Universal health care

The Royal Aberdeen Children's Hospital is a specialist children's hospital within NHS Scotland. The National Health Service provides publicly-funded universal health care within the United Kingdom.

Universal health care is health care coverage for all eligible residents of a political region and often covers medical, dental and mental health care. Typically, costs are borne in the majority by government-funded programs.

"Single-payer health insurance" is used to describe the primary systems of health care funding used in Canada and the United Kingdom. Multi-payer systems are used in France and Germany, but like Canada and the United Kingdom, health care in both of these countries is primarily financed by publicly controlled insurers.

Health care systems vary according to the extent of government involvement in providing care, ranging from nationalized health care systems (such as the U.K. and Sweden) to decentralized private or non-profit institutions (as in Germany and France). Universal health care is implemented in all industrialized countries, with the exception of the United States. It is also provided in many developing countries.

Implementation and Comparisons

See also: Health care system

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 extending access to health care as widely as possible 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. Usually some costs are borne by the patient at the time of consumption but the bulk of costs come from a combination of compulsory insurance and tax revenues. 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. The UK government's National Audit Office in 2003 published an international comparison of ten different health care systems in ten developed countries, nine universal systems against one non-universal system (the U.S.), and their relative costs and key health outcomes. A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004 In some cases, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care.

Americas

Argentina, Brazil (see below), Canada (see below), Chile, Costa Rica, Cuba, Mexico (see below), Panama, Peru (see below), Uruguay, Trinidad and Tobago and Venezuela all have public universal health care provided.

Brazil

Main article: Health care in Brazil

The universal health care system was adopted in Brazil in 1988 after the end of the military regime's rule.

Canada

Main article: Health care in Canada

In 1984, the heyy whats goodCanada 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."

The system is for the most part publicly funded, yet most of the services are provided by private enterprises or private corporations, although most hospitals are public. Most doctors do not receive an annual salary, but receive a fee per visit or service. About 29% of Canadians' health care is paid for by the private sector or individuals. This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and vision care. Many Canadians have private health insurance, often through their employers, that cover these expenses.

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. 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 which favour the public over the private system and preserve the integrity of the public system.

Colombia

Main article: Health in Colombia

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.

Mexico

Further information: Health care in Mexico

On December 1, 2006 the Mexican government created the Health Insurance for a New Generation also known as "life insurance for babies".

On May 28, 2009 Mexico announced Universal Care Coverage for Pregnant Women.

Peru

On April 9, 2009 the Government of Peru published the Law on Health Insurance to enable all Peruvians to access quality health services, and contribute to regulate 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).

Trinidad and Tobago

Main article: Health care in Trinidad and Tobago

The 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.

United States

See also: Health care reform in the United States and Health care in the United States

The United States is the only industrialized nation that does not have a universal health care system. The government directly covers 27.8% of the population through health care programs for the elderly, disabled, military service families and veterans, children, and some of the poor, through Medicare, Medicaid, SCHIP, and TRICARE. Federal law ensures public access to emergency services regardless of ability to pay. Some analysts say that this unfunded “safety net” mandate has contributed to increasing strain on the health system, because of the many patients who cannot pay their bills for emergency treatment. Furthermore, this system encourages use of the emergency facilities for primary care and not just for emergency purposes. Certain types of medical spending, particularly health insurance, benefit from significant tax subsidies; in particular, employer-sponsored health insurance is a non-taxable benefit. In all, government spending accounted for 45.1% of total health spending in the U.S. in 2005. Current estimates put U.S. health care spending at more than 15% of GDP, a greater portion than in any other United Nations member state except for East Timor (Timor-Leste).

Whether a government-mandated system of universal health care should be implemented in the US remains a hotly debated political topic, with Americans divided in their views of the U.S. health system and what should be done to improve it. Those in favor of government-guaranteed universal health care argue that the large number of uninsured Americans creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality. Opponents of government mandates or programs for universal health care argue that people should be free to opt out of health insurance, and that there is already in place a system for those that are underprivileged. Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.

