they favored federal action to help provide access to care, but only 42 percent of Republicans supported the same idea in 2020..
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Creating medical care for all Americans is a policy choice, not a legal matter. Decades of litigation provide solid constitutional support for alternative ways to achieve universal health care. The tax and spend power of Congress is the foundation for traditional Medicare. A federal state partnership, Medicaid, which provides medical insurance to some groups of people, is fine, as long as the federal government doesn\u2019t coerce the states into doing something that states oppose. In the big Affordable Care Act (ACA) case, NFIB v. Sebelius, 567 U.S. 519 (2012), the Court ruled that the federal government cannot mandate you to buy insurance, but it can tax you if you don\u2019t. Paying for medical care directly through government owned and government-operated facilities like the U.S. Department of Veterans Affairs or indirectly through community health center grants is well established. The government can set or negotiate the prices it will pay, for example, the Medicare hospital and physician fee schedules. Congress made the policy choice to prohibit Medicare from negotiating or setting prices when it created the Medicare prescription drug program in 2005. The constitutional basis for a universal health coverage policy will almost certainly remain even if the Supreme Court declares the current ACA unconstitutional next year, based on the theory that the individual mandate was central to the whole scheme (California v. Texas).
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President Obama made a political policy choice to build on existing private and public insurance mechanisms for his health plan, not replace them. If the ACA had been implemented as designed, it would have covered about 95 percent of the people in the country through tax- favored employer-sponsored or subsidized individual private insurance, Medicaid or Medicare. Most of the people left out were non-citizens. The Supreme Court decision that made Medicaid expansion voluntary at the state level left about 6 million people, mostly in southern States, with no health insurance. Some of these people have since gotten coverage, as more states have agreed to expand the program, but 14 states have still not expanded Medicaid. At the beginning of 2020, about 28 million, or about 10 percent, of non-elderly Americans had no health insurance. Another 20 million to 30 million people who had employer-sponsored insurance at the beginning of 2020 may have no insurance by the end of the year. Some will be eligible for Medicaid, depending on where they live, but many will have nothing. The pandemic is putting the design and operation of the ACA to a severe test. How it performs will be a key part of the policy debate next year.
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The United States could have a national health plan that covers all residents at prices they can afford. The Congress and the president just have to decide to do it. The 100-year history of attempts to deliver universal health coverage to Americans shows this is easier said than done. Major medical care reforms happen only when one party has dominant control over the White House and both houses of Congress. Medicare, Medicaid, and the Affordable Care Act passed when Democrats had control of the White House, the House of Representatives, and a filibuster-proof majority in the Senate. The death of Senator Edward Kennedy caused Democrats in the Senate to lose their filibuster-proof majority just as the House was about to pass its version of the ACA. If the House had not accepted the previously passed Senate version, it is unlikely that anything would have become law. Republicans controlled the White House and both houses of Congress in 2017, but their majority in the Senate was not great enough to achieve their primary objective\u2014repeal of the ACA.
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Medical care policy is controversial because it is redistributive. Those of us who are healthier and wealthier help pay for the care of those who are sicker or poorer. Often the transfers are not transparent and therefore rarely set off political firestorms. A majority of hospitals in the country report they lose money or barely break even on Medicaid and Medicare patients. However, hospitals typically make about a 30 percent profit on employer-sponsored insurance to make up for these losses\u2014an invisible redistribution. Progressive federal and state tax regimes redistribute wealth when some of that tax money is used to pay Medicaid expenses. Those of us with higher salaries pay more in Medicare payroll tax than lower-wage workers, but we are all entitled to the same benefits. As soon as the Medicare for All debate among Democrats got into the details of how it would be paid for, the redistributive aspects became transparent and open to political attack as \u201csocialized medicine.\u201d
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Other factors will also shape the health care policy debates in 2021: COVID-19, past policy choices that determine how\u2014and how much\u2014we pay for medical care, and efforts to address systemic health disadvantage among Black and brown Americans.
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COVID-19 is exposing many of the sordid truths about health care in America that have been hidden in plain sight for many years. The cumulative effects of racial and ethnic discrimination make Black and brown Americans far more likely to get the virus and die from it. Employer-based health insurance becomes unavailable for millions of people when they lose their jobs. Tens of thousands of nursing home residents died because those facilities did not have even minimally adequate infection-control programs. Long-term disinvestment in public health infrastructure and staffing enabled the virus to spread unseen and unchecked.
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We do not yet understand the population health effects of the pandemic or how they will be interpreted in policy debates. What difference in population health, good or bad, did shutting the ambulatory care system for three months have? COVID-19 may accelerate care delivery changes and consumer expectations. Telehealth has exploded, and consumers seem to like it. The air has been cleaner in some places because driving and industrial activity declined sharply. If it turns out that heart attacks and asthma also sharply declined in these places, policy choices that invest more in pollution prevention may become more urgent. Inconsistent, ill-informed, and self-serving policy choices made by the president and agencies under his control enabled the virus to spread and kill tens of thousands of people. In the summer of 2020, the president made even wearing a face mask a politically based choice. Nobody knows how this government and political failure will play out, but whatever happens is likely to shape the health care debate in 2021 and beyond.
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Determining how universal health coverage will be paid for has always been a challenge. The ACA ducked the issue by building on the existing framework while leaving its inequities in place. As medical care consumers, we want all the care we think we need, but we want to pay less out of pocket for it. We engage in magical thinking to have someone else pay for it: our employers, insurance companies, or the \u201cgovernment.\u201d Bernie Sanders told us that we would pay more in taxes but less in premiums and out-of-pocket costs, and therefore we would come out ahead in the end. Nobody believed him. We pay Medicare payroll taxes for 40 years based on the promise that it will be there for us but reject doing the same to pay for the care we get now.
