As the United States Supreme Court upholds the Affordable Care Act’s mandate requiring all Americans to have health insurance, the U.S. falls in line with dozens of other countries that have recently begun moving toward universal health coverage.
Worldwide, countries that were once considered universal-health “blind spots,” such as India and South Africa, are developing systems that provide access to medical care for nearly all of their citizens, according to Yanzhong Huang, a senior fellow at the Council on Foreign Relations, writing for the Yale Center for the Study of Globalization.
In light of the Supreme Court’s decision, here’s a look at how other countries have grappled with the expensive and persistent problem of universal access to medical care -- with varying degrees of success:
Singapore and South Korea were considered “1990s miracles,” said Laurie Garrett, a senior fellow at the Council on Foreign Relations. Singapore has the advantage of a tiny population, a high per-capita income and few immigration issues. It relies on mandatory health savings accounts, price transparency among health-care providers and incentives to choose less-expensive options. (For example, a patient who chooses an open hospital ward may get a larger government subsidy than one who chooses a more comfortable, closed ward, according to Tim Hartford, who reviewed the country’s health care system for his book, The Undercover Economist.)
Each country that seeks to expand health coverage has its reasons: For some, it’s a social justice issue. For others, it’s a way to cope with a rapidly aging population or an attempt to curb the spread of communicable diseases. Then there’s the fact that government involvement in health care simply isn’t as taboo elsewhere as it is in the U.S.:
“Universal health coverage is not a controversial topic in other countries,” said Gina Lagomarsino, a managing director at the Results for Development Institute. “I have one colleague who said it’s like motherhood and apple pie in most parts of the world. There is some debate about how you get there, though.”
Most of Latin America is on track to reach universal health coverage within a few years, according to Garrett and two other public health scholars, who wrote a 2009 Lancet piece on the subject.
Colombia initially created two health-care systems -- a subsidized version for poorer citizens and a contribution-based one for richer ones. As it attempted to unify the two systems, it categorized people into priority levels, such as pregnant women and the elderly, and created caps on enrollment based on the categories, according to Lagomarsino.
Then there’s Brazil, where half the population had no health coverage in 1988. Now, more than 75 percent of the country’s people rely exclusively on the government system for their health-care coverage,. according to a 2010 World Health Organization bulletin. Inadequate funds and staffing shortages have plagued the system from the start, but still, “infant mortality has decreased from 46 per 1000 live births in 1990 to 18 per 1000 live births in 2008,” the WHO wrote.
South Africa has provided free primary health services for its population for years, but good-quality care has largely been attainable only by the country’s rich minority, who could afford private doctors. This year, the government rolled out a universal health plan, which requires everyone who earns above a certain income to contribute to a fund to cover medical care. The plan has slogged through financing issues, but the government hopes to fully implement it by 2025, according to Reuters.
Beginning in the early 2000s, the Rwandan system called “Mutuelles” combined government financing and individual payments of $2 per year to achieve coverage levels of about 90 percent, according to the Yale study. But because Rwanda is a poor nation with a history of chronic diseases, foreign donors pick up the tab for many of those who can’t afford the premiums. And, as a 2010 New York Times article points out, it’s a no-frills experience: A maternity ward contains “padded benches with stir-ups” and MRIs and dialysis machines are practically nonexistent.
Thailand extended its public health-care system in 2002, granting coverage to 18 million people who were previously uninsured, according to a 2010 WHO report, but it excluded coverage for dialysis and kidney transplants because officials felt those procedures would excessively strain the system.
After a public campaign by the advocacy group Thai Kidney Club, renal-replacement therapy was added to the Thai health system in 2008. Unfortunately, the public health officials were right, and soon renal-replacement treatments had soaked up $76 million of the country’s $3.26 billion health budget. The National Health Security Office then tried “to reduce some costs by encouraging patients to perform their own peritoneal dialysis at home,” the WHO reported, by periodically filtering their own blood. In a less gruesome measure, they’re also encouraging people to lead healthier lifestyles so they won’t contract kidney diseases in the first place.
China and India have also taken steps to give their massive populations regular access to medical care, but the two countries have a tough road because they are highly diverse and have huge income gaps.
“It would be a little early to judge them; they have the biggest struggles,” Garrett said.
China once had an extensive system of state-owned public health-care facilities, but as government subsidies began to wane in the past few decades, “public hospitals began to operate like they were in the free market,” Lagomarsino said. The government tried capping prices on medical services, but that only encouraged doctors to eschew inexpensive treatments in favor of high-tech procedures.
The country is now attempting to reconcile its patchwork of health plans, and it’s close to completing a $124 billion project that aims to insure 90 percent of the nation’s residents, according to a recent LA Times report.
In India, the RSBY system, which was started in 2008, has given 100 million people who live below the poverty line access to public and private hospitals. While there have been some quality-control issues, Lagomarsino said, it does have two characteristics that would make any American health-insurance consumer salivate:
It’s completely paperless -- people carry smart-cards that pay providers automatically --- and costs just 60 cents to enroll in.
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