In lieu of a national program, supporters of universal health care have sought implementation of such programs at the state and municipal level. The state of Massachusetts implemented a near-universal health care system by mandating that residents purchase health insurance by July 1, 2007. The City of San Francisco is also undertaking a universal health care system for uninsured residents. Hawaii has, since 1974, required employers to provide employees working more than 20 hours per week with a comprehensive health insurance plan. California, Maine and Vermont are also considering or seeking to implement universal or near-universal systems.

Since 2005, Universal Health Care Foundation of Connecticut has developed relationships with several key groups that would be instrumental in creating broad change in the health system, including medical societies, hospitals, businesses, labor and clergy. In January 2009 the foundation unveiled SustiNet, a proposal for a statewide health care plan for Connecticut that would provide residents with their choice of health coverage and care regardless of their employment status, age, or pre-existing conditions. An estimated 1,000 people attended a rally at Union Station (Hartford) for the release of the plan. SustiNet would emphasize preventive care and the management of chronic illnesses. It would create a large health insurance pool by combining state employees, retirees, and people covered by state assistance programs. The pool would also be open to members of the public without insurance, those with inadequate insurance, and employers, starting with small businesses, nonprofits and municipalities. Eventually, Sustinet would be open to larger employers wishing to buy into the plan for their employees In February, the 18,500-member Connecticut Association of REALTORS announced its support for the SustiNet health care plan. REALTORS are independent contractors and are representative of the plight of many independent contractors and small business employees in Connecticut in that they do not have access to group health insurance. Also in that month, the independent statewide organization "Small Businesses for Health Care Reform" endorsed the SustiNet health care reform proposal and encouraged other business owners to review and support it. In March 2009, the foundation's SustiNet plan was formally endorsed by the Interfaith Fellowship for Universal Health Care, a group devoted to health reform, as well as by dozens of other religious leaders representing a wide range of faiths in Connecticut. Fellowship members include Rabbi Stephen Fuchs of Congregation Beth Israel in West Hartford, a co-chairman of the Interfaith Fellowship, and Bilal Ansari, a Muslim chaplain at Saint Francis Hospital & Medical Center in Hartford, where much of his counseling involves helping families cope with not just the stress of a relative's illness, but the worries about how they will pay for it.

SustiNet passed its first legislative hurdle Thursday, March 26, receiving an endorsement from the state legislature's Public Health Committee. The committee voted 22-8 to move the bill forward. On April 22, SustiNet received a favorable report from a second committee, the Human Services Committee, which voted 13-6 for the bill. On April 29, SustiNet received a favorable report from a third committee, the Labor and Public Employees Committee, which voted 8-3 for the bill. On May 7, 2009, Sustinet received a favorable report from a fourth committee, the Insurance and Real Estate Committee, which voted 13-4 for the bill.

On May 20, 2009, the Connecticut House of Representatives voted 107-35 for SustiNet. On May 30, 2009, the Connecticut Senate voted 23-12 for SustiNet. SustiNet was sent to Governor Jodi Rell, who vetoed it on July 8. On July 20 2009, the governor's vetoes were overridden by the Connecticut House of Representatives with a vote of 102 to 40 and then by the Connecticut Senate with a vote of 24-12.

The SustiNet law establishes a nine-member board to recommend to the legislature, by January 1, 2011, the details of and implementation process for a self-insured health care plan called SustiNet. The recommendations must address (1) the phased-in offering of the SustiNet plan to state employees and retirees, HUSKY A and B beneficiaries, people without employer-sponsored insurance (ESI) or with unaffordable ESI, small and large employers, and others; (2) establishing an entity that can contract with insurers and health care providers, set reimbursement rates, develop medical homes for patients, and encourage the use of health information technology; (3) a model benefits package; and (4) public outreach and ways to identify uninsured citizens.

The board must establish committees to make recommendations to it about health information technology, medical homes, clinical care and safety guidelines, and preventive care and improved health outcomes. The act also establishes an independent information clearinghouse to inform employers, consumers, and the public about SustiNet and private health care plans and creates task forces to address obesity, tobacco usage, and health care workforce issues. The effective date of the SustiNet law was July 1, 2009 for most provisions.

