essay on universal healthcare system

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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• Universal Health Care

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

• Policy Statements and Advocacy
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• 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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Available at: https://www.commonwealthfund.org/publications/issue-briefs/2018/mar/americans-views-health-insurance-end-turbulent-year. Accessed August 28, 2020. 6. Tolbert J, Orgera K, Singer N, Damico A. Key facts about the uninsured population. Available at: https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/. Accessed September 12, 2020. 7. Banthin J, Simpson M, Buettgens M, Blumberg LJ, Wang R. Changes in health insurance coverage due to the COVID-19 recession. Available at: https://www.urban.org/research/publication/changes-health-insurance-coverage-due-covid-19-recession. Accessed September 30, 2020. 8. Gaffney AW, Himmelstein DU, McCormick D, Woolhandler S. Health and social precarity among Americans receiving unemployment benefits during the COVID-19 outbreak. J Gen Intern Med. 2020;35(11):3416–3419. 9. Lutfiyya MN, Gross AJ, Soffe B, Lipsky MS. Dental care utilization: examining the associations between health services deficits and not having a dental visit in the past 12 months. BMC Public Health. 2019;19(1):265. 10. Rudowitz R, Hinton, E. Early look at Medicaid spending and enrollment trends amid COVID-19. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/early-look-at-medicaid-spending-and-enrollment-trends-amid-covid-19/. Accessed August 14, 2020. 11. Roubein R, Goldberg D. States cut Medicaid as millions of jobless workers look to safety net. Available at: https://www.politico.com/news/2020/05/05/states-cut-medicaid-programs-239208. Accessed August 14, 2020. 12. Garfield R, Claxton G, Damico A, Levitt L. Eligibility for ACA health coverage following job loss. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/eligibility-for-aca-health-coverage-following-job-loss/. Accessed August 14, 2020. 13. U.S. Department of Health and Human Services. Renewal of determination that a public health emergency exists. Available at: https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx. Accessed September 30, 2020. 14. Rudowitz RC, Garfield R. How much fiscal relief can states expect from the temporary increase in the Medicaid FMAP? Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-fiscal-relief-can-states-expect-from-the-temporary-increase-in-the-medicaid-fmap/. Accessed August 14, 2020. 15. Downs J. Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction. New York, NY: Oxford University Press; 2015. 16. Schwartz K, Damico A. Distribution of CARES Act funding among hospitals. Available at: https://www.kff.org/health-costs/issue-brief/distribution-of-cares-act-funding-among-hospitals/?utm_campaign=KFF-2020-Health-Costs&utm_source=hs_email&utm_medium=email&utm_content=2&_hsenc=p2ANqtz-_NBOAd_787Yk73Ach1gaH-KDgGLsgoe4vPuqKuidkHwExyNBpENTaB_1ofCIpXrzNoNCx8ACiem-YqMKAF8-6Zv7xDXw&_hsmi=2. Accessed August 15, 2020. 17. Rader B, Astley CM, Sy KTL, et al. Geographic access to United States SARS-CoV-2 testing sites highlights healthcare disparities and may bias transmission estimates. J Travel Med. 2020;27(7):taaa076. 18. Artiga S, Garfield R, Orgera K. Communities of color at higher risk for health and economic challenges due to COVID-19. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/. Accessed August 14, 2020. 19. Azar K, Shen Z, Romanelli R, et al. Disparities in outcomes among COVID-19 patients in a large health care system in California. 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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Dylan Scott answers 9 key questions about universal health care around the world

Vox policy reporter Dylan Scott traveled to Taiwan, Australia, and the Netherlands to see their health systems.

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Vox policy reporter Dylan Scott traveled the world last fall to explore what the US can learn from other countries’ health systems , visiting Taiwan, Australia, and the Netherlands. His trips were the foundation for Everybody Covered , a Vox series on health care that also reported on health systems in the United Kingdom and Maryland .

Dylan did a Reddit Ask Me Anything session on Wednesday, January 29, discussing everything from how countries pay for universal health care to what it will take to achieve further health care reform in America. Here’s a roundup of some of the most interesting questions and answers, lightly edited for clarity.

1) How do countries pay for public health insurance?

