universal health coverage essay

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15.10 Persuasive Essay

Learning objective.

• Read an example of the persuasive rhetorical mode.

Universal Health Care Coverage for the United States

The United States is the only modernized Western nation that does not offer publicly funded health care to all its citizens; the costs of health care for the uninsured in the United States are prohibitive, and the practices of insurance companies are often more interested in profit margins than providing health care. These conditions are incompatible with US ideals and standards, and it is time for the US government to provide universal health care coverage for all its citizens. Like education, health care should be considered a fundamental right of all US citizens, not simply a privilege for the upper and middle classes.

One of the most common arguments against providing universal health care coverage (UHC) is that it will cost too much money. In other words, UHC would raise taxes too much. While providing health care for all US citizens would cost a lot of money for every tax-paying citizen, citizens need to examine exactly how much money it would cost, and more important, how much money is “too much” when it comes to opening up health care for all. Those who have health insurance already pay too much money, and those without coverage are charged unfathomable amounts. The cost of publicly funded health care versus the cost of current insurance premiums is unclear. In fact, some Americans, especially those in lower income brackets, could stand to pay less than their current premiums.

However, even if UHC would cost Americans a bit more money each year, we ought to reflect on what type of country we would like to live in, and what types of morals we represent if we are more willing to deny health care to others on the basis of saving a couple hundred dollars per year. In a system that privileges capitalism and rugged individualism, little room remains for compassion and love. It is time that Americans realize the amorality of US hospitals forced to turn away the sick and poor. UHC is a health care system that aligns more closely with the core values that so many Americans espouse and respect, and it is time to realize its potential.

Another common argument against UHC in the United States is that other comparable national health care systems, like that of England, France, or Canada, are bankrupt or rife with problems. UHC opponents claim that sick patients in these countries often wait in long lines or long wait lists for basic health care. Opponents also commonly accuse these systems of being unable to pay for themselves, racking up huge deficits year after year. A fair amount of truth lies in these claims, but Americans must remember to put those problems in context with the problems of the current US system as well. It is true that people often wait to see a doctor in countries with UHC, but we in the United States wait as well, and we often schedule appointments weeks in advance, only to have onerous waits in the doctor’s “waiting rooms.”

Critical and urgent care abroad is always treated urgently, much the same as it is treated in the United States. The main difference there, however, is cost. Even health insurance policy holders are not safe from the costs of health care in the United States. Each day an American acquires a form of cancer, and the only effective treatment might be considered “experimental” by an insurance company and thus is not covered. Without medical coverage, the patient must pay for the treatment out of pocket. But these costs may be so prohibitive that the patient will either opt for a less effective, but covered, treatment; opt for no treatment at all; or attempt to pay the costs of treatment and experience unimaginable financial consequences. Medical bills in these cases can easily rise into the hundreds of thousands of dollars, which is enough to force even wealthy families out of their homes and into perpetual debt. Even though each American could someday face this unfortunate situation, many still choose to take the financial risk. Instead of gambling with health and financial welfare, US citizens should press their representatives to set up UHC, where their coverage will be guaranteed and affordable.

Despite the opponents’ claims against UHC, a universal system will save lives and encourage the health of all Americans. Why has public education been so easily accepted, but not public health care? It is time for Americans to start thinking socially about health in the same ways they think about education and police services: as rights of US citizens.

Online Persuasive Essay Alternatives

Martin Luther King Jr. writes persuasively about civil disobedience in Letter from Birmingham Jail :

• http://www.stanford.edu/group/King/frequentdocs/birmingham.pdf
• http://web.cn.edu/kwheeler/documents/Letter_Birmingham_Jail.pdf
• http://www.oak-tree.us/stuff/King-Birmingham.pdf

Michael Levin argues The Case for Torture :

• http://people.brandeis.edu/~teuber/torture.html

Alan Dershowitz argues The Case for Torture Warrants :

• http://blogs.reuters.com/great-debate/2011/09/07/the-case-for-torture-warrants/

Alisa Solomon argues The Case against Torture :

• http://www.villagevoice.com/2001-11-27/news/the-case-against-torture/1

Writing for Success Copyright © 2015 by University of Minnesota is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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• Universal Health Care

The Importance of Universal Health Care in Improving Our Nation’s Response to Pandemics and Health Disparities

• Policy Statements and Advocacy
• Policy Statement Database
• Development Process
• Archiving Process
• Proposed Policy Statements
• Date: Oct 24 2020
• Policy Number: LB20-06

Key Words: Health Insurance, Health Care, Health Equity

Abstract The COVID pandemic adds a new sense of urgency to establish a universal health care system in the United States. Our current system is inequitable, does not adequately cover vulnerable groups, is cost prohibitive, and lacks the flexibility to respond to periods of economic and health downturns. During economic declines, our employer-supported insurance system results in millions of Americans losing access to care. While the Affordable Care Act significantly increased Americans’ coverage, it remains expensive and is under constant legal threat, making it an unreliable conduit of care. Relying on Medicaid as a safety net is untenable because, although enrollment has increased, states are making significant Medicaid cuts to balance budgets. During the COVID-19 pandemic, countries with universal health care leveraged their systems to mobilize resources and ensure testing and care for their residents. In addition, research shows that expanding health coverage decreases health disparities and supports vulnerable populations’ access to care. This policy statement advocates for universal health care as adopted by the United Nations General Assembly in October 2019. The statement promotes the overall goal of achieving a system that cares for everyone. It refrains from supporting one particular system, as the substantial topic of payment models deserves singular attention and is beyond the present scope.

Relationship to Existing APHA Policy Statements We propose that this statement replace APHA Policy Statement 20007 (Support for a New Campaign for Universal Health Care), which is set to be archived in 2020. The following policy statements support the purpose of this statement by advocating for health reform:

• APHA Policy Statement Statement 200911: Public Health’s Critical Role in Health Reform in the United States
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health

In addition, this statement is consistent with the following APHA policies that reference public health’s role in disaster response:

• APHA Policy Statement 20198: Public Health Support for Long-Term Responses in High-Impact, Postdisaster Settings
• APHA Policy Statement 6211(PP): The Role of State and Local Health Departments in Planning for Community Health Emergencies
• APHA Policy Statement 9116: Health Professionals and Disaster Preparedness
• APHA Policy Statement 20069: Response to Disasters: Protection of Rescue and Recovery Workers, Volunteers, and Residents Responding to Disasters

Problem Statement Discussions around universal health care in the United States started in the 1910s and have resurfaced periodically.[1] President Franklin D. Roosevelt attempted twice in the 1940s to establish universal health care and failed both times.[1] Eventually, the U.S. Congress passed Medicare and Medicaid in the 1960s. Universal health care more recently gained attention during debates on and eventual passage of the Affordable Care Act (ACA).[2]

To date, the U.S. government remains the largest payer of health care in the United States, covering nearly 90 million Americans through Medicare, Medicaid, TRICARE, and the Children’s Health Insurance Program (CHIP).[3] However, this coverage is not universal, and many Americans were uninsured[4] or underinsured[5] before the COVID-19 pandemic.

The COVID-19 pandemic has exacerbated underlying issues in our current health care system and highlighted the urgent need for universal health care for all Americans.

Health care is inaccessible for many individuals in the United States: For many Americans, accessing health care is cost prohibitive.[6] Coverage under employer-based insurance is vulnerable to fluctuations in the economy. Due to the COVID-19 pandemic, an estimated 10 million Americans may lose their employer-sponsored health insurance by December 2020 as a result of job loss.[7] When uninsured or underinsured people refrain from seeking care secondary to cost issues, this leads to delayed diagnosis and treatment, promotes the spread of COVID-19, and may increase overall health care system costs.