Most national surveys find that the majority of Americans strongly support universal healthcare for all citizens. A CBS News/New York Times poll taken in April 2009 found that healthcare is the most important issue after the economy, and that 57 percent of Americans are willing to pay higher taxes for universal healthcare, compared to 38 percent that are not. Also 54 percent of Americans feel that providing health insurance for all is more important than the problem of keeping health costs down (49 percent). Also, most Americans feel that the country needs to proceed with health care reform. According to a Kaiser Health Tracking Poll taken in August 2009, fifty-three percent feel that health reform is more important than ever now, while 42 percent feel that we cannot afford to take on health care reform now.

Asia

Bhutan, Brunei, China, Hong Kong SAR, India, Kuwait, Qatar, UAE, Saudi Arabia, Israel, Japan, Malaysia, South Korea, Seychelles, Sri Lanka, Taiwan,, Pakistan and Thailand have universal health care.

Bhutan

Main article: Healthcare in Bhutan

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.

People's Republic of China

Main article: Healthcare system reform in the People's Republic of China

Since the founding of the People's Republic of China, the goal of health care programs has been to provide care to every member of the population and to make maximum use of limited health-care personnel, equipment, and financial resources.

China is undertaking a reform on its health care system, which was largely privatized in the 1990s. The New Rural Co-operative Medical Care System (NRCMCS), is a new 2005 initiative to overhaul the healthcare system, particularly intended to make it more affordable for the rural poor. Under the NRCMCS, the annual cost of medical cover is 50 yuan (US$7) per person. Of that, 20 yuan is paid in by the central government, 20 yuan by the provincial government and a contribution of 10 yuan is made by the patient. As of September 2007, around 80% of the whole rural population of China had signed up (about 685 million people). The system is tiered, depending on the location. If patients go to a small hospital or clinic in their local town, the scheme will cover from 70-80% of their bill. If they go to a county one, the percentage of the cost being covered falls to about 60%. And if they need specialist help in a large modern city hospital, they have to bear most of the cost themselves, the scheme would cover about 30% of the bill.

On January 21, 2009, the Chinese government announced that a total of 850 billion yuan will be provided between 2009 and 2011 in order to improve the existing health care system.

Hong Kong SAR

Main article: Healthcare in Hong Kong

Hong Kong is one of the healthiest places in the world. Because of its early health education, professional health services, and well-developed health care and medication system, Hongkongers enjoy a life expectancy of 84 for females and 78 for males, which is the second highest in the world, and 2.94 infant mortality rate, the fourth lowest in the world.

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 adult to adult live donor liver transplant in 1993.

India

Main article: Healthcare in India

India has a universal health care system run by the local (state or territorial), governments. The government hospitals, some of which are among the best hospitals in India, provide treatment at taxpayer expense. Most essential drugs are offered free of charge in these hospitals.

Government hospitals provide treatment either free or at minimal charges. For example, an outpatient card at AIIMS (one of the best hospitals in India) costs a one time fee of rupees 10 (Around 20 cents US) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on financial condition of the patient and facilities utilized by him but are usually much less than the private sector. For instance, a patient is waived treatment costs if he is below poverty line. Another patient may seek for an air-conditioned room if he is willing to pay extra for it. The charges for basic in-hospital treatment and investigations are much less compared to the private sector. The cost for these subsidies comes from annual allocations from the central and state governments.

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. 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). However, the fact that the government sector is understaffed and underfinanced and poor services at state run hospitals forces many people to visit private medical practitioners.

Now organizations like Hindustan Latex Family Planning Promotional Trust and other private organizations have started creating hospitals and clinics in India, which also provide free or subsidized health care and subsidized insurance plans.