Icantnotthink: Where does the payment for public health care come from in other countries?

Dylan: Most of these countries use some mix of 1) payroll taxes for individuals, 2) employer contributions, and 3) general government revenue and progressive/sin taxes. To be honest, there isn’t one model to follow. Each country had its own health funding plan that has since been reformed to meet the needs of their current system, just as the US would. But other countries are looking for health care dollars in many of the same places Medicare-for-all supporters think we should here.

2) When it comes to covering everyone, is a country’s population density important?

Verybalnduser: How important would you say a country’s population density is to keeping total cost down?

Dylan Scott: It’s a huge asset. Taiwan has been able to keep its overall spending low — people on the left would say their single-payer program is actually underfunded — and cost sharing low for patients in large part because its urbanized nature makes it easier for a smaller workforce to meet the needs of its patient population. The Netherlands has been very innovative in delivery reforms, meant to keep costs in check, something that’s clearly been aided by its density. Australia , on the other hand, even with a universal public insurance plan, has still struggled with access in its more rural areas.

3) Is there a lot of paperwork in a single-payer system?

ZenBacle: How much paperwork do patients in single-payer systems have to fill out? And how much time do those patients have to spend fighting with health care providers to get them to honor their coverage?

Dylan Scott: One of the benefits of single-payer is there’s a lot less administration. We visited a hospital in Taipei, Taiwan, and while all the clinic lobbies were full, the cashier’s desk was basically empty. One survey finding that stuck out to me showed the doctors in the Netherlands (with private insurance) are more annoyed about paperwork than their peers in more socialized systems. So while I wouldn’t want to try to quantify it off the top of my head, there seems to be less of a paperwork headache.

Everybody Covered

What the US can learn from other countries’ health systems

• Taiwan’s single-payer success story — and its lessons for America
• Two sisters. Two different journeys through Australia’s health care system.
• The Netherlands has universal health insurance — and it’s all private
• The answer to America’s health care cost problem might be in Maryland
• In the UK’s health system, rationing isn’t a dirty word

4) Between Taiwan, Australia, and the Netherlands, which policy would translate most easily to the US?

Doctor_YOOOOU: Which of these universal health care systems is “closest” in terms of the amount of reform required to the United States?

Dylan: This is a tricky one — no country looks much like the US status quo. The Netherlands does have a lot of the same features as Obamacare (ban on preexisting conditions, individual mandate, government assistance to cover the costs), but it’s available to everybody and it’s stricter. The mandate penalty is harsher, the government rules on cost sharing are more stringent, and the government actually helps set prices and an overall budget for health care. So it’s much more involved than the US government is in administering that private health insurance. And almost all of the insurers are nonprofits.

So we’re talking about huge changes to move the US system to something that looks more like the Dutch — and that’s one I’d name as closest (along with Japan) to what we have right now.

5) Do solutions exist within the US that can be applied to the rest of the country?

Blakestonefeather: You traveled the world to explore what the US can learn, but did you also travel the US to learn if the US can learn? [In other words,] what are the barriers we in America face to learning/being able to learn?

Dylan Scott: We actually did one story in the US, on Maryland’s unique system for paying hospitals . (Every insurer — private, Medicare and Medicaid — pays the same rates for the same services.)

But there is a huge challenge in translating policies from abroad to the US. Taiwan and Australia have about the same population as Texas, but Taiwan’s is contained to a tiny island off the coast of China and Australia is a continent. The Netherlands is one of the most densely populated countries in the world; the United States is one of the least.

Then you’ve got political differences; Princeton economist Uwe Reinhardt famously didn’t believe single-payer could work in the US, not because it’s not a good idea but because the government was too beholden to corporate interests. The recent failure of surprise billing legislation in Congress in the face of industry opposition is certainly a warning sign to any aspiring reformers.

So the dissatisfying answer to “so what can the US learn from these other countries’ successes?” is: It’s complicated. But my hope for this series is it would speak to the kinds of values and strategies, if less the specific policies, that are necessary to achieve universal health care.

6) What does the American health care system get right?

taksark: What’s something good about the American health care system that could be kept and improved on in a better version?