The ACA reformed health care by, for instance, eliminating exclusions for preexisting conditions, requiring coverage of 10 standardized essential health care services, capping out-of-pocket expenses, and significantly increasing the number of insured Americans. However, many benefits remain uncovered, and out-of-pocket costs can vary considerably. For example, an ACA average deductible ($3,064) is twice the rate of a private health plan ($1,478).[4] Those living with a disability or chronic illness are likely to use more health services and pay more. A recent survey conducted during the COVID-19 pandemic revealed that 38.2% of working adults and 59.6% of adults receiving unemployment benefits from the Coronavirus Aid, Relief, and Economic Security (CARES) Act could not afford a $400 expense, highlighting that the COVID-19 pandemic has exacerbated lack of access to health care because of high out-of-pocket expenses.[8] In addition, the ACA did not cover optometry or dental services for adults, thereby inhibiting access to care even among the insured population.[9]

Our current health care system cannot adequately respond to the pandemic and supply the care it demands: As in other economic downturns wherein people lost their employer-based insurance, more people enrolled in Medicaid during the pandemic. States’ efforts to cover their population, such as expanding eligibility, allowing self-attestation of eligibility criteria, and simplifying the application process, also increased Medicaid enrollment numbers.[10] The federal “maintenance of eligibility” requirements further increased the number of people on Medicaid by postponing eligibility redeterminations. While resuming eligibility redeterminations will cause some to lose coverage, many will remain eligible because their incomes continue to fall below Medicaid income thresholds.[10]

An urgent need for coverage during the pandemic exists. Virginia’s enrollment has increased by 20% since March 2020. In Arizona, 78,000 people enrolled in Medicaid and CHIP in 2 months.[11] In New Mexico, where 42% of the population was already enrolled in Medicaid, 10,000 more people signed up in the first 2 weeks of April than expected before the pandemic.[11] Nearly 17 million people who lost their jobs during the pandemic could be eligible for Medicaid by January 2021.[12]

While increasing Medicaid enrollment can cover individuals who otherwise cannot afford care, it further strains state budgets.[11] Medicaid spending represents a significant portion of states’ budgets, making it a prime target for cuts. Ohio announced $210 million in cuts to Medicaid, a significant part of Colorado’s $229 million in spending cuts came from Medicaid, Alaska cut $31 million in Medicaid, and Georgia anticipates 14% reductions overall.[11]

While Congress has authorized a 6.2% increase in federal Medicaid matching, this increase is set to expire at the end of the public health emergency declaration (currently set for October 23, 2020)[13] and is unlikely to sufficiently make up the gap caused by increased spending and decreased revenue.[14] Given the severity and projected longevity of the pandemic’s economic consequences, many people will remain enrolled in Medicaid throughout state and federal funding cuts. This piecemeal funding strategy is unsustainable and will strain Medicaid, making accessibility even more difficult for patients.

Our health care system is inequitable: Racial disparities are embedded in our health care system and lead to worse COVID-19 health outcomes in minority groups. The first federal health care program, the medical division of the Freedmen’s Bureau, was established arguably out of Congress’s desire for newly emancipated slaves to return to working plantations in the midst of a smallpox outbreak in their community rather than out of concern for their well-being.[15] An effort in 1945 to expand the nation’s health care system actually reinforced segregation of hospitals.[15] Moreover, similar to today, health insurance was employer based, making it difficult for Black Americans to obtain.

Although the 1964 Civil Rights Act outlawed segregation of health care facilities receiving federal funding and the 2010 ACA significantly benefited people of color, racial and sexual minority disparities persist today in our health care system. For example, under a distribution formula set by the U.S. Department of Health and Human Services (DHHS), hospitals reimbursed mostly by Medicaid and Medicare received far less federal funding from the March 2020 CARES Act and the Paycheck Protection Program and Health Care Enhancement Act than hospitals mostly reimbursed by private insurance.[16] Hospitals in the bottom 10% based on private insurance revenue received less than half of what hospitals in the top 10% received. Medicare reimburses hospitals, on average, at half the rate of private insurers. Therefore, hospitals that primarily serve low-income patients received a disproportionately smaller share of total federal funding.[16]

Additional barriers for these communities include fewer and more distant testing sites, longer wait times,[17] prohibitive costs, and lack of a usual source of care.[18] Black Americans diagnosed with COVID-19 are more likely than their White counterparts to live in lower-income zip codes, to receive tests in the emergency department or as inpatients, and to be hospitalized and require care in an intensive care unit.[19] Nationally, only 20% of U.S. counties are disproportionately Black, but these counties account for 52% of COVID-19 diagnoses and 58% of deaths.[20] The pre-pandemic racial gaps in health care catalyzed pandemic disparities and will continue to widen them in the future.

Our health care system insufficiently covers vulnerable groups: About 14 million U.S. adults needed long-term care in 2018.[21] Medicare, employer-based insurance, and the ACA do not cover home- and community-based long-term care. Only private long-term care insurance and patchwork systems for Medicaid-eligible recipients cover such assistance. For those paying out of pocket, estimated home care services average $51,480 to $52,624 per year, with adult day services at more than $19,500 per year.[22]

Our current health care system also inadequately supports individuals with mental illness. APHA officially recognized this issue in 2014, stating that we have “lacked an adequate and consistent public health response [to behavioral health disorders] for several reasons” and that the “treatment of mental health and substance use disorders in the United States has been provided in segregated, fragmented, and underfunded care settings.”[23]

The COVID-19 pandemic has brought urgency to the universal health care discussion in the United States. This is an unprecedented time, and the pandemic has exacerbated many of the existing problems in our current patchwork health care system. The COVID-19 pandemic is a watershed moment where we can reconstruct a fractured health insurance system into a system of universal health care.

Evidence-Based Strategies to Address the Problem We advocate for the definition of universal health care outlined in the 2019 resolution adopted by the United Nations General Assembly, which member nations signed on to, including the United States. According to this resolution, “universal health coverage implies that all people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative, rehabilitative and palliative essential health services, and essential, safe, affordable, effective and quality medicines and vaccines, while ensuring that the use of these services does not expose the users to financial hardship, with a special emphasis on the poor, vulnerable and marginalized segments of the population.”[24]

Our current system is inaccessible, inflexible, and inequitable, and it insufficiently covers vulnerable populations. Here we present supporting evidence that universal health care can help address these issues.

Universal health care can increase accessibility to care: Evidence supporting universal health care is mostly limited to natural experiments and examples from other countries. Although countries with universal health care systems also struggle in containing the COVID-19 pandemic, their response and mortality outcomes are better owing to their robust universal systems.[25]

While individuals in the United States lost health care coverage during the pandemic, individuals in countries with universal health care were able to maintain access to care.[26–28] Some European and East Asian countries continue to offer comprehensive, continuous care to their citizens during the pandemic.

Taiwan’s single-payer national health insurance covers more than 99% of the country’s population, allowing easy access to care with copayments of $14 for physician visits and $7 for prescriptions. On average, people in Taiwan see their physician 15 times per year.[27] Also, coronavirus tests are provided free of charge, and there are sufficient hospital isolation rooms for confirmed and suspected cases of COVID-19.[28]

Thai epidemiologists credit their universal health care system with controlling the COVID-19 pandemic.[29] They have described how their first patient, a taxi driver, sought medical attention unencumbered by doubts about paying for his care. They benefit from one of the lowest caseloads in the world.[29]

Universal health care is a more cohesive system that can better respond to health care demands during the pandemic and in future routine care: Leveraging its universal health care system, Norway began aggressively tracking and testing known contacts of individuals infected with COVID-19 as early as February 2020. Public health officials identified community spread and quickly shut down areas of contagion. By April 30, Norway had administered 172,586 tests and recorded 7,667 positive cases of COVID-19. Experts attribute Norway’s success, in part, to its universal health care system.[26] Norway’s early comprehensive response and relentless testing and tracing benefited the country’s case counts and mortality outcomes.

Once China released the genetic sequence of COVID-19, Taiwan’s Centers for Disease Control laboratory rapidly developed a test kit and expanded capacity via the national laboratory diagnostic network, engaging 37 laboratories that can perform 3,900 tests per day.[28] Taiwan quickly mobilized approaches for case identification, distribution of face masks, containment, and resource allocation by leveraging its national health insurance database and integrating it with the country’s customs and immigration database daily.[28] Taiwan’s system proved to be flexible in meeting disaster response needs.

Although these countries’ success in containing COVID-19 varied, their universal health care systems allowed comprehensive responses.

Universal health care can help decrease disparities and inequities in health: Several factors point to decreased racial and ethnic disparities under a universal health care model. CHIP’s creation in 1997 covered children in low-income families who did not qualify for Medicaid; this coverage is associated with increased access to care and reduced racial disparities.[30] Similarly, differences in diabetes and cardiovascular disease outcomes by race, ethnicity, and socioeconomic status decline among previously uninsured adults once they become eligible for Medicare coverage.[31] While universal access to medical care can reduce health disparities, it does not eliminate them; health inequity is a much larger systemic issue that society needs to address.

