Universal Health Care
Central to Debate: Defining Who, What System Covers
In the great debate on health care, the two terms most confused or misunderstood are “universal” and “single-payer.” They often are used interchangeably, or even standing alone, are incorrectly defined. This confusion has skewed the dialogue on what is an ideal model for California health care. Efforts to improve health care in California must first define universal health care, clarify what it entails and quantify how close California already is to actually achieving it.
Universal Health Care Defined
Universal health care, as widely defined, is the ability, of all citizens and legal residents of a state or country, to access quality, affordable health care. There are many ways of achieving universal health care. One of those ways is through a multi-payer model, which is used in California and the United States, wherein health care is paid for through multiple sources, such as employers, government and individuals. Another way is through a “single-payer” model wherein the government is the sole payer for health care. Both models can be a means to achieving a goal of universal health care.
Universal Health Care Does Not Mean All Health Care Is Provided
The word “universal” in the term “universal health care” references the individuals who are covered—meaning all of the legal residents of a country or state have access to health care. “Universal” does not define the type of care covered.
For example, Taiwan has a single-payer system and is close to achieving universal health care. Ninety-nine percent of its legal residents are registered for coverage by the country’s National Health Insurance system. In Taiwan, there is an insurance mandate to buy and a penalty for not buying. There is only one insurance option and that’s the public insurance option.
The fact that Taiwan is so close to achieving universal health care may seem impressive, but as mentioned above, the term “universal” covers only the who and not the what. Preventive medicine, screenings and physicals are not covered and have to be paid for “out of pocket” by Taiwanese citizens. Taiwan has a fee-for-service health care model, which means physicians are paid for each visit rather than on health outcomes. As such, medical appointments generally are limited to 5 minutes each and subsequent visits have to be made if all treatment cannot be completed in the first 5 minutes. If a patient is seen too many times by a physician, the government sends an official from the Bureau of National Health Insurance to inquire and discuss the overuse of the system in an effort to reduce costs on the system. It would be hard to imagine tolerance of such government interference in an individual’s health in the United States or California.
Only Two Countries Have Universal Health Care Through a Single-Payer Model
Due to the frustration with the rising cost of health care, the recent narrative that has arisen and taken hold in California and the United States is that a single-payer health care system is the key to achieving universal health care. Attacks on the Patient Protection and Affordable Care Act (ACA) at the federal level, including the elimination of the individual mandate penalty and cost sharing reduction subsidies, have only further fueled the argument that the single-payer, government-run health care model is the only road to universal health care.
This idea, however, is undermined by the experience of other countries. Most countries that have been able to achieve universal health care have not done so using a single-payer model, but rather a multi-payer model. The very few countries, arguably two in the entire world (Canada and Cuba), that have achieved universal health care through a single-payer model are realizing that a single-payer model is unsustainable.
Canada has tried to remain true to its single-payer model and has prohibited private health insurance in most provinces. Yet, Canada’s Supreme Court held in a 2005 case that “the evidence in this case shows that delays in the public health care system are widespread and that in some serious cases, patients die as a result of waiting lists for public health care.” The court concluded that “the prohibition on obtaining private health insurance is not constitutional where the public system fails to deliver reasonable services.”
Even Taiwan, which has a single-payer system but has not fully achieved universal health care, is facing significant health care system challenges. The cost of Taiwan’s health care system is greater than the premiums currently being collected, so the government has been borrowing money from banks to pay for health care. Premiums are regulated by politicians who are afraid to raise the premiums for fear of not being elected again, even though premiums need to rise to meet costs. There is only so much borrowing the country can do until it has to face the reality of increasing premiums to match the true rising cost of health care.
California Close to Achieving Universal Health Care
California currently has an uninsured rate of 7%—2.7 million people of its total population of 39.78 million people. Of the 2.7 million Californians without health care coverage, approximately 900,000 are legal residents. The remaining uninsured are undocumented residents. Countries touted to have universal health care often do not provide health care to undocumented immigrants.
Thus, in a fair comparison of health care around the world and using the widely accepted definition of universal health care, California is very close to achieving universal health care at 97.6 % coverage of its legal residents. California’s success of universal health care will, in part, be determined by how it defines “universal.”
A closer look at health care systems around the world that are touted to be universal health care systems reveals that they do not cover undocumented immigrants and often are multi-payer rather than single-payer health care systems. Additionally, such countries that say they have achieved universal health care for all citizens and legal residents exempt many types of coverage and services that Californians believe to be essential health care and for which they expect health plan coverage, such as preventive care, prescription medication, ambulance transport, and physical, occupational and speech therapy, as well as others.
In an era of too much information and a lot of misinformation, before idealizing and replicating health care systems, we need to ensure that a health care system we are considering replicating in California is truly what we believe it to be and ultimately what we want.
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