Dylan Scott: The geographic immensity of the US has forced a lot of experimentation with telemedicine, and that is both a necessity and an area where other countries have tried to draw from what the US has done. I heard a lot from doctors about coming to the US to learn the latest on best practices for delivering care.

I think the US is still seen as a leader in innovative medicine — the question is why can’t we give more people access to it?

7) Besides America, what other countries have private health insurance?

To_Much_Too_Soon: How many other countries besides America have private health insurance?

Dylan: The US relies much more on private health insurance than any other country I’m aware of. About half of US citizens depend on private insurance as their primary coverage, and about 8 percent of our GDP is private health spending; most other developed economies don’t top 4 percent of GDP for private spending.

There are countries like the Netherlands with universal private insurance. But their private insurance is a lot different than ours: Almost all of the insurers are nonprofits, the government sets rules about premiums and cost sharing, there is a global budget for health care costs, etc.

Some countries with single-payer programs, like Australia, allow private insurance as a supplement — so you can get more choice in doctor or can skip the line for surgery. But no developed economy I know of is so dependent on private insurance as the US and with comparatively few regulations about its benefits.

8) What surprised you the most throughout your reporting?

JoseyGunner: What shocked you the most during your travels?

Dylan Scott: I was surprised how often people I talked to were shocked by the worst parts of US health care. The uninsured rates, the deductibles we have to pay, the very idea of a surprise medical bill — all of it was unfathomable to many of the people I met.

9) What are the biggest hurdles to any future health reforms in the US?

Flogopickles: What do you see as America’s biggest hurdle to achieving any sort of movement in affordable care for our citizens?

Dylan Scott: The status quo is powerful for two reasons: One, it’s good enough for enough people that big change feels like a risky proposition to a lot of the population and, two, health industry interests are so influential in Washington, DC. Overcoming those two things — people’s inherent aversion to risk in health care and the power of industry to constrain policymaking, especially price constraints for medical care — are the biggest hurdles to any future health reforms.

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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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Canada's universal health-care system: achieving its potential

Danielle martin.

a Women's College Hospital and Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

b Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

Ashley P Miller

c Division of General Internal Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada

Amélie Quesnel-Vallée

d McGill Observatory on Health and Social Services Reforms, Department of Epidemiology, Biostatistics and Occupational Health, and Department of Sociology, McGill University, Montréal, QC, Canada

Nadine R Caron

e Department of Surgery, Northern Medical Program and Centre for Excellence in Indigenous Health, University of British Columbia, Prince George, BC, Canada

Bilkis Vissandjée

f School of Nursing and Public Health Research Institute, Université de Montréal, SHERPA Research Centre, Montréal, QC, Canada

Gregory P Marchildon

g Johnson-Shoyama Graduate School of Public Policy, University of Regina, Regina, SK, Canada

Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicare's founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity.

This is the first in a Series of two papers about Canada's health system and global health leadership

Introduction

Founded on Indigenous lands and the product of Confederation that united former British colonies in 1867, Canada is a complex project. 36 million people from a rich diversity of ethnocultural backgrounds live on a vast geography bounded by the Arctic, Pacific, and Atlantic Oceans, across six time zones and eight distinct climate regions.

Canada is among the world's most devolved federations, with substantial political power and policy responsibility held by its ten provinces and three territories. The province of Quebec, with its unique French-speaking linguistic and cultural context, often charts a policy path that is independent from the rest of the country. 1 The decentralisation of the Canadian polity is expressed in its health-care system—known as Medicare—which is not a national system per se, but rather a collection of provincial and territorial health insurance plans subject to national standards. 2 , 3 These taxation-based, publicly funded, universal programmes cover core medical and hospital services for all eligible Canadians, and are free at the point of care ( figure 1 ).

Overview of the Canadian health system

Adapted from 2 , 3 .

To Canadians, the notion that access to health care should be based on need, not ability to pay, is a defining national value. This value survives despite a shared border with the USA, which has the most expensive and inequitable health-care system in the developed world. 4

Canadian Medicare is more than a set of public insurance plans: more than 90% of Canadians view it as an important source of collective pride. 5 This pride points to an implicit social contract between governments, health-care providers, and the public—one that demands a shared and ongoing commitment to equity and solidarity. 6 Such a commitment is inevitably challenged in each generation by an array of external shocks and internal problems. Currently, wait times for elective care, inequitable access to health services in both the public and private systems, and the urgent need to address health disparities for Indigenous Canadians threaten this equity and solidarity.