Israel

Main article: Health care in Israel

In Israel, the National Health Insurance Law (or National Health Insurance Act) is the legal framework which enables and facilitates basic, compulsory universal health care. The Law was put into effect by the Knesset on January 1, 1995, and was based on recommendations put forward by a National Committee of Inquiry which examined restructuring the health care system in Israel in the late 1980s. Prior to the law's passage approximately 85% of the population was already covered by voluntarily belonging to one of four nation-wide, not-for-profit health maintenance organizations (HMOs/sick funds). However, there were three problems associated with this arrangement. First, membership in the largest HMO, Clalit, required one to belong to the Histadrut labor organization, even if a person did not wish to (or could) have such an affiliation while other HMOs restricted entry to new members based on age, pre-existing conditions or other factors. Second, different HMOs provided different levels of benefit coverage or services to their members and lastly was the issue mentioned above whereby a certain percentage of the population, albeit a small one, did not have health insurance coverage at all.

Before the law went into effect, all the HMOs collected premiums directly from members. However, upon passage of the law, a new progressive national health insurance tax was levied through Israel's social security agency which then re-distributes the proceeds to the HMOs based on their membership and its demographic makeup. This ensured that all citizens would now have health coverage. While membership in one of the HMOs now became compulsory for all, free choice was introduced into movement of members between HMOs (a change is allowed once per year), effectively making the various HMOs 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 which all HMOs must provide as a minimum service to all their members. Achieving this level of equality ensured that all citizens are guaranteed to receive basic healthcare regardless of their HMO affiliation which was one of the principal aims of the law. An appeals process was put in place to handle rejection of treatments and procedures by the HMOs and evaluating cases falling outside the "basket" of services or prescription formulary.

While the law is generally considered a success and Israeli citizens enjoy a high standard of medical care comparatively, with more competition having been introduced into the field of health care in the country, and order having been brought into what was once a somewhat disorganized system, the law nevertheless does have its critics. First and foremost among the criticisms raised is that the "basket" may not provide enough coverage. To partly address this issue, the HMOs and insurance companies (often in conjunction with employers) began offering additional "supplementary" insurance to cover certain additional services not included in the basket. However, since this insurance is optional, critics argue that it goes against the spirit of the new law which stressed equality among all citizens with respect to healthcare. Another criticism is that in order 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.

Singapore

Main article: Health care in Singapore

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. Singapore currently has the lowest infant mortality rate in the world (equaled only by Iceland) and among the highest life expectancies from birth, according to the World Health Organization. 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 catastrophic 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.

Taiwan (Republic of China)

Main article: Health care in Taiwan

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 which 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. NHI is mainly financed through premiums, which are 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.

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. Taiwan’s citizens no longer have to worry about going bankrupt due to medical bills.

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. Working people do not have to worry about losing their jobs or changing jobs because they will not lose their insurance. 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.

Thailand

Main article: Health care in Thailand

Thailand introduced universal coverage reforms in 2001, becoming one of only a handful of lower-middle income countries to do so. 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 which allows them to access services in their health district, and, if necessary, be referred 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, 35% was from private sources. 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.

Europe

Virtually all of Europe has publicly sponsored and regulated health care. The public plans in some countries provide basic or "sick" coverage only; their citizens can purchase supplemental insurance for additional coverage. Countries with universal health care include Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, the Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Ukraine and the United Kingdom.

Austria

In Austria, public health care (the care, not the running of hospitals itself) is funded by means of so called "Social insurance contributions" accounting for approx. 24% of the salary, they are therefore no taxes as such. 7% of the contribution is reserved for health coverage in one of Austria's 22 public insurances, but cannot exceed EUR 281,- monthly (USD 399,-). Depending on the job, somebody will be insured at one of the 9 state-run territorial health funds or at job specific insurances, e.g. public employees or farmers have their own (compulsory) health insurance. 22 public insurances for 8 million people is subject to violent criticism, as tremendous savings could be reached by unifying the insurances to one centralized provider. However, no Austrian state is willing to give up its own public insurances as it is sphere of action for electoral campaigns. The operation of hospitals is not paid by social contributions, but by taxes. This means that general health coverage adds up to much more and is therefore more expensive as often depicted. Austria spends approx. 10% of its GDP for health coverage.