Universal health care better supports the needs of vulnerable groups: The United States can adopt strategies from existing models in other countries with long-term care policies already in place. For example, Germany offers mandatory long-term disability and illness coverage as part of its national social insurance system, operated since 2014 by 131 nonprofit sickness funds. German citizens can receive an array of subsidized long-term care services without age restrictions.[32] In France, citizens 60 years and older receive long-term care support through an income-adjusted universal program.[33]

Universal health care can also decrease health disparities among individuals with mental illness. For instance, the ACA Medicaid expansion helped individuals with mental health concerns by improving access to care and effective mental health treatment.[34]

Opposing Arguments/Evidence Universal health care is more expensive: Government spending on Medicare, Medicaid, and CHIP has been increasing and is projected to grow 6.3% on average annually between 2018 and 2028.[35] In 1968, spending on major health care programs represented 0.7% of the gross domestic product (GDP); in 2018 it represented 5.2% of the GDP, and it is projected to represent 6.8% in 2028.[35] These estimates do not account for universal health care, which, by some estimates, may add $32.6 trillion to the federal budget during the first 10 years and equal 10% of the GDP in 2022.[36]

Counterpoint: Some models of single-payer universal health care systems estimate savings of $450 billion annually.[37] Others estimate $1.8 trillion in savings over a 10-year period.[38] In 2019, 17% of the U.S. GDP was spent on health care; comparable countries with universal health care spent, on average, only 8.8%.[39]

Counterpoint: Health care services in the United States are more expensive than in other economically comparable countries. For example, per capita spending on inpatient and outpatient care (the biggest driver of health care costs in the United States) is more than two times greater even with shorter hospital stays and fewer physician visits.[40] Overall, the United States spends over $5,000 more per person in health costs than countries of similar size and wealth.[40]

Counterpoint: Administrative costs are lower in countries with universal health care. The United States spends four times more per capita on administrative costs than similar countries with universal health care.[41] Nine percent of U.S. health care spending goes toward administrative costs, while other countries average only 3.6%. In addition, the United States has the highest growth rate in administrative costs (5.4%), a rate that is currently double that of other countries.[41]

Universal health care will lead to rationing of medical services, increase wait times, and result in care that is inferior to that currently offered by the U.S. health care system. Opponents of universal health care point to the longer wait times of Medicaid beneficiaries and other countries as a sign of worse care. It has been shown that 9.4% of Medicaid beneficiaries have trouble accessing care due to long wait times, as compared with 4.2% of privately insured patients.[42] Patients in some countries with universal health care, such as Canada and the United Kingdom, experience longer wait times to see their physicians than patients in the United States.[43] In addition, some point to lower cancer death rates in the United States than in countries with universal health care as a sign of a superior system.[44]

Another concern is rationing of medical services due to increased demands from newly insured individuals. Countries with universal health care use methods such as price setting, service restriction, controlled distribution, budgeting, and cost-benefit analysis to ration services.[45]

Counterpoint: The Unites States already rations health care services by excluding patients who are unable to pay for care. This entrenched rationing leads to widening health disparities. It also increases the prevalence of chronic conditions in low-income and minority groups and, in turn, predisposes these groups to disproportionately worse outcomes during the pandemic. Allocation of resources should not be determined by what patients can and cannot afford. This policy statement calls for high-value, evidence-based health care, which will reduce waste and decrease rationing.

Counterpoint: Opponents of universal health care note that Medicaid patients endure longer wait times to obtain care than privately insured patients[42] and that countries with universal health care have longer wait times than the United States.[43] Although the United States enjoys shorter wait times, this does not translate into better health outcomes. For instance, the United States has higher respiratory disease, maternal mortality, and premature death rates and carries a higher disease burden than comparable wealthy countries.[46]

Counterpoint: A review of more than 100 countries’ health care systems suggests that broader coverage increases access to care and improves population health.

Counterpoint: While it is reasonable to assume that eliminating financial barriers to care will lead to a rise in health care utilization because use will increase in groups that previously could not afford care, a review of the implementation of universal health care in 13 capitalist countries revealed no or only small (less than 10%) post-implementation increases in overall health care use.[47] This finding was likely related to some diseases being treated earlier, when less intense utilization was required, as well as a shift in use of care from the wealthy to the poorest.[47]

Alternative Strategies States and the federal government can implement several alternative strategies to increase access to health care. However, these strategies are piecemeal responses, face legal challenges, and offer unreliable assurance for coverage. Importantly, these alternative strategies also do not necessarily or explicitly acknowledge health as a right.

State strategies: The remaining 14 states can adopt the Medicaid expansions in the ACA, and states that previously expanded can open new enrollment periods for their ACA marketplaces to encourage enrollment.[48] While this is a strategy to extend coverage to many of those left behind, frequent legal challenges to the ACA and Medicaid cuts make it an unreliable source of coverage in the future. In addition, although many people gained insurance, access to care remained challenging due to prohibitively priced premiums and direct costs.

Before the pandemic, the New York state legislature began exploring universal single-payer coverage, and the New Mexico legislature started considering a Medicaid buy-in option.[49] These systems would cover only residents of a particular state, and they remain susceptible to fluctuations in Medicaid cuts, state revenues, and business decisions of private contractors in the marketplace.

Federal government strategies: Congress can continue to pass legislation in the vein of the Families First Coronavirus Response Act and the CARES Act. These acts required all private insurers, Medicare, and Medicaid to cover COVID-19 testing, eliminate cost sharing, and set funds to cover testing for uninsured individuals. They fell short in requiring assistance with COVID-19 treatment. A strategy of incremental legislation to address the pandemic is highly susceptible to the political climate, is unreliable, and does not address non-COVID-19 health outcomes. Most importantly, this system perpetuates a fragmented response to the COVID-19 pandemic.

An additional option for the federal government is to cover the full costs of Medicaid expansion in the 14 states yet to expand coverage. If states increased expansion and enforced existing ACA regulations, nearly all Americans could gain health insurance.[50] This alternative is risky, however, due to frequent legal challenges to the ACA. Furthermore, high costs to access care would continue to exist.

Action Steps This statement reaffirms APHA’s support of the right to health through universal health care. Therefore, APHA:

• Urges Congress and the president to recognize universal health care as a right.
• Urges Congress to fund and design and the president to enact and implement a comprehensive universal health care system that is accessible and affordable for all residents; that ensures access to rural populations, people experiencing homelessness, sexual minority groups, those with disabilities, and marginalized populations; that is not dependent on employment, medical or mental health status, immigration status, or income; that emphasizes high-value, evidence-based care; that includes automatic and mandatory enrollment; and that minimizes administrative burden.
• Urges Congress and states to use the COVID-19 pandemic as a catalyst to develop an inclusive and comprehensive health care system that is resilient, equitable, and accessible.
• Urges the DHHS, the Agency for Healthcare Research and Quality, the Institute of Medicine, the National Institutes of Health, academic institutions, researchers, and think tanks to examine equitable access to health care, including provision of mental health care, long-term care, dental care, and vision care.
• Urges Congress, national health care leaders, academic institutions, hospitals, and each person living in the United States to recognize the harms caused by institutionalized racism in our health care system and collaborate to build a system that is equitable and just.
• Urges Congress to mandate the Federal Register Standards for Accessible Medical Diagnostic Equipment to meet the everyday health care physical access challenges of children and adults with disabilities.
• Urges national health care leaders to design a transition and implementation strategy that communicates the impact of a proposed universal health care system on individuals, hospitals, health care companies, health care workers, and communities.
• Urges Congress, the Centers for Disease Control and Prevention, the DHHS, and other public health partners, in light of the COVID-19 pandemic, to recognize the need for and supply adequate funding for a robust public health system. This public health system will prepare for, prevent, and respond to both imminent and long-term threats to public health, as previously supported in APHA Policy Statement 200911.