In this first paper of a two-part Series on Canada's health system and global health leadership, 7 we analyse the unique history and features of the Canadian health-care system and consider the key factors challenging domestic policy makers and the system's potential to be a model for the world. We then propose a renewal of the tripartite social contract in service of accessible, affordable, high-quality care for all residents of Canada in the decades to come.

Key messages

• • Canada's universal, publicly funded health-care system—known as Medicare—is a source of national pride, and a model of universal health coverage. It provides relatively equitable access to physician and hospital services through 13 provincial and territorial tax-funded public insurance plans.
• • Like most countries that are members of the Organisation for Economic Co-operation and Development (OECD), Canada faces an ageing population and fiscal constraints in its publicly funded programmes. Services must be provided across vast geography and in the context of high rates of migration and ethnocultural diversity in Canadian cities.
• • In 2017, the 150th anniversary of Canadian Confederation, the three key health policy challenges are long waits for some elective health-care services, inequitable access to services outside the core public basket, and sustained poor health outcomes for Indigenous populations.
• • To address these challenges, a renewal of the tripartite social contract underpinning Medicare is needed. Governments, health-care providers (especially physicians), and the public must recommit to equity, solidarity, and co-stewardship of the system.
• • To fully achieve the potential of Medicare, action on the social determinants of health and reconciliation with Indigenous peoples must occur in parallel with health system reform.
• • Without bold political vision and courage to strengthen and expand the country's health system, the Canadian version of universal health coverage is at risk of becoming outdated.

History: a social democratic foundation

The words health and health care were nowhere to be found in the original Canadian Constitution of 1867. However, provincial governments were given explicit authority over hospitals in the constitutional division of powers between the federal government and the provinces and territories. Over time, these subnational governments became the presumed primary authorities over most health-care services.

In the early 1900s, Thomas Clement “Tommy” Douglas, then a young boy growing up in Winnipeg (MB), nearly lost a limb to osteomyelitis because his family was unable to pay for care. When Douglas later became the Social Democratic Premier of Saskatchewan, he implemented universal public health insurance for the province, making it the first jurisdiction with universal health coverage in North America. 8 This insurance initially covered hospital care in 1947. It was expanded to medical care (mainly defined as physician services) in 1962. Services were resourced by a provincial tax-financed plan. Hospitals and physicians maintained a high degree of autonomy, billing the public plan while designing their own models of care.

The federal government played a part in the emergence of universal health coverage during that period through its spending power, which it used, and continues to use, to maintain national standards for universal health coverage. Thus, the Saskatchewan approach was adopted in the rest of the country through the encouragement of the federal government, which originally offered 50 cents for every provincial dollar spent on universal health coverage. Panel 1 outlines key events in this complex historical process that culminated in the unanimous adoption of the Canada Health Act 9 in Canada's Parliament in 1984.

An abbreviated history of Canadian Medicare

Led by Premier Tommy Douglas, the Saskatchewan Hospital Services Plan is introduced as the first universal hospital insurance programme in North America

Led by Prime Minister Louis St. Laurent, the Hospital Insurance and Diagnostic Services Act establishes 50:50 cost sharing with provincial hospital insurance plans that meet the criteria of comprehensiveness, universality, accessibility, and portability (user fees are discouraged despite no explicit prohibition)

Implementation of the Hospital Insurance and Diagnostic Services Act, with five provinces participating

Premier Tommy Douglas announces his plan for universal publicly funded medical insurance coverage (Medicare) in Saskatchewan

Organised medicine launches a large-scale campaign against Medicare

All ten provinces now participating in the Hospital Insurance and Diagnostic Services Act

July 1, 1962

The Saskatchewan Medical Care Insurance Act takes effect, establishing universal publicly funded medical insurance for Saskatchewan residents

July 1–23, 1962

Saskatchewan doctors' strike, led by the Keep our Doctors committee

July 23, 1962

Saskatoon Agreement ends the strike, establishing opt-out provisions and protections for the fee-for-service, private practice model