Finland

Main article: Healthcare in Finland

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 . 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%. Finnish health care expenditures are below the European average. 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.

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 €11 per visit with annual €33 cap; hospital outpatient treatment €22 per visit; a hospital stay, including food, medical care and medicines €26 per 24 hours, or €12 if in a psychiatric hospital. After a patient has spent €590 per year on public medical services (including prescription drugs), all treatment and medications thereafter in that year are free.

Germany

Main article: Health care in Germany

Germany has the world's oldest universal health care system, with origins dating back to Otto von Bismarck's Health Insurance Act of 1883. As mandatory health insurance, it originally applied only to low-income workers and certain government employees, but has gradually expanded to cover virtually the entire population. The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population is covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher income workers sometimes choose to pay a tax and opt out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status.

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, comprised of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries. 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. 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). 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).

Ireland

Main article: Health care in Ireland

The public health care system of the Republic of Ireland is governed by the Health Act 2004, which established a new body to be responsible for providing health and personal social services to everyone living in Ireland - the Health Service Executive. The new national health service came into being officially on 1 January 2005; however the new structures are currently in the process of being established as the reform programme continues. In addition to the public-sector, there is also a large private healthcare market.

Netherlands

Main article: Health care in the Netherlands

The Netherlands has a dual-level system. All primary and curative care (i.e. the family doctor service and 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 from taxation. According to the WHO, the health care system in the Netherlands was 62% government funded and 38% privately funded as of 2004.

Insurance companies must offer a core universal insurance package for the universal primary, curative care which includes the cost of all prescription medicines. They must do this at a fixed price for all. The same premium is paid 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 which a doctor has determined to be 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). All insurance companies receive additional funding from the regulator's fund. 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 will receive more from the regulator than those with low payouts. Thus 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 and quality high. The competition regulator is charged with checking for abuse of dominant market positions and the creation of cartels that act against the 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.

Hospitals in the Netherlands are also regulated and inspected but are mostly privately run and 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.

Insurance companies can offer additional services at 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 €100 per month. Persons on 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.

United Kingdom

Main article: Healthcare in the United Kingdom

Each of the Countries of the United Kingdom has a National Health Service that provides public healthcare to all UK permanent residents that is free at the point of need and paid for from general taxation. However, since Health is a devolved matter, considerable differences are developing between the systems in each of the countries.

England

Main article: Healthcare in England

The National Health Service (NHS), created by the National Health Service Act 1946 has provided the majority of healthcare in England since its launch on 5 July 1948.

The NHS Constitution for England documents at 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 which govern the service. 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. Wait times are low, with most people able to see their primary care doctor on the same day or the following day and 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 similar (e.g. child birth) . No patient should experience a delay of more than 18 weeks from initial hospital referral to final treatment. This includes the time for all investigative tests and consultations, and two thirds of patients are currently treated in under 12 weeks.

Although centrally funded there is no large central bureaucracy to manage it. Responsibility is highly devolved to geographical areas through Strategic Health Authorities and even more locally through NHS primary care trusts , NHS hospital trusts and increasingly to NHS foundation trusts which are more like local co-operatives are providing even more decentralized services within the NHS framework, with more decision making taken by local people, patients and staff. The central government office, the Department of Health, is 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, but it does lay down general guidelines for them to follow. Local trusts are accountable to their local populations, whilst government ministers are accountable to Parliament for the service overall.

The NHS provides, among other things, primary care, in-patient care, long-term healthcare, psychiatric care and treatments ophthalmology and dentistry. All treatment is free with the exception of certain charges for prescriptions, dentistry and ophthalmology (which themselves are free to children, the elderly, the unemployed and those on low incomes). The charge for NHS prescriptions is alat rate of £7.20, except those under 16 or over 60 do not pay for prescriptions and others may cap their annual charges. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services. 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 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 excessive strain on the public sector borrowing requirement.

Northern Ireland

Main article: Health and Social Care in Northern Ireland

Health and Social Care in Northern Ireland is the designation of the national public health service in Northern Ireland.