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Health Aff (Millwood). 2020;39(7):1253–1262. 20. Millett GA, Jones AT, Benkeser D, et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020;47:37–44. 21. Hado E, Komisar H. Long-term services and supports. Available at: https://www.aarp.org/ppi/info-2017/long-term-services-and-supports.html. Accessed September 1, 2020. 22. GenWorth Financial. Cost of care survey. Available at: https://www.genworth.com/aging-and-you/finances/cost-of-care.html. Accessed September 1, 2020. 23. American Public Health Association. Policy statement 201415: support for social determinants of behavioral health and pathways for integrated and better public health. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/28/14/58/support-for-social-determinants-of-behavioral-health. Accessed September 1, 2020. 24. UN General Assembly. Resolution adopted by the General Assembly on 10 October 2019—political declaration of the high-level meeting on universal health coverage. Available at: https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf. Accessed September 30, 2020. 25. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012;367(11):1025–1034. 26. Jones A. I left Norway’s lockdown for the US: the difference is shocking. Available at: https://www.thenation.com/article/world/coronavirus-norway-lockdown/. Accessed September 1, 2020. 27. Maizland L. Comparing six health-care systems in a pandemic. Available at: https://www.cfr.org/backgrounder/comparing-six-health-care-systems-pandemicX. Accessed August 20, 2020. 28. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA. 2020;323(14):1341–1342. 29. Gharib M. Universal health care supports Thailand’s coronavirus strategy. Available at: https://www.npr.org/2020/06/28/884458999/universal-health-care-supports-thailands-coronavirus-strategy. Accessed August 30, 2020. 30. Shone LP, Dick AW, Klein JD, Zwanziger J, Szilagyi PG. Reduction in racial and ethnic disparities after enrollment in the State Children’s Health Insurance Program. Pediatrics. 2005;115(6):e697–e705. 31. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007;298(24):2886–2894. 32. Rhee JC, Done N, Anderson GF. Considering long-term care insurance for middle-income countries: comparing South Korea with Japan and Germany. Health Policy. 2015;119(10):1319–1329. 33. Doty P, Nadash P, Racco N. Long-term care financing: lessons from France. Milbank Q. 2015;93(2):359–391. 34. Wen H, Druss BG, Cummings JR. Effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions. Health Serv Res. 2015;50(6):1787–1809. 35. Congressional Budget Office. Projections of federal spending on major health care programs. Available at: https://www.cbo.gov/system/files/115th-congress-2017-2018/presentation/53887-presentation.pdf. Accessed October 12, 2020. 36. Blahous C. The costs of a national single-payer healthcare system. Available at: https://www.mercatus.org/publications/government-spending/costs-national-single-payer-healthcare-system. Accessed October 10, 2020. 37. Galvani AP, Parpia AS, Foster EM, Singer BH, Fitzpatrick MC. Improving the prognosis of health care in the USA. Lancet. 2020;395(10223):524–533. 38. Friedman G. Funding HR 676: the Expanded and Improved Medicare for All Act. How we can afford a national single-payer health plan. Available at: https://www.pnhp.org/sites/default/files/Funding%20HR%20676_Friedman_7.31.13_proofed.pdf. Accessed September 15, 2020. 39. Organisation for Economic Co-operation and Development. Health expenditure and financing. Available at: https://stats.oecd.org/Index.aspx?ThemeTreeId=9. Accessed September 27, 2020. 40. Kurani N, Cox C. What drives health spending in the U.S. compared to other countries? Available at: https://www.healthsystemtracker.org/brief/what-drives-health-spending-in-the-u-s-compared-to-other-countries/. Accessed September 30, 2020. 41. Tollen L, Keating E, Weil A. How administrative spending contributes to excess US health spending. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200218.375060/abs/. Accessed August 30, 2020. 42. U.S. Government Accountability Office. Medicaid: states made multiple program changes, and beneficiaries generally reported access comparable to private insurance. Available at: https://www.gao.gov/assets/650/649788.pdf. Accessed August 30, 2020. 43. How Canada Compares: Results from the Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries. Ottawa, Ontario, Canada: Canadian Institute for Health Information; 2017. 44. Organisation for Economic Co-operation and Development. Deaths from cancer: total, per 100,000 persons, 2018 or latest available. Available at: https://data.oecd.org/healthstat/deaths-from-cancer.htm. Accessed October 12, 2020. 45. Hoffman B. Health Care for Some: Rights and Rationing in the United States since 1930. Chicago, IL: University of Chicago Press; 2012. 46. Kurani N, McDermott D, Shanosky N. How does the quality of the U.S. healthcare system compare to other countries? Available at: https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-start. Accessed September 20, 2020. 47. Gaffney A, Woolhandler S, Himmelstein D. The effect of large-scale health coverage expansions in wealthy nations on society-wide healthcare utilization. J Gen Intern Med. 2020;35(8):2406–2417. 48. King JS. COVID-19 and the need for health care reform. N Engl J Med. 2020;382(26):e104. 49. Hughes M. COVID-19 proves that we need universal health care. States are exploring their options. Available at: https://rooseveltinstitute.org/2020/06/25/covid-19-proves-that-we-need-universal-health-care-states-are-exploring-their-options/. Accessed September 1, 2020. 50. Blumenthal D, Fowler EJ, Abrams M, Collins SR. COVID-19—implications for the health care system. N Engl J Med. 2020;383(15):1483–1488.

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Point Turning Point: the Case for Universal Health Care

An argument that the COVID-19 pandemic might be the turning point for universal health care.

Why the U.S. Needs Universal Health Care

As we all grapple with our new reality, it's difficult to think of anything beyond the basics. How do we keep our families safe? Are we washing our hands enough ? Do we really have to sanitize the doorknobs and surfaces every day? How do we get our cats to stop videobombing our Zoom meetings? Do we have enough toilet paper?

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The more we read the headlines, the more we feel the need to do something, or at least say something. Change is happening – ready or not. Maybe talking about some of these important issues can lead to action that will help us steer out of this skid.

Historically, Americans have found ways to meet their circumstances with intention, moving in mass to make heretofore unimaginable change that has sustained and improved our lives to this day. The Great Depression lead to the creation of the New Deal and Social Security. The Triangle Shirtwaist Factory fire brought about change in labor conditions. The Cuyahoga River fire lead to the founding of the Environmental Protection Agency.

Could the COVID-19 pandemic be the turning point for universal health care? We can't think of a more propitious time. In the first two weeks of April, 5.2 million Americans filed for unemployment. Economists believe that 30% unemployment is possible by fall. For most Americans, our health care is tied to our employment, and because of this, millions of Americans are losing their health care just when they may need it the most. Economists predict that health insurance premiums will likely increase by 40% in the next year due to less payers and more who are in need of care and the eventual collapse of private health care insurance .

Our current circumstances have illustrated the need for universal health care in a way that is obvious and undeniable. Below we have listed the most frequent arguments in opposition followed by an evidence-based rebuttal.

1. Point: "Governments are wasteful and shouldn't be in charge of health care."

Counterpoint: In 2017, the U.S. spent twice as much on health care (17.1% of GDP) as comparable Organization for Economic Co-Operation and Development countries (OECD) (8.8% of GDP), all of whom have universal health care. The country with the second highest expenditure after the U.S. is Switzerland at 12.3%, nearly 5% less. Of all these countries, the U.S. has the highest portion of private insurance. In terms of dollars spent, the average per capita health care spending of OECD countries is $3,558, while in the U.S. it's $10,207 – nearly three times as costly.

Bottom line: Among industrialized countries with comparable levels of economic development, government-provided health care is much more efficient and more economical than the U.S. system of private insurance.

2. Point: "U.S. health care is superior to the care offered by countries with universal health care."

Counterpoint: According to the Commonwealth Health Fund , in the U.S., infant mortality is higher and the life span is shorter than among all comparable economies that provide universal health care. Maternal mortality in the U.S. is 30 per 100,000 births and 6.4 per 100,000 births on average in comparable countries, which is nearly five times worse.

In addition, the U.S. has the highest chronic disease burden (e.g., diabetes, hypertension) and an obesity rate that is two times higher than the OECD average. In part due to these neglected conditions, in comparison to comparable countries, the U.S. (as of 2016) had among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.

The Peterson-Kaiser Health System Tracker , which is a collaborative effort to monitor the quality and cost of U.S. health care, shows that among comparable countries with universal health care, mortality rate is lower across the board on everything from heart attacks to child birth. The U.S. also has higher rates of medical, medication and lab errors relative to similar countries with universal health care.

Bottom line: With our largely privately funded health care system, we are paying more than twice as much as other countries for worse outcomes.

3. Point: "Universal health care would be more expensive."

Counterpoint: The main reason U.S. health care costs are so high is because we don't have universal health care. Unlike other first world countries, the health care system in the U.S. is, to a great extent, run through a group of businesses. Pharmaceutical companies are businesses. Insurance companies are businesses. Hospital conglomerates are businesses. Even doctors' offices are businesses.

Businesses are driven to streamline and to cut costs because their primary goal is to make a profit. If they don't do this, they can't stay in business. It could mean that in the process of "streamlining," they would be tempted to cut costs by cutting care. Under the current system, a share of our health care dollars goes to dividends rather than to pay for care, hospitals are considered a "financial asset" rather than a public service entity and a large portion of their budgets are dedicated to marketing rather than patient care.