Led by Justice Emmett Hall, the Royal Commission on Health Services recommends comprehensive universal health coverage for all Canadians

Led by Prime Minister Lester Pearson, federal Liberals announce support for 50:50 cost sharing with provincial health plans that meet the criteria of comprehensiveness, portability, universality, and public administration

Dec 8, 1966

The Medical Care Insurance Act is passed in Parliament, legislating federal support of provincial Medicare plans that meet the criteria of comprehensiveness, portability, universality, and public administration

July 1, 1968

The Medical Care Insurance Act comes into effect

All provinces now have established comprehensive medical insurance plans that meet the federal criteria for funding eligibility

Led by Prime Minister Pierre Elliott Trudeau, federal Liberals introduce Established Programs Financing, which provides block funding transfers to provinces and lessens federal involvement in health-care provision

Led by Justice Emmett Hall, the Health Services Review raises concerns about the increase in user fees and extra billing by physicians

The Indian Health Policy is adopted, formalising the federal government's responsibility for health-care provision for Indigenous Canadians as directed by constitutional and statutory provisions, treaties, and customary practice

Prime Minister Pierre Elliott Trudeau and Queen Elizabeth II sign the Constitution Act, establishing Canadian sovereignty through patriation; previously established Constitutional convention remained unchanged, including provincial jurisdiction over health service delivery and financing, and a federal role in pharmaceutical regulation, public health, provincial oversight, and provision of services for those groups under federal Constitutional authority (such as Indigenous peoples, armed forces, veterans, inmates, and refugees)

Under Minister of National Health and Welfare Monique Bégin, the Canada Health Act is passed unanimously by Parliament, explicitly banning extra billing and establishing criteria for transfer payment eligibility (with penalties for violations): public administration, comprehensiveness, universality, portability, and accessibility

The Canada Health Act outlines the terms and conditions to which all provincial and territorial plans must adhere in order to access federal funding for health care: portability, universality, accessibility, comprehensiveness, and public administration ( panel 2 ). Three of these conditions are particularly effective in ensuring some commonality across 13 health systems: portability, universality, and accessibility. Portability allows insured residents to keep their coverage when travelling or moving within Canada. 11 Universality stipulates that access must be on uniform terms and conditions—ie, individuals do not have preferential access based on the ability to pay privately. Accessibility means that no user fees are charged for publicly insured services: when a Canadian visits a doctor or is cared for in any department of a hospital, there is no payment or deductible. Provincial and territorial governments have upheld the principles of the Canada Health Act through various laws and policies to ensure ongoing federal funding; currently, federal transfer payments amount to approximately 20% of provincial health budgets. 12

Overview of the Canada Health Act

The following criteria and conditions must be met for provinces and territories to receive federal contributions under the Canada Health Transfer.

• • Public administration: plans must be administered and operated on a non-profit basis by a public authority
• • Comprehensiveness: plans must cover all insured health services provided by hospitals, physicians, or dentists (for surgical dental procedures that require a hospital setting)
• • Universality: all insured residents must be entitled to the insured health services on uniform terms and conditions
• • Portability: insured residents moving from one province or territory to another, or temporarily absent from their home province or territory or Canada, must continue to be covered for insured health services (within certain conditions)
• • Accessibility: not to impede or preclude, either directly or indirectly, whether by user charges or otherwise, reasonable access to insured health services

Adapted from 9 , 10 .

Financing: deep public coverage of a narrow basket of services

Financing in three layers.

Expenditures on health constitute 10·4% of Canada's gross domestic product (GDP; table ). This figure increased consistently for many years and peaked in 2010, at 11·6%, but decreased steadily in the years following the 2008–09 recession. 14 Although this figure seems to have stabilised, 14 it has not yet recovered to its previous peak.

Canada versus OECD comparators by indicators of the Triple Aim

OECD=Organisation for Economic Co-operation and Development. HAQ=Health Access and Quality. NA=not available. GDP=gross domestic product. PPP=purchasing power parity.