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The prices Americans pay for medical care are dramatically higher than any other developed country as the result of past policy choices. President Johnson agreed that the federal government would pay hospitals and doctors their full costs and prevailing prices to get their support for creating Medicare and Medicaid. Prices started rising immediately. Administrations since then have tried to claw some money back without ever challenging the fundamental policy that in the United States, health care providers get to set their own prices. Medicare and Medicaid now pay providers significantly less than their posted prices, but private insurers pay much higher prices because they have limited bargaining power over the providers.
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The United States has huge government deficits and high unemployment. Opponents of universal coverage will argue that the country cannot afford it now. A huge pitfall on the path to universal coverage is the reality that to afford care for all, we probably need to lower the prices we pay for medical care. The ACA paid for Medicaid expansion by reimbursement changes that slow down growth in Medicare expenses without lowering any Medicare member\u2019s benefits. The perceived threat to Medicare became a foundation of the Tea Party Movement that cost Democrats control of the House in 2012.
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Some Medicare for All proposals made a frontal assault on costs by setting all payments at or near current Medicare rates. That is a big deal. Tens of billions of dollars would disappear from hospitals and doctors. Because more than 60 percent of health care spending is salaries for workers, hundreds of thousands of jobs would also disappear. Congress may not be willing to take a policy ax to high prices if consumers perceive the changes as a threat to their access.
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The health care policy debate of 2021 will take place in the middle of a huge national discussion and perhaps reckoning about systemic racism. Black and brown Americans have been subjected to poor and discriminatory medical care forever. Black life expectancy is three years shorter than it is for whites. Black babies and mothers are much more likely to die than whites. Their shorter, sicker lives are more likely a reflection of the cumulative effect of the discrimination they have faced in education, employment, housing, and wealth accumulation than just the lack of medical care itself. Research has shown that having medical insurance improves health, in part by reducing stress; but giving someone with long-term health and social disadvantage an insurance card is not a complete solution. Racial and ethnic health disparities persist even when people of color have insurance. Systems of care and the people who provide it will also have to change. Major investments in other social determinants of health will be needed for years to close the gaps we now recognize. If the country makes a policy choice to spend a lot more on personal medical care, the relative paucity of spending on the social supports that actually improve population health may continue. It is important to note that other rich countries which have better population health than the United States spend less on medical care but much more on the social supports of education, housing, job security, and early childhood development than we do.
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For all these reasons, there will be a window for health policy changes in 2021. COVID-19 is likely to still be raging. Millions will be unemployed and without health insurance. The Supreme Court may find the ACA unconstitutional. The outcomes of the elections will shape the package.
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If Democrats take control of the White House and both houses of Congress, the reforms they pass will depend on the size of their majority in the Senate or their willingness to destroy the filibuster. A commanding majority in the Senate will enable them to pass universal health coverage for all citizens and perhaps non-citizen residents as well. They may make modest steps toward controlling provider prices, especially in ways that lower consumer out-of-pocket costs. They will retain all the popular features of the ACA, especially coverage for pre-existing conditions. A supermajority democratic Congress might decouple insurance from employment for most Americans through a national single-payer program. It is unlikely to pass a bill that eliminates private insurance companies. As Medicare does today, individuals will be able to choose to get their care through the public program or by joining a private managed care program sponsored by an insurance company, union, employer, or some other group. There will be a required broad benefit package for all plans, but the packages could vary in a number of ways that enable consumers to make trade-offs between out-of-pocket costs and provider or supplemental benefit choices. State-run Medicaid programs will continue, but the federal government might substantially expand its share of the cost. The supermajority reform is likely to be the most expensive way to provide universal health coverage, but Democrats have given priority to coverage and access over cost control since Medicare was created. Some newly empowered Democrats might well call this Medicare for All, but Nancy Pelosi and Joe Biden are more likely to say they were finally able to deliver the full promise of Obamacare.
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If the Democrats win only a modest majority in the Senate or if there is a split in the control of Congress, conditions may still open the window for policy change, but the result will be more modest. The focus will be on expanding access to care for COVID-19 services and immunization and perhaps an effort to expand Medicaid to all states in a way that is noncoercive. There will be some tinkering that seeks to lower consumer out-of-pocket costs. State Medicaid programs are likely to get additional money to cover the costs of newly enrolling unemployed individuals and their children.
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Republican control of the federal government in 2021 will bring different health policy choices. Despite COVID-19 and the recession, they will try again to repeal the ACA with or without help from the Supreme Court. The focus will be on limiting cost to the federal government, a republican goal for many years. Medicaid expansion will be repealed and replaced by fixed grants to the states to support traditional Medicaid coverage for pregnant women, infants, and frail, poor elderly. Options for private insurance coverage will be expanded to include policies that have narrow benefit packages to enable consumers to buy the coverage they want. Efforts to change Medicare into a premium support program that limits total federal financial exposure and shifts more costs to Medicare recipients are likely to be renewed.
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Depending on which party wins the elections, there may be other major policy reforms in 2021 that will have a greater impact on population health than changes in medical finance and organization. Clean energy investment that creates jobs and significantly lowers air pollution will reduce deaths. Conversely, continued hollowing out pollution standards will create more disease and deaths. Huge expansion of early childhood education, especially for low-income and rural residents, will lead to lifetime improvements in health and employment.
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Medical care policy is very likely to change in 2021; circumstances will demand it, and the election outcome will shape the response. Whether the result will be Medicare for All will remain in the eyes of the beholder.
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David Rosenbloom,PhD, is a professor at the Boston University School of Public Health. He served as Boston Commissioner of Health and Hospitals from 1975 to 1983 and has been the founder, chair, and director of several nonprofit and for-profit health organizations.
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