Given all these business expenses, it shouldn't be surprising that the business-oriented privately funded health care system we have is more expensive and less effective than a government provided universal system. In addition, for the health care system as a whole, universal health care would mean a massive paperwork reduction. A universal system would eliminate the need to deal with all the different insurance forms and the negotiations over provider limitations. As a result, this would eliminate a large expense for both doctors and hospitals.

The economist Robert Kuttner critiques the system this way: "For-profit chains … claim to increase efficiencies by centralizing administration, cutting waste, buying supplies in bulk at discounted rates, negotiating discounted fees with medical professionals, shifting to less wasteful forms of care and consolidating duplicative facilities." As he points out, "using that logic, the most efficient 'chain' of all is a universal national system."

Evidence to support these points can be found in a recent Yale University study that showed that single-payer Medicare For All would result in a 13% savings in national health-care expenditures. This would save the country $450 billion annually.

Bottom line: Universal health care would be less expensive overall, and an added benefit would be that health care decisions would be put in the hands of doctors rather than insurance companies, which have allegiances to shareholders instead of patient care.

4. Point: "I have to take care of my own family. I can't afford to worry about other people."

Counterpoint: It is in all of our best interests to take care of everyone. Aside from the fact that it is the compassionate and moral thing to do, viruses do not discriminate. When people don't have insurance, they won't go to the doctor unless they're gravely ill. Then, they're more likely to spread illness to you and your family members while they delay getting the care they need.

In addition, when people wait for care or don't get the prophylactic care then need, they end up in the emergency room worse off with more costly complications and requiring more resources than if they had been treated earlier. Taxpayers currently cover this cost. This affects everyone, insured or not. Why not prevent the delay upfront and make it easy for the patient to get treatment early and, as an added bonus, cost everyone less money?

In addition, the health of the economy impacts everyone. Healthy workers are essential to healthy businesses and thus a healthy economy. According to the Harvard School of Public Health , people who are able to maintain their health are more likely to spend their money on goods and services that drive the economy.

Bottom line: The health of others is relevant to the health of our families either through containment of infectious diseases such as COVID-19 or through the stability of the economy. Capitalism works best with a healthy workforce.

5. Point: "Entrepreneurship and innovation is what makes the U.S. a world leader."

Counterpoint: Imagine how many people in the U.S. could start their own businesses or bring their ideas to market if they didn't have to worry about maintaining health care for their families. So many people stay tethered to jobs they hate just so their family has health care. With workers not needing to stay in jobs they don't like in order to secure health insurance, universal healthcare would enable people to acquire jobs where they would be happier and more productive. Workers who wanted to start their own business could more easily do so, allowing them to enter the most creative and innovative part of our economy – small businesses.

In his book, "Everything for Sale," economist Robert Kuttner asserts that it's important to understand that businesses outside of the U.S. don't have to provide health care for their employees, which makes them more competitive. From a business point of view, American companies, released from the burden of paying employee insurance, would be more competitive internationally. They would also be more profitable as they wouldn't have to do all the paperwork and the negotiating involved with being the intermediary between employees and insurance companies.

Bottom line: Unburdening businesses from the responsibility of providing health insurance for their employees would increase competitiveness as well as encourage entrepreneurship and innovation, and allow small businesses room to thrive.

6. Point: "The wait times are too long in countries with universal health care."

Counterpoint: The wait times on average are no longer in countries with universal healthcare than they are in the U.S., according to the Peterson-Kaiser Health System Tracker . In some cases, the wait times are longer in the U.S., with insurance companies using valuable time with their requirements to obtain referrals and approvals for sometimes urgently needed treatments. On average, residents of Germany, France, UK, Australia, and the Netherlands reported shorter wait times relative to the U.S.

Bottom line: Wait times are longer in the U.S. when compared with many countries with a universal health care system.

7. Point: "My insurance is working just fine, so why change anything?"

Counterpoint: A comprehensive study conducted in 2018 found that 62% of bankruptcies are due to medical bills and, of those, 75% were insured at the time. Most people who have insurance are insufficiently covered and are one accident, cancer diagnosis or heart attack away from going bankrupt and losing everything. The U.S. is the only industrialized country in the world whose citizens go bankrupt due to medical bills. And, if you survive a serious illness and don't go bankrupt, you may end up buried in bills and paperwork from your insurance company and medical providers. All of this takes time and energy that would be better spent healing or caring for our loved ones. Besides, we don't need to abolish private health insurance. Some countries like Germany have a two-tiered system that provides basic non-profit care for all but also allows citizens to purchase premium plans through private companies.

Bottom line: Private insurance does not protect against medical bankruptcy, but universal health care does. The residents of countries with universal health care do not go bankrupt due to medical bills.

8. Point: "I don't worry about losing my insurance because if I lose my job, I can just get another one."

Counterpoint: We can't predict what will happen with the economy and whether another job will be available to us. This pandemic has proven that it can all go bad overnight. In addition, if you lose your job, there is less and less guarantee that you will find a new job that provides insurance . Providing insurance, because it is so expensive, has become an increasingly difficult thing for companies to do. Even if you're able to find a company that provides health care when you change jobs, you would be relying on your employer to choose your health plan. This means that the employee assumes that the company has his or her best interests in mind when making that choice, rather than prioritizing the bottom line for the benefit of the business. Even if they're not trying to maximize their profit, many companies have been forced to reduce the quality of the insurance they provide to their workers, simply out of the need to be more competitive or maintain solvency.

Bottom line: There are too many factors beyond our control (e.g., pandemic, disability, economic recession) to ensure anyone's employment and, thus, health care. Universal health care would guarantee basic care. Nobody would have to go without care due to a job loss, there would be greater control over costs and businesses would not have to fold due to the exorbitant and rising cost of providing health insurance to their employees.

9. Point: "Pharmaceutical companies need to charge so much because of research and development."

Counterpoint: It's usually not the pharmaceutical companies developing new drugs. They develop similar drugs that are variations on existing drugs, altered slightly so that they can claim a new patent. Or they buy out smaller companies that developed new drugs, thus minimizing their own R&D costs. Most commonly, they manufacture drugs developed under funding from the National Institutes of Health, and thus, the tax payers are the greatest funder of drug development via NIH grants provided to university labs.

Oddly, this investment in R&D does not appear to extend any discount to the tax payers themselves. In "The Deadly Costs of Insulin, " the author writes that insulin was developed in a university lab in 1936. In 1996, the cost of a vial of insulin was $21. Today, the cost of a vial of insulin could be as much as $500, causing some without insurance to risk their lives by rationing or going without. The cost of manufacturing the drug has not gone up during that time. So, what accounts for the huge increase in price? In " The Truth About Drug Companies ," the author demonstrates that drug companies use the bulk of their profits for advertising, not R&D or manufacturing. A universal health care system would not only not need to advertise, but would also be more effective at negotiating fair drug prices. Essentially, the government as a very large entity could negotiate price much more effectively as one large system with the government as the largest purchaser.

Bottom line: Taxpayers contribute most of the money that goes into drug development. Shouldn't they also reap some of the benefits of their contribution to R&D? Americans should not have to decide between their heart medication and putting food on the table when their tax dollars have paid for the development of many of these medications.

10. Point: "I don't want my taxes to go up."

Counterpoint: Health care costs and deductibles will go down to zero and more than compensate for any increase in taxes, and overall health care needs will be paid for, not just catastrophic health events. According to the New York Times , “…when an American family earns around $43,000, half of the average compensation when including cash wages plus employer payroll tax and premium contributions, 37% of that ends up going to taxes and health care premiums. In high-tax Finland, the same type of family pays 23% of their compensation in labor taxes, which includes taxes they pay to support universal health care. In France, it’s 2%. In the United Kingdom and Canada, it is less than 0% after government benefits.”

Bottom line: With a universal health care system, health care costs and deductibles will be eliminated and compensate for any increase in taxes.

11. Point: "I don't want to have to pay for health care for people making bad choices or to cover their pre-existing conditions."

Counterpoint: Many of the health problems on the pre-existing conditions list are common, genetically influenced and often unavoidable. One estimate indicates that up to 50% – half! – of all (non-elderly) adults have a pre-existing condition. Conditions on the list include anxiety, arthritis, asthma, cancer, depression, heart defect, menstrual irregularities, stroke and even pregnancy. With universal health care, no one would be denied coverage.

It's easy to assume that your health is under your control, until you get into an accident, are diagnosed with cancer or have a child born prematurely. All of a sudden, your own or your child's life may rely on health care that costs thousands or even millions of dollars. The health insurance that you once thought of as "good enough" may no longer suffice, bankruptcy may become unavoidable and you (or your child) will forever have a pre-existing condition. Some people may seem careless with their health, but who's to judge what an avoidable health problem is, vs. one that was beyond their control?