Pundits and think tanks often claim that governments in Canada have a public monopoly on health care, but only 70·9% of total health expenditure is publicly sourced, mainly through general taxation. 15 This percentage represents a considerably lower public share than that of the UK and most other nations in western Europe ( table ). Approximately half of the 30% private expenditure comes from out-of-pocket payments by patients; the other half is covered by private supplemental health insurance plans.

The financing of health services in Canada involves three layers ( figure 1 ). Layer one comprises public services (those that Canadians recognise as Medicare): medically necessary hospital, diagnostic, and physician services. These services are financed through general tax revenues and provided free at the point of service, as required by the Canada Health Act. Coverage is universal in this single-payer system. The most important quality of this layer is relatively equitable access to physician and hospital care. 16 Another benefit is cost containment: within Canadian publicly funded insurance plans, administrative overhead is extremely low—less than 2%—because of the simplicity of the single-payer scheme. 17

Layer two services are financed through a mix of public and private insurance coverage and out-of-pocket payments, and include provision of outpatient prescription drugs, home care, and institutional long-term care. Provinces and territories each have a diverse mix of public programmes in this layer, without any national framework. For example, in some provinces, such as Ontario, all senior citizens older than 65 years have public prescription drug coverage, whereas in others, such as British Columbia, drug coverage is income tested. 18

Layer three s ervices are financed almost entirely privately and include dental care, outpatient physiotherapy, and routine vision care for adults when provided by non-physicians. 3

Approximately 65% of surveyed Canadians have private supplemental health insurance, mostly through their employers. 19 This insurance covers some or all of the costs of layer two and three services, notably outpatient prescription medicines, generally with co-payments or deductibles. 20 An additional 11% of people have access to supplemental services through government-sponsored insurance plans. 19 However, many Canadians do not have supplemental insurance, with provincial estimates ranging from a quarter to a third of the total population. 19 , 21 These individuals have to pay out of pocket for outpatient medicines, counselling services (when provided by non-physicians), and more. Such spending has been steadily increasing, particularly for low-income Canadians. 14 More than CAN$6·5 billion in household funds was spent on pharmaceuticals alone in 2014. 18 The large number of Canadians who do not have access to supplemental insurance has led to concerns about equity, fuelling calls for public coverage of a wider range of services than are currently available in layer one.

The federal government holds special responsibilities for providing health coverage and services to Canadian Forces personnel, inmates of federal prisons, eligible Indigenous people, veterans, and certain groups of refugees. 22 The federal government also has stewardship responsibilities for pharmaceutical regulation, health data collection, and health research funding ( figure 1 ).

A small number of Canadian residents do not have public insurance for layer one services. Most are newcomers experiencing provincially mandated delays in coverage, rejected refugee claimants, and temporary residents with expired work or education permits. 23 In Ontario, a province of 13·6 million people, approximately 250 000 people are non-status residents and might therefore be unable to access health-care coverage. 24 When necessary, these people often attempt to access care through emergency departments, where upfront payment is not required. 25

Decentralisation of delivery: a defining feature of Medicare

Medicare is a single-payer layer of financing that is highly decentralised in terms of service delivery. This split between financing and provision of care evolved very differently from, for example, the more centralised National Health Service in the UK.

Doctors are most commonly independent contractors, billing public insurance plans on a fee-for-service or other basis. 26 Despite the fact that they work within the boundaries of regional or provincial health authorities and in hospitals financed almost entirely publicly, few accountability relationships exist between physicians and health authorities, hospitals, or governments. 27

This structure can again be traced back to Saskatchewan, where physicians responded to the single-payer model with a province-wide strike for 23 days, demanding to preserve their ability to bill patients or private insurance plans rather than the government. 28 The strike ended with the Saskatoon Agreement, a truce whereby doctors would become part of the system as publicly paid but self-employed professionals with minimal engagement in or accountability to system-wide governance. 29

Further fragmentation is inherent in the fact that hospitals, health authorities, and other organisations often have their own independent boards and separate budgets, and thus make decisions about the kinds of services they will provide independently of other parts of the system. 9

The centralised data collection that occurs in single-payer insurance plans has great potential to support quality improvement of the health system. Currently, these data inform the strategic directions of health ministries and support excellent health services research in most provinces. Unfortunately, their use for operational purposes to drive front-line improvements has been scarce. Data are seldom provided in real time to organisations and providers delivering care because of the prioritisation of privacy, data security, and the difficulties involved in provision of just-in-time data from large administrative databases. 30

The ease of innovation scale-up that should in theory characterise a single-payer environment remains under-realised. 31 , 32 In Canada, the rate of adoption of electronic medical records increased from about 23% of health-care practitioners in 2006 to an estimated 73% in 2015. 33 Nonetheless, hospital-based systems and primary care systems are commonly designed in isolation from each other. This separation makes information sharing difficult as patients move through distinct parts of the system that use different electronic tools unlinked to each other, causing further fragmentation of care.

