[ Those beliefs are not evil but are stopping our healthcare
system from being universally accessible to all Americans.
Consequently, let’s examine how each assumption is challenged by how
our healthcare compares to other nations’ healthcare plans.]
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HOW AMERICAN CULTURAL ASSUMPTIONS KEEP US FROM HAVING UNIVERSAL
HEALTH CARE  
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Nick Licata
March 29, 2023
Counterpunch
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_ Those beliefs are not evil but are stopping our healthcare system
from being universally accessible to all Americans. Consequently,
let’s examine how each assumption is challenged by how our
healthcare compares to other nations’ healthcare plans. _

, Photo by Tim Cooper

 

American attitudes dissuade citizens from having a universal health
care system (UHC). Those beliefs have outweighed considering the
health benefits gained from providing affordable health coverage to
every citizen.

However, since the Affordable Care Act was passed, there has been
greater acceptance of moving our nation’s health standards to what
citizens enjoy in other economically developed democracies.  Still,
two beliefs continue to resist universal health care.

The first belief is that America is the greatest nation in the world,
and hence our health care is better than anywhere else. Second,
collecting taxes makes for a big government to interfere in people’s
private lives.

Those beliefs are not evil but are stopping our healthcare system from
being universally accessible to all Americans.  Consequently,
let’s examine how each assumption is challenged by how our
healthcare compares to other nations’ healthcare plans.

BEING THE GREATEST NATION HAS LIMITS

The belief that one’s country is a unique great nation is a
sentiment other nations have also possessed. Britain, Russia, Germany,
China, etc., sometimes believed they were the greatest. And each
declined as they limited what they were willing to learn from other
countries. We need not make that mistake.

We are the wealthiest nation in the world, measured by both GDP and
per capita GDP. Moreover, our federal military and health budgets are
roughly equal. However, compared to other developed democracies, our
military’s performance is unmatched, while our health care is
dismal.

Our politicians, for the most part, have shunned investigating how
other nations have surpassed us in delivering health care. As a
result, Americans are only aware of the difference from other
countries once they experience receiving health care elsewhere. Of
course, each person will have a different experience, but they will
all be starkly different from how they are treated in the US. For
example, you can read about the experience of two of my readers with
universal health care (UHC) in Italy and Germany here
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I invite others to submit their stories to me, and I’ll post them on
my website under the tab Resources.

MEASURING THE QUALITY OF A NATION’S HEALTH CARE

A nation’s cultural assumptions are dynamic in that political power
energizes them to achieve objectives that benefit those who wield
power. Nevertheless, despite this condition in other democracies,
their societies have adopted (UHC) despite resistance from their
established health industry. The results are evident when their health
systems are compared to the US as measured by three indexes: Medical
drug expenditures per capita, health expenditure per capita, and life
expectancy. The detail for each index follows.

COST OF MEDICAL DRUGS – A study on Retail Rx spending per capita
(1980–2015) showed that the US spent more than nine other
high-income nations of similar population sizes. For example,
Americans spent $1,011 annually, while Australia, Canada, France,
Germany, and the United Kingdom spent considerably less. Germany came
the closest to the US, spending $686 a year.

Findings concluded that Americans consume similar amounts of drugs as
people in other countries, so the high US cost was not due to our
greater demand.

HEALTH EXPENDITURE PER CAPITA – The data is expressed
in Purchasing power parities (PPPs) which equalize the purchasing
power of different currencies. In 2021, the US had the
highest expenditure at $12.3 thousand. This amount includes both
public and private expenditures.

Of the nine other comparable developed democracies, seven in Europe
and two in Asia, Germany, at $7.4 thousand, had the next highest per
capita ranking. All the other countries had per capita amounts that
ranged from six to four thousand dollars per capita.

LIFE EXPECTANCY – In the US, the average life expectancy is 79.11
years,
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ranks at #46 out of 149 countries based on the latest _United
Nations Population Division_ estimates. We rank last among
economically developed democracies. On average, citizens in the three
nations with our closest cultural heritage, Canada, England, and
Australia, live five years longer than Americans.

Although the public may need to become more familiar with these
metrics, a 2019 survey by Statista revealed that only 33% of
Americans were satisfied
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our national health system. Compared to other economically
developeddemocracies, the UK ranked highest with 53% satisfied,
followed by Australia, France, Canada, Spain, Germany, South Korea,
Japan, Italy, and the US. The Statista survey also showed that 43% of
Americans were dissatisfied with our health system.