For the sake of argument, let's say that there are some folks in the mix who are engaging in poor health-related behaviors. Do we really want to withhold quality care from everyone because some don't take care of their health in the way we think they should? Extending that supposition, we would withhold public education just because not everyone takes it seriously.

Bottom line: In 2014, protections for pre-existing conditions were put in place under the Affordable Care Act. This protection is under continuous threat as insurance company profits are placed above patient care. Universal health care would ensure that everyone was eligible for care regardless of any conditions they may have.

And, if universal health care is so awful, why has every other first-world nation implemented it? These countries include: Australia, Austria, Bahrain, Belgium, Brunei, Canada, Cyprus, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Singapore, Slovenia, South Korea, Spain, Sweden, Switzerland, United Arab Emirates and the U.K.

Changing collective minds can seem impossible. But there is precedent. Once unimaginable large-scale change has happened in our lifetime (e.g. legalization of gay marriage, election of the first black president of the U.S. and the #MeToo movement), and support for universal health care has never been higher (71% in favor, according to a 2019 Hill-HarrisX survey ).

Point: As Chuck Pagano said, "If you don't have your health, you don't have anything."

Counterpoint: If good health is everything, why don't we vote as if our lives depended on it? This pandemic has taught us that it does.

Bottom line: Launching universal health care in the U.S. could be a silver lining in the dark cloud of this pandemic. Rather than pay lip service to what really matters, let's actually do something by putting our votes in service of what we really care about: the long-term physical and economic health of our families, our communities and our country.

Photos: Hospital Heroes

Tags: health insurance , health care , Coronavirus , pandemic , New Normal

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Winner of the 2023 Wakley Prize Essay: the importance of universal health coverage

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Taiwan’s path to universal health coverage—an essay by William C Hsiao

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• William C Hsiao , K T Li professor of economics , emeritus
• Harvard T H Chan School of Public Health, Boston, USA
• hsiao{at}hsph.harvard.edu

Who could pass up a chance to redesign a society’s healthcare system, no matter how challenging it may be? William C Hsiao describes how he responded

I was teaching economics at the Harvard School of Public Health when, in 1988, I received a surprising telephone call from the deputy chairman of the Taiwanese government’s planning commission. Could I come to Taiwan and lead a taskforce that was developing plans to provide access to affordable healthcare for the whole population? The task was daunting. Success would require a major revamping of Taiwan’s healthcare system, and the high level taskforce had been suffering from a lack of leadership.

Taiwan was then an emerging economy with 20 million people. Only 40% of its citizens were covered by social health insurance—civil servants and their families and employed workers but not their families. Private health insurance was almost non-existent. The social health insurance plans were run inefficiently by bureaucrats; providers were filing costly fraudulent claims; paying for care was a real challenge for most of the uninsured; and health costs were rising much faster than Taiwan’s high economic growth rate. The government didn’t have much tax revenue available or the technical expertise to overhaul its health system.

Nevertheless, I could see that Taiwan had already created some favourable conditions for universal health coverage (UHC). It was moving from an authoritarian state to a democracy, and the emerging grassroots opposition party was pushing for UHC. The government had asked the taskforce to plan a healthcare system with three clear goals: universal coverage with equal access to quality care, efficient use of health resources, and controlling the rise in health expenditure.

Taiwan had a strong central government with a powerful political elite that could make difficult decisions, and a fast growing economy that created larger economic capacity. Organised vested interest groups were weak because the previous authoritarian regime of the Kuomintang (KMT) Party discouraged them. And Taiwan’s tiny private health insurance industry was not a political force.

But I could see some severe challenges as well. Though most Taiwanese citizens perceived UHC as a benefit for them, they did not grasp that they would have to pay higher taxes or social insurance premiums. Meanwhile, most businesses opposed UHC because they feared the costs. The conservative wing of the ruling KMT party was opposing UHC for ideological reasons, and the governmental ministries and bureaucrats managing the existing plans that covered civil servants and employed workers strongly opposed UHC because they saw it as a threat to their power and influence. Physicians, hospitals, and pharmacies were worried that their incomes and profits would be reduced. Taiwan’s primary care largely consisted of private clinics that pursued profits by overprescribing and overtreating. How could UHC nudge these private physicians to alter their practice?

I took heart that the planning commission overseeing the planning of UHC included all the cabinet ministers that handled domestic affairs. The commission therefore had broad views and was not hindered by the narrow views of the Ministry of Health. Three weeks after the phone call, I arrived in Taiwan to become the chief adviser and chair of the taskforce.

Planning like a doctor

I initiated a planning approach that was based on the systematic process that physicians take with patients. We first diagnosed the causes of Taiwan’s major health problems with solid evidence, then we gathered the global knowledge and experience to treat these problems effectively, in a way that would work for the patient in front of us: Taiwan.

The diagnostic process required the taskforce to collect and analyse Taiwanese health and socioeconomic data as well as examine the historical development of Taiwan’s health system. Around 20 professionals collected and analysed the data and created a cost projection and financing model.

Taiwan had defaulted its financing and delivery of healthcare to the free market. As a result, it had a patchwork healthcare system. The quality of healthcare was highly varied. Some of the physicians and nurses were unqualified, and there was little quality assurance. Privately practising physicians charged high prices and made handsome profits from overprescribing. There was no effective constraint on health expenditure and no government regulations or market forces to encourage efficiency. Delivery of healthcare was fragmented, with separation of prevention, primary, and tertiary care. Government was responsible for prevention, and private clinics provided primary care. Inpatient hospital services and specialist services were a mixture of public, non-profit, and for-profit.

In 1989, we organised a three day international conference that commissioned papers and brought the top academic experts from the UK, US, Canada, Germany, and Japan to share the successes and failures of their health financing and delivery approaches with the taskforce and Taiwan’s top policy makers. Taskforce members also visited several countries to get a more in-depth understanding.

The taskforce had to tackle a broad question: the role of government versus private markets. Ideologies were debated and argued—sometimes heatedly. We organised several meetings with academics and politicians to debate this issue. Eventually, evidence convinced most people that the private market would not be able to achieve universal coverage or finance it, and that the sales and administrative expenses of private health insurance would be huge. Delivery of healthcare could be a mixture of government and private.

At the international conference, the tremendous advantages of a single payer system were brought out by Canadian and US experts. This information convinced the taskforce and leading policy makers to adopt a single payer approach.

Designing the benefit package was the greatest challenge. We knew we couldn’t reduce what some people already had. There were fundamental decisions about what should be covered—Prevention? Primary care? Long term care? Rehabilitation? Three areas were particularly controversial: dental care, eye care, and Chinese medicine. So we examined the cost and effectiveness of various services.

Meanwhile, many economists argued that health insurance created “moral hazard”—insurance providing free or reduced priced services and drugs induces some patients to demand more than they need medically. There was worldwide evidence for that. The economists therefore suggested co-payments, but some on the taskforce worried that co-payments, co-insurance, and deductibles would deter patients from seeking necessary preventive and medical services.

The taskforce also grappled with incentive systems to pay providers (that is, physicians and hospitals) to enhance efficiency and quality of healthcare. We were mindful that the existing fee-for-service payment method promotes increased expenditure. Better methods have been adopted by many advanced nations. There were some good options: capitation, salaried physicians, hospital global budget, bundled payment, and diagnosis related group payment for inpatient hospital services.

The taskforce developed a model to estimate the costs of different options in benefit coverage and payment methods. Next, we explored various methods of financing them and presented the options to the policy makers. Ultimately, what determined coverage were the costs and the estimated amount of financing required to sustain a plan over 10 years.

In 1989, once we had determined the causes of Taiwan’s major health problems, President Teng-hui Lee asked me to brief him every month. I also met regularly with several other leaders, including K T Li, a political leader from the moderate wing of the KMT. The business community was concerned about the cost of UHC and what it must pay. (It was eventually convinced by the argument that it would maintain the loyalty of workers in a tight labour market by offering health insurance that included family members.)

The planning commission organised public meetings for the taskforce to present our preliminary recommendations and obtain public feedback in 1990. We also presented a proposed plan to various legislative committees. We revised our recommendations based on the feedback, including adding Chinese traditional medicine to the benefit package.

We issued the final plan in 1990, called the national health insurance (NHI) plan. A new team was appointed in the Ministry of Health to flesh out the details of the plan, and the president began strongly pushing the Taiwanese legislature to pass the plan in 1993. As a result, the legislature made only modest revisions and passed it in 1994.