Scotland

Main article: Healthcare in Scotland

NHS Scotland, created by the National Health Service (Scotland) Act 1947, was also launched on 5 July 1948 though it has always been a separate organisation. Since devolution, NHS Scotland follows the policies and priorities of the Scottish Government, including the phasing out of all prescription charges by 2011.

Wales

Main article: Healthcare in Wales

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, in turn being transferred under devolution to what is now the Welsh Assembly Government.

Australia

File:Medicare-brand.png

Medicare logo

Main article: Medicare (Australia)

In Australia, Medibank — as it was then known — was introduced, by the Whitlam Labor government on 1 July 1975, through the Health Insurance Act 1973. The Australian Senate rejected the changes multiple times and they were passed only after a joint sitting after the 1974 double dissolution election. However, Medibank was supported by the subsequent Fraser Coalition (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, and 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.

During the 1980s, 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. 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) and do not have adequate levels of private hospital coverage. 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.

New Zealand

Main article: Health care in New Zealand

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

Economics

Main article: Health care economics

Funding models

Universal health care in most countries has been achieved by a mixed model of funding. General taxation revenue is the primary source of funding, but in many countries it is supplemented by specific levies (which may be charged to the individual and/or an employer) or with the option of private payments (either direct or via optional insurance) for services beyond that covered by the public system.

Almost all European systems are financed through a mix of public and private contributions. The majority of universal health care systems are funded primarily by tax revenue (e.g. Portugal and Spain). Some nations, such as Germany, France and Japan employ a multi-payer system in which health care is funded by private and public contributions. However, much of the non-government funding is by defined contributions by employers and employees to regulated non-profit sickness funds. These contributions are compulsory and vary according to a person's salary, and are effectively a form of hypothecated taxation.

A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency.

Universal health care systems are modestly redistributive. Progressivity of health care financing has limited implications for overall income inequality.

Single-payer

Main article: Single-payer health care

The term single-payer health care is used in the United States to describe a funding mechanism meeting the costs of medical care from a single fund. Although the fund holder is usually the government, some forms of single-payer employ a public-private system.

Public

Some countries (notably the United Kingdom, Italy and Spain) have eliminated insurance entirely and choose to fund health care directly from taxation. Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation, either by directly paying their medical bills or by paying for insurance premiums for those affected.

Compulsory insurance

This is usually enforced via legislation requiring residents to purchase insurance, though sometimes, in effect, the government provides the insurance. Sometimes there may be a choice of multiple public and private funds providing a standard service (e.g. as in Germany) or sometimes just a single public fund (as in Canada).

In some European countries where there is private insurance and universal health care, such as Germany, Belgium, and The Netherlands, the problem of adverse selection (see Private insurance below) is overcome using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price and there is no advantage to eliminate people with higher risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but then mainly compete on price and service. In some countries the basic coverage level is set by the government and cannot be modified.

Ireland at one time had a "community rating" system through VHI, effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. This resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market which then made higher profits at VHI's expense. The government later re-introduced community rating through a pooling arrangement and at least one main major insurance company, BUPA, then withdrew from the Irish market.

Private insurance

In some countries with universal coverage, private insurance often excludes many health conditions which are expensive and which the state health care system can provide. For example in the UK, one of the largest private health care providers is BUPA which has the following list of general exclusions.

Dental/oral treatment (such as fillings, gum disease, jaw shrinkage, etc)†; pregnancy and childbirth†; temporary relief of symptoms†; convalescence, rehabilitation and general nursing care†; drugs and dressings for out-patient or take-home use†; screening and preventive treatment; birth control, conception, sexual problems and sex changes†; allergies or allergic disorders; chronic conditions†; eyesight†; physical aids and devices†; *deafness; cosmetic, reconstructive or weight loss treatment† ; ageing, menopause and puberty ; dialysis† ; complications from excluded or restricted conditions/ treatment ; HRT and bone densitometry†; learning difficulties, behavioural and developmental problems ; overseas treatment and repatriation ; AIDS/HIV† ; pre-existing or special conditions ; experimental drugs and treatment† ; sleep problems and disorders ; speech disorders†

all of which (except overseas repatriation) are available for free or very low cost from the NHS. († indicates that treatment may be provided in certain circumstances)