THE FEAR OF BIG GOVERNMENT IS HURTING US.

Republican President Ronald Reagan gets credit for the best quote
about fearing Big Government when he said, _“The nine most
terrifying words in the English language are: I’m from the
Government, and I’m here to help. “_

Since 1980, Republicans have opposed tax increases for expanding
Medicare and Medicaid and enacting ACA. Providing more health care is
a precursor to producing a big government with more bureaucracy and
poorer service. Most countries with effective and affordable UHC
heavily fund it through taxes. Tax-financed expenditures as a
percentage of US national health expenditures were 65.7 % in 2020.
That is in the high range for comparable nations but not unusual.

However, our private per capita health expenditure is the highest of
all of them
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It is 17% higher than what citizens spend in Australia, Canada, and
South Korea, which spend the following highest amounts per capita. US
tax dollars do not offset out-of-pocket costs that individuals must
pay for health coverage, while citizens in nations providing UHC pay
less out-of-pocket expenses. This discrepancy is not a problem of a
big government; it is a problem of how our tax dollars are spent.

Nevertheless, a note of caution is necessary. First, of course, a
national government must be involved in the planning or delivery of
health services. However, a government declaring total coverage does
not guarantee good health care. For instance, Brazil is the only
country where any individual is eligible to receive free healthcare
with no previous application. Consequently, one would expect them to
have a health care system with the most satisfied citizens. But
that’s not so.

Brazil is ranked 63 among nations in providing a sound quality health
system. Meanwhile, the US is ranked 30 by the CEOWORLD MAGAZINE
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Care Index. Also, 63% of Brazilians are dissatisfied with their health
care system, a far higher percentage than Americans are dissatisfied
with ours. Therefore, government involvement is critical for achieving
an efficient UHC, but only if it is one of many. Comparable countries
to the US with UHC involve private companies, hospitals, physicians,
and non-profit organizations in some capacity of service delivery,
cost sharing, and planning.

HOW UHC FUNCTIONS IN OTHER NATIONS

All nations implementing universal health care (UCF) do so through
regulation and taxation. The legislation directs what kind of care
must be provided, subject to the ability to make a co-payment for a
minimum amount for service or medications.

The following is a brief sampling of how comparable nations to the US
have consistently rated among the top dozen nations providing the best
health care to their citizens (Australia, Canada, France, Germany,
Italy, Japan, Spain, and the United Kingdom’s England).

In looking across multiple nations, UHC can be described by how they
address four common elements: Funding source, health costs, coverage
provided, and how services are delivered. Remember that health plans
reflect conditions over the past few years. Countries continuously
adjust their plans as political and economic conditions impact the
health of their citizens.

FUNDING SOURCE 

All the comparable countries have some national healthcare insurance
that receives substantial tax revenue. That revenue comes
from central and local governments through income, sales, and
corporate taxes. Some have specific levies for national health
insurance, like Australia, which has a 2% levy and a surcharge for
people over 35 that don’t have private health insurance. Exemptions
and reductions are available for low-income Australian earners.

Businesses in most of this sampling also pick up a significant portion
of healthcare costs for their employees. For instance,
German employers pay for half of their employees’ health insurance
contributions, while self-employed workers pay the entire contribution
themselves with some exceptions.

HEALTH COSTS

One of the critical tools employed is the government regulating health
costs for medical procedures and prescription medicines and not
leaving the profit-oriented marketplace to determine prices.

Japan has used a national uniform fee schedule for reimbursing health
providers for decades. Canada determines physician fees through
periodic negotiations between the ministry and provincial medical
associations (the Canadian version of the American Medical
Association). France sets the insurance premium levels to be charged
related to income and determines the prices of goods and services
refunded.

By the government influencing the costs, it can insert community
social goals, such as access to health care based on need. For
example, Germany calculates individual health insurance premiums
based on income and not age or the number of dependents. Australia
made hospitalization free for permanent residents; in France, only
3.7% of hospital treatment costs are reimbursed through private
insurance.

COVERAGE PROVIDED

Although these nations commit to providing affordable healthcare, it
is not free of requiring copayments. For instance, the national
insurance plans in Canada and Japan cover 70 percent of the costs.
However, in the case of Canada, the 30 percent typically relates to
services not covered or only partially covered by their national
insurance, such as prescription drugs, eye care, and dentistry.