Taiwan’s NHI plan covers all citizens with a comprehensive set of services, including secondary prevention; all physician, inpatient, and rehabilitation services; Chinese traditional medicine; eye and hearing care; most dental care; and visiting nurses. But it doesn’t cover long term care in institutions. Patients must make modest co-payments for clinic visits and drugs, but the total amount any family must pay is capped each year. Employers, workers, and government each pay one third of the cost of employed workers’ insurance. The government pays the premiums for poor people and veterans as well as subsidies for workers in the informal sector. People can buy private insurance for services not covered by the plan such as cosmetic surgery, private hospital rooms, private nursing, and uncovered new expensive but less effective drugs.

A fundamental principle in controlling expenditure was established by Premier Chan Lien when he reviewed the taskforce’s report. The amount of NHI revenue determines the payment rates and amounts paid to healthcare providers. However, subsequent governments have been reluctant to raise the taxes or premiums, which put pressure on lowering the payment to providers. The NHI Administration, a quasi-government agency set up to oversee the plan, also established mechanisms to control the use of new expensive medical technology and drugs to moderate the pressure for expenditure increases.

The taskforce recommended that Taiwan reform its payment system to healthcare providers by introducing bundled payments and diagnosis related group payment methods as well as capitation. Moving away from a fee-for-service system would also reduce the incentive for increased usage induced by physicians. President Lee assured me he’d fight for the payment reforms, but in the end strong opposition from physicians stopped them. Taiwan continued to pay providers on a fee-for-service basis but with a point system to cap the total amount that would be paid out each year. This point system remains today.

The taskforce also recommended prioritisation of quality improvement. This included periodic recertification of hospitals, continuing education of physicians, and, most importantly, monitoring the quality of medical services and discipline the poor performers. However, the progress is slow.

At the recommendation of the taskforce, the government set up a board of directors for NHI which included representatives of payers and payees. Members negotiate what changes in benefits and payments the two sides can agree on, with “neutral” members, including academics, breaking any tied votes. This approach takes the government out of the middle.

Did it work?

Taiwan was fortunate to appoint a capable official to implement the plan, Dr Ching-chuan Yeh. He did a superb job. Since the plan came into effect in 1995 no major revisions have been made, except for financing. In 2012, the legislature added a new source of revenue: an earmarked tax on unearned income.

Now, the plan covers 99% of Taiwan’s citizens with comprehensive benefits; the remaining 1% reside overseas and did not enrol. 1 The health status of Taiwanese people continues to improve. Infant mortality is 4.3/1000 live births and life expectancy 81 years, 1 which is comparable with the UK and better than the US. Impoverishment caused by medical expenditure is minuscule. (That said, personal expenditure on long term care is substantial.) Patients have free choice of providers, with no gatekeeper. Almost all patients can access physician services within 24 hours. There are no long waits for specialty services, imaging, or laboratory tests. Health expenditure is well controlled, with the annual rate of increase in line with growth in gross domestic product (GDP). In 2016, Taiwan spent 6.3% of its GDP on health compared with the UK’s 9.7% or US’s 17.1%. 2

According to the government’s monthly poll, more than 70% of people are very satisfied or satisfied with Taiwan’s health system. 3 Nevertheless, there are media reports of some Taiwanese patients and physicians complaining that Taiwan is too slow in using the latest expensive medical technology and drugs. A comprehensive evaluation of NHI by the government found some specialists believe they are overworked and underpaid, which resulted in a shortage of physicians in these specialties. 4

Although there is no pressing political demand to improve Taiwan’s health system, there are latent problems. The plan is slightly underfunded because the government and the public are reluctant to impose higher tax or premium rates. Consequently, some provider complaints about inadequate revenues are legitimate. I would like to see the clinical quality of healthcare improved in Taiwan—a real challenge given that quality data are controlled by medical specialty societies that are mostly concerned about physicians’ earnings rather than assuring quality of care. Taiwan’s capped fee-for-service payment method impairs the prevention of non-communicable diseases. At the same time, it encourages providers to increase the number of services they provide, increasing health expenditure. Meanwhile, the organisation of Taiwan’s health system remains fragmented with the separation of primary care, specialist, and hospital care. As a result, Taiwan lacks continuity and integration of healthcare.

Taiwan’s experience in establishing and sustaining UHC shows the need for political determination, leadership, technical expertise, and data and that technical design must consider the political realities. 5 International knowledge, experience, and evidence played a major role in informing the design. Taiwan found it was easier to establish a new funding mechanism for UHC than to reform the payment and healthcare delivery system, which requires wide support from the captains of the medical ship: physicians, hospital directors, and nurses.

William C Hsiao has worked on health system design and reform in many developed and developing nations, most recently Malaysia, China, and South Africa. He received his PhD in economics from Harvard University and is a professor at the Harvard T H Chan School of Public Health. He has published more than 180 papers and several books and has advised international organisations, including the World Bank, World Health Organization, and the International Monetary Fund.

Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned; not externally peer reviewed.

• ↵ Taiwan Ministry of Health and Welfare. 2018 Taiwan health and welfare report. 2019. https://www.mohw.gov.tw/cp-137-47558-2.html
• ↵ WHO. Global health expenditure database. http://apps.who.int/nha/database
• ↵ Central Health Insurance Agency, Ministry of Health and Welfare. Public opinion surveys. https://www.nhi.gov.tw/Content_List.aspx?n=B25D8946F7648C14&topn=CDA985A80C0DE710
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Universal Health Care Coverage, Essay Example

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This paper posits to detail the requirements of universal health-care coverage policy to the citizens of America which has been a cause of a heated debate in the political landscape. The debate is attributed the challenges that have been associated with this policy with regard to the question of its need as a fundamental human right. The goals allied to the policy is the provision of systems of health among the citizens, contribution to the financial needs of the citizens to meet their health needs and offering an appropriate response to the anticipations of the population the policy also aims at achieving quality, generation of resources, financing and provide services of health care to the entire population (Appleby, 2007).

The policy has been a subject of some challenges with moist people who support it being for the argument that, the greater percentage of the population (up to 60%) can access insurance on health care under the funding of the government (Families USA, 2009).  Consequently, they perceive the policy as a replacement of the spending from individuals along with their employees on individual scope through their taxes. On the other hand, the people who oppose the policy argue along the lines of increased death rates which is attributed to waiting for extremely long periods for health care to be delivered. Other arguments highlight accessibility of high quality health care services on unequal footage in different parts aided with universal health care. A hot debate on the issue is anticipated to be ongoing.

The US Government has been cited as the only democratic government in the western world that do not have a universal health care system to protect its citizens.  This creates a tremendous strain on the disadvantaged groups and poor people in order to have adequate health care insurance. (White, 2011)

There is a high degree of public opinion in the USA that supports a universal health coverage system, similar to the NHS in the UK or the Medicare system in Canada.  Healthcare is considered a universal right of all citizens and not something that should only be for the wealthy or affluent members of society. There is also a need to assist those people with pre-existing conditions and not exclude them from treatment on pure financial grounds. (Families USA, 2009).  There seems little doubt that that the Health Care system in the USA is in need of a major policy reform if it is to meet the need of all of its Citizens and not just those with the ability to afford the high insurance premiums.  In times of recession this becomes even more vital to the less advantaged members of society.  (Jackson, 2010).

Issues of un-sustainability of the policy have been cited therefore a need for changes aimed at removing the dysfunctional conditions is imperative. As a result of the ever escalating costs and increasing inflation levels, a need for changes in the policy is inevitable in order to streamline the universal health-care coverage policy for the benefits of Americans (Donnelly, 2007).  The continued recycling of the ideas that have failed to work in the past is a continued violation of fundamental human rights. Standing on moral principles and giving respect to the human rights shall call for dismantling of the existing system and adopt the relevant changes

Families USA. (2009). About the Uninsured . Retrieved 9 29, 2011, from Families USA:             http://www.familiesusa.org/resources/publications/reports/health-reform/pre-existing-conditions.html

Jackson, D. (2010, 3 23). Obama signs health care bill generations have ‘hungered to see’. Retrieved 4 th October, 2011, from USA Today.

White, D. (2011). Pros & Cons of Government Healthcare. Retrieved 9 29, 2011, from About.com: http://usliberals.about.com/od/healthcare/i/GovHealthCare.htm

Appleby, J., ( 2007). “Health insurance premiums vault past inflation,” USA Today , September 11,

Donnelly, J., (2007). “47 million Americans are uninsured,” Boston Globe , August 29,

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The Sprinter Van’s Glamorous Turn

Famous actors, singers, athletes and housewives are fans of the Mercedes-Benz van, which has become a staple in streets outside events like the Met Gala.