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

Politics

See also: Health care politics

Health care systems throughout the world face sustainability challenges that may require far-reaching changes in national policy. Over the last decade, health spending has been accelerating as a percent of Gross Domestic Product (GDP) among Organisation for Economic Co-operation and Development (OECD) countries. Many industrialized countries have aging populations, with resulting increases in health care utilization, while others face rapid population growth. One recent study, by global consulting firm PriceWaterhouseCoopers, projected that global health care spending would triple in real dollars by 2020, consuming 21% of GDP in the U.S. and 16% of GDP in other OECD countries.

In the United States

See also: Health care reform in the United States

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

Critics of this argument note that there is very little correlation between life expectancy and infant mortality with the quality of health care, due to such factors as alternate causality and variations in the way countries collect their statistical data. In fact, the U.S. led the world in life expectancy twenty years ago with virtually the same health system. Rather, many analysts attribute the lower life expectancy to a great surge in obesity rates. Opponents of universal health care programs argue that people should be free to opt out of health insurance and that government programs would require higher taxes, increase utilization, and reduce health care quality. They also claim that the absence of a market mechanism may slow innovation in treatment and research, and lead to rationing of care through waiting lists. However, contra arguments are also heard. That waiting is actually not uncommon in the United States that the American system merely "rations by income and insurance status" and a more rational system would take the view that "health care should be considered a right, not a commodity".

Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.

Survey research shows that Americans see expanding coverage as a top national priority, and a majority express support for universal health care. There is, however, much more limited support for tax increases to support health care reform. Most Americans report satisfaction with their own personal health care.

Opponents of America's Affordable Health Choices Act of 2009 have claimed the bill, H.R.3200, will lead to a creation of a socialized medicine system, government death panels, government nationalization of the health care system, higher taxes, removal of choice, abortion on demand, and free health care for illegal immigrants. Respected fact check organizations based on the content of the bills currently passing through Congress dispute much of this. The proposed government insurance plan would be allowed to pay for abortions, just as some private insurers do, but it is argued that the Hyde amendment does not apply, because the funds are private since they are paid for by those opting to buy the public plan. Democrats claim this definition of public funds is too narrow, while pro-life groups claim it is too broad as the amendment only applies to Medicaid. Affordability credits within HR3200 would allow poor people to buy health insurance but due the Capps amendment the plan chosen (public or private) would not be allowed to apply affordability credits for the purposes of abortion, but it is unclear whether other funds in the public plan (i.e.premiums) are "public funds" in the same way as tax dollars are.An NBC News/Wall Street Journal polled Americans on what they felt was "likely to happen" as a result of health care reform:

• Health care to illegal immigrants - 55%
• Pay for abortions - 50%
• Government takeover - 54%
• Government decides on health care for the elderly - 45%

Proponents state this is a result of advertising and political activism trying to create a culture of fear surrounding health care reform by using straw man arguments. The media has focused on several Town Hall meetings in August that have broken out into noisy and emotional protests on both sides of the argument for reform.

Debate in the United States

The following is a listing of universal health care pros and cons as argued by supporters and opponents. Template:MultiCol Common arguments forwarded by supporters of universal health care systems include:

• Health care is a basic human right or entitlement.
• Ensuring the health of all citizens benefits a nation economically.
• About 59% of the U.S. health care system is already publicly financed with federal and state taxes, property taxes, and tax subsidies - a universal health care system would merely replace private/employer spending with taxes. Total spending would go down for individuals and employers.
• A single payer system could save $286 billion a year in overhead and paperwork. Administrative costs in the U.S. health care system are substantially higher than those in other countries and than in the public sector in the US: one estimate put the total administrative costs at 24 percent of U.S. health care spending.
• Several studies have shown a majority of taxpayers and citizens across the political divide would prefer a universal health care system over the current U.S. system
• Wastefulness and inefficiency in the delivery of health care would be reduced.
• America spends a far higher percentage of GDP on health care than any other country but has worse ratings on such criteria as quality of care, efficiency of care, access to care, safe care, equity, and waiting times, according to the Commonwealth Fund.
• A universal system would align incentives for investment in long term health-care productivity, preventive care, and better management of chronic conditions..
• Universal health care could reduce the burden of healthcare on business. The Big Three of U.S. car manufacturers cited health-care provision as a reason for their recent financial travails. The cost of health insurance to U.S. car manufacturers adds between USD 900 and USD 1,400 to each car made in the U.S.A.)
• The profit motive adversely affects the cost and quality of health care. If managed care programs and their concomitant provider networks are abolished, then doctors would no longer be guaranteed patients solely on the basis of their membership in a provider group and regardless of the quality of care they provide. Theoretically, quality of care would increase as true competition for patients is restored.
• A 2008 opinion poll of 2,000 US doctors found support for a universal health care plan at 59%-32%, which is up from the 49%-40% opinion of physicians in 2002. These numbers include 83% of psychiatrists, 69% of emergency medicine specialists, 65% of pediatricians, 64% of internists, 60% of family physicians and 55% of general surgeons. The reasons given are an inability of doctors to decide patient care and patients who are unable to afford care.
• According to an estimate by Dr. Marcia Angell roughly 50% of health care dollars are spent on health care, the rest go to various middlepersons and intermediaries. A streamlined, non-profit, universal system would increase the efficiency with which money is spent on health care.
• In countries in Western Europe with public universal health care, private health care is also available, and one may choose to use it if desired. Most of the advantages of private health care continue to be present, see also two-tier health care.
• Universal health care and public doctors would protect the right to privacy between insurance companies and patients.
• Public health care system can be used as independent third party in disputes between employer and employee.
• Conservatives can favor universal health care, because in countries with universal health care, the government spends less tax money per person on health care than the U.S. For example, in France, the government spends $569 less per person on health care than in the United States. This would allow the U.S. to adopt universal health care, while simultaneously cutting government spending and cutting taxes.

| class="col-break " | Common arguments forwarded by opponents of universal health care systems include:

• Health care is not a right. As such, it is not the responsibility of government to provide health care.
• Universal health care could result in increased waiting times, which could result in unnecessary deaths.
• Unequal access and health disparities still exist in universal health care systems.
• The performance of administrative duties by doctors results from medical centralization and over-regulation, and may reduce charitable provision of medical services by doctors.
• Many problems that universal health insurance is meant to solve are presumed caused by limitations on the free market. As such, free market solutions have greater potential to improve care and coverage.
• The widely quoted health care system ranking by the World Health Organization, in which the US system ranked below other countries' universal health care systems, used biased criteria, giving a false sense of those systems' superiority.
• Empirical evidence on the Medicare single payer-insurance program demonstrates that the cost exceeds the expectations of advocates. As an open-ended entitlement, Medicare does not weigh the benefits of technologies against their costs. Paying physicians on a fee-for-service basis also leads to spending increases. As a result, it is difficult to predict or control Medicare's spending. Large market-based public program such as the Federal Employees Health Benefits Program and CalPERS can provide better coverage than Medicare while still controlling costs as well.

See also

• Health care compared - tabular comparisons of the US, Canada, and other countries not shown above.
• Health care reform debate in the United States
• Health insurance cooperative
• National health insurance
• Publicly-funded health care
• Single-payer health care

External links

• Conservatives for Patients' Rights A group that opposes the current health care reform plans.
• Health Care for America NOW!. An advocacy group that supports a public health insurance option for universal health care.
• Health Care Is a Right, Not a Privilege by U.S. Senator Bernie Sanders, The Huffington Post, June 8 2009
• Healthcare-NOW!. A nonprofit advocacy group for single-payer universal healthcare.
• Progressive Democrats of America, Democrats who support single-payer universal healthcare.
• Single Payer Action. Activist organization supporting single-payer universal healthcare.
• Universal Health Care Foundation of Connecticut