In Japan, the individual contribution percentage could drop to 10 or
20 percent, depending on the family’s income and the insured’s
age. Seniors who are covered by Japan’s national Senior Insurance
plan only pay 10% out of pocket.

While some of these eight nations have no-cost emergency medicine and
general doctor visits, individual co-pays are common in all the
countries. Often it does not apply to public health needs; instead, it
applies to specialties like dental and eye work. Italy has a small
parallel private healthcare system specializing in dentistry
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needs.

Even with universal health coverage, some items still need to be
covered. For instance, Australia does not cover the cost of ambulance
services, most dental care, glasses, contact lenses, or hearing aids.
However, most of these are covered by state and territory governments
or under private health insurance.

HOW SERVICES ARE DELIVERED

Surprisingly nations adopting UHC have not created large central
bureaucracies. As a result, the decision-making and delivery of
services are more decentralized than expected.

In the UK, which has one of the most extensive UHCs, responsibility is
divided among geographical areas through strategic health authorities
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And within each of the UK’s states (England, Scotland, Wales, and
Northern Ireland), their legislatures make changes that address their
citizens’ concerns.

Italy permits considerable variation in the quality and outcomes of
care by region. For example, when measured at their Local Health
Authority level, the results varied between 5% and more than 60%.
And Australia’s state and territory governments regulate and
administer the significant elements of healthcare, such as doctors,
public hospitals, and ambulance services.

Germany has a unique arrangement where the Federal Joint Committee
executes its healthcare system, making binding regulations and routine
decisions. The Committee consists of representatives of public health
insurance, hospitals, doctors, and dentists and three impartial
members. In addition, on a local level, regional groups of sickness
funds negotiate with regional doctors’ and dentists’ associations
for payment for ambulatory and dental care.

Canada has a single payer system operated by a third-party payer
responsible for paying health care providers for medical services. The
government generally doesn’t own hospitals or employ doctors
directly, and health services are delivered through provincial and
territorial systems.

Each nation has a different way of planning and delivering health
services. But they all manage to provide health coverage more
cost-effectively and equitably than what the US is accomplishing.

TO MOVE FORWARD, WE MUST QUESTION OUR ASSUMPTIONS.

President Biden said, in a New York Times guest editorial, that “he
will make Medicare “solvent beyond 2050 without cutting a penny in
benefits.” Biden knows that adults 65 and older with Medicare
coverage (94%) report being very satisfied or satisfied with the
quality of their medical care and the availability of specialists.

Conservatives and portions of the health industry are attacking his
suggestion to raise funds through fees and taxes. They are tapping
into two cultural assumptions hindering America from moving forward:
taxes produce a big ineffective government, and America has nothing
essential to learn from other nations.

Opponents of Biden’s plan fear a more significant trend, support
for a public health insurance option now winning over 80% of
Democrats and 56% of Republicans. Having the opportunity to choose
public or private insurance is one of the critical elements of the
comparable nations’ universal health care plans.

Biden needs to use his executive authority to begin a year-long
process to evaluate how other developed democracies serve their
citizens’ health needs compared to what we are providing to ours. He
should invite both houses to pursue this effort with him. He should
also reach out to health medical professionals and providers.

This discussion must be debated openly, not with ominous predictions
or utopian promises, but with facts gathered from the leaders and
users of UHC in other nations. Let them explain how it works to our
citizens. Let them talk not just in DC but in forums around the US.

Those forums should be held in at least the seven states
that approved Medicaid expansion by ballot measure, Idaho, Maine,
Missouri, Nebraska, Oklahoma, South Dakota, and Utah. They should also
appear in Florida and Wyoming, the only remaining states that have
rejected expanding Medicaid but can expand it by ballot initiative.
All these states except Maine voted for Donald Trump in 2020, who
campaigned to eliminate ACA.

The US will never adopt UCF, Medicare for All plan, or a public
insurance option until Senators and Congressional Representatives from
those and similar red states are pushed to support it by their
residents. Until then, Congressional Republicans will block the
creation of any national health insurance plan.

_Nick Licata is author of_ Becoming A Citizen Activist,
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served 5 terms on the Seattle City Council, named progressive
municipal official of the year by The Nation, and is founding board
chair of Local Progress, a national network of 1,000 progressive
municipal officials._

* Universal Health Care
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* cultural bias
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* healthcare outcomes
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