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By Brett Berk

When Kendall Jenner attended the 2022 Met Gala in a Prada gown with an enormous flowing skirt , getting her to the Metropolitan Museum of Art required special transportation. A limousine would not do, nor would an SUV — walking in the dress was a challenge; sitting, impossible. The solution: Ms. Jenner would be driven, standing, in a Mercedes-Benz Sprinter van.

On the way to the event, as a way to relieve her anxiety about running late, Ms. Jenner relieved herself in an ice bucket while standing in the van. “Best decision I ever made,” she said of that moment in an episode of “The Kardashians” on Hulu.

The Sprinter van, a towering box on wheels with nearly six-and-a-half feet of headroom, is a direct descendant of the earliest motorized caravans developed by Karl Benz in 1896. (Some 30 years later, he and Gottlieb Daimler founded the Mercedes-Benz company.) The Sprinter, first released in Europe in 1995, started being sold domestically in 2010. Last year, Mercedes-Benz unveiled an electric version .

The van — which can be used to transport up to 15 passengers (or cargo ) — is appreciated by automotive enthusiasts for its build quality, reliability and versatility, as well as for the thrust and longevity of the diesel engine in most versions.

But other people have come to recognize the Sprinter for different reasons, among them its proximity to celebrities. The van has become a preferred mode of transportation for actors, singers, athletes and “Real Housewives,” and is now a staple in streets outside star-studded events like the Oscars and the Met Gala.

The vans have become so popular as transportation to the spring gala in New York that demand for them can outstrip the local supply. “Sprinters are being brought in from Los Angeles, Las Vegas, Miami,” said Etienne Haro, the general manager of the Mark Hotel on the Upper East Side of Manhattan, where many Met Gala guests spend time both before and after the main event.

In recent years, between 50 and 70 guests have traveled to the gala from the Mark, with about 40 to 50 of those people riding in Sprinters. Many of those vans are rented and driven by guests’ personal chauffeurs. On the day of the gala, the Mark has a team of about 30 people tracking vehicles’ locations to ensure their passengers arrive punctually, Mr. Haro said.

Sprinter riders often take advantage of the van’s roomy interior to ensure they also arrive looking flawless. “The entourage, glam team, stylist — everyone can hop in to put on the finishing touches,” Mr. Haro said.

But occasionally, he added, some Sprinter passengers have hit bumps in the road on their way to and from the gala.

“Getting out of a Sprinter with a voluminous gown and high heels can be challenging,” Mr. Haro said, noting one instance in which a Mark employee caught a Met Gala guest “in midair” as she was falling out of a van. He recalled another guest “whose dress was so intricate that she could not enter her vehicle.”

Though it bears Mercedes-Benz’s three-point-star logo, the Sprinter has an otherwise innocuous exterior that, for some famous fans, has as much appeal as its capacious interior.

“Our clients say, ‘The paparazzi are chasing us around; we don’t want to be in something that’s sticking out like a sore thumb, like a Rolls or a Bentley,” said Howard Becker, the founder of Becker Automotive Design in Southern California, which has customized Sprinter vans and other vehicles for people like the director Steven Spielberg, the actor Mark Wahlberg and the television host Steve Harvey.

“The Sprinter kind of fades in,” said Mr. Becker, 75.

The starting price for a diesel-engine van is about $50,000; electric Sprinters start at about $72,000. But models outfitted by Mr. Becker or by Gabi Mashal, whose Southern California company Bespoke Coach also customizes the vans, typically cost between $350,000 and $450,000.

Their distinctive features can include temperature-controlled, lie-flat seats with built-in massagers, secure internet routers, state-of-the-art stereo and video systems and onboard bathrooms for their owners.

“These people can’t use a public restroom,” said Mr. Mashal, 60, who has customized vans for the singer Mark Anthony and the boxer Floyd Mayweather Jr.

The Sprinter’s size and luxurious reputation are reasons it has replaced vehicles like limousines and SUVs as the rental transportation of choice on many versions of “The Real Housewives,” said Nate Green, an executive producer of “The Real Housewives of Miami.” He described the Sprinter as a friend of the “Housewives,” using a term given to supporting characters in the franchise who appear regularly in episodes.

Mr. Green said his show’s crew also favors Sprinters because the van’s cabin has enough room for camera operators to stand — and to film from several angles.

“This is really important,” Mr. Green said, “because ‘Housewives’ is sometimes more about the reaction than about the actual dialogue.”

Throughout the reality TV franchise’s 18 years on Bravo, Sprinter vans have been a place where housewives have drunkenly fallen down, signed divorce papers, passionately kissed co-stars, engaged in verbal spats and been approached by officers with the Department of Homeland Security.

“When people see a Sprinter van, they know that there’s going to be something that happens that’s going to be iconic,” said Lisa Shannon, an executive producer of the New York and Salt Lake City installments of “The Real Housewives,” as well as its “Ultimate Girls Trip” spinoff.

The Sprinter, while strongly associated with the “Housewives” franchise, has appeared in more than 4,000 movies and TV episodes . Like many tokens of pop culture, it has been imitated on “ The Simpsons ,” and it recently joined one of cinema’s most distinguishable automotive fleets: the vehicles in “Ghostbusters.”

In the series’s latest film, “Ghostbusters: Frozen Empire,” released in March, a new van called Ecto-Z — a black Sprinter outfitted with racks for proton packs — is featured alongside the tail-finned 1959 Cadillac ambulance known to many as the Ecto-1.

Eric Reich, an executive producer of “Ghostbusters: Frozen Empire,” said a Sprinter was chosen for the Ecto-Z role after Mercedes-Benz and Sony, the film’s distributor, had meetings to discuss product placement. He added that a Sprinter, like a Cadillac, made sense for transporting the Ghostbusters and their gear because both vehicles blend “luxury and function.”

That amalgamation has also made Sprinters popular among so-called vanlifers — people known for cavorting, traveling and sleeping in customized vans . Many of them document their lifestyles online, including Peter Holcombe , 51, who has spent much of the last decade living with his wife, Kathy, 50, and daughter, Abby, 19, in four Sprinter vans outfitted by the motor-home company Winnebago. (The Holcombes are brand ambassadors for Mercedes-Benz and Winnebago; they bought three of their vans at a discount.)

In their vans, the family has visited all 50 states, several national parks and 19 European countries. (Last year, Abby moved out of the family vehicle and into one of her own.) The Holcombes are currently driving what’s known as the Pan-American Highway , a network of roads that runs from Alaska to the southern tip of South America.

“We’ve done over 400,000 miles in Sprinters,” Mr. Holcombe said.

Wes Siler, a backcountry camper and a columnist for Outside magazine in Bozeman, Mont., is less of a fan.

Mr. Siler, 43, who camps out of a converted pickup truck, said the cost of buying and customizing a Sprinter for outdoor exploring is excessive for what he described as little more than a “poseur backdrop.”

“They’re cool on Instagram,” he said. “That’s, like, the entire story.”

But even Mr. Siler, who grew up in Europe, recognizes that the van has a certain appeal. He recalled getting to prom at his high school in London in a Sprinter that had been outfitted as a party bus.

“You couldn’t want a better limo,” he said.

Our Coverage of the 2024 Met Gala

Zendaya Makes Two Arrivals: The actress wore a second John Galliano design to make a late (re)entrance at the Met Gala . The first was a custom Maison Margiela couture dress he created specifically for her.

A Fitting Literary Inspiration: In 1962, J.G. Ballard published “The Garden of Time,” a short story about aristocrats overrun by “an immense rabble.” It was a fitting but ironic choice as this year’s  dress-code theme .

The Body Spectacle: The night saw Kim Kardashian engaged in a kind of body modification  via extreme corseting. While Tyla, the South African singer and songwriter, appeared coated in sand .

Arrests and Protests: As expected, protesters gathered near the Met Gala to protest the war in Gaza, creating an atmosphere far different  from the one inside the event.

The ‘Naked’ Trend: What better way to distinguish oneself  from hundreds of well-dressed competitors than to wear almost nothing at all?

A Night of Firsts: Here’s the story behind Rebecca Ferguson’s sequin, bird-covered dress , Da’Vine Joy Randolph’s all-denim look , Pamela Anderson’s new incarnation , Christian Cowan and Sam Smith’s debut as a couple , and Amanda Seyfried’s semi-recycled look .