National bodies that could overcome fragmentation of coverage or service delivery have had varying degrees of success. The special Canadian brand of decentralisation is illustrated in the case of health technology assessment, an area in which many countries use arm's length agencies to make nationwide decisions about funding allocation (eg, the National Institute for Health and Care Excellence in the UK). The Canadian version is the Canadian Agency for Drugs and Technologies in Health (CADTH), an intergovernmental body that provides evidence-informed funding recommendations as to which drugs and technologies should be publicly covered. However, unlike most international health technology assessment organisations, CADTH's outputs are advisory only. Although regional health plans made coverage decisions consistent with these recommendations in more than 90% of cases between 2012 and 2013, manufacturers must nonetheless navigate 13 provincial and territorial labyrinthine approval processes even after receiving CADTH sanction. 32 Furthermore, 85% of private plans provide coverage for all prescriptions, including those that CADTH recommends against, with the result that evidence-informed recommendations do not necessarily cross the public–private divide. 34

The context for change

Fiscal constraints.

As Canadian governments, providers, and the public consider how to address the important health policy challenges of the day, their options are defined by several factors. Some of these factors are common across many countries in the Organisation for Economic Co-operation and Development (OECD), such as fiscal constraints, population ageing, and the social determinants of health; other factors have uniquely Canadian elements, such as geography and particular patterns of migration.

Following the recession of 2008–09, economic growth in Canada was slower than it had been throughout much of the post-World War 2 era, with GDP growth averaging just over 2% annually between 2011 and 2016. 35 In the past decade, provincial governments have increasingly focused on reducing the rate of growth in health-care spending, which constitutes 38% of provincial budgets based on the pan-Canadian average. 14

Population ageing

In demographic terms, Canada is still a younger country than many European nations. 36 The fertility rate in Canada, which was 1·6 children per woman in 2015 ( table ; data from World Data Bank Portal), has remained relatively stable over the past decade, largely because of higher rates of childbearing among Indigenous and foreign-born Canadian women than among the general population. 37

Nevertheless, ageing remains an inevitable reality as the baby boom generation enters its senior years. People aged 65 years and older represent Canada's fastest growing age group, and 85% of seniors aged 65–79 years reported having at least one chronic condition in 2012. 38 The financial burden of ageing is not expected to be catastrophic, contributing an estimated less than 1% per year to health-care spending; however, the trend is important for design of health services. 39 The traditional hospital-focused and physician-focused nature of the Canadian system must evolve to meet the growing need for home-based and community-based care, interprofessional team-based care, and institutional long-term care. 40

Social determinants of health

The Lalonde Report of 1974 ( panel 3 ) served as a catalyst for widespread recognition that health is determined more by social, cultural, economic, and gender-based determinants of health than by access to health-care services. 41 In a country where the contribution of health services to health is estimated to be only 25%, the impact of other determinants including poverty is considerable. 42 More than 13% of Canadians were living in a low-income household in 2016. 43 This hardship disproportionately affects vulnerable Canadians from particular ethnocultural backgrounds and some groups of migrants who are more than twice as likely to experience poverty than other Canadians. 44 Thus, as is the case across high-income countries, policies aimed at income redistribution, housing support, and early education and childhood development programmes will continue to be crucial to the health of the population. 45

The history of national commissions and inquiries on health care in Canada

1961–64: Royal Commission on Health Services (Hall Commission)

Led by Justice Emmett Hall, the Commission recommended comprehensive health coverage for all Canadians and development of national policy in health services, health personnel, and health-care financing.

1973–74: A New Perspective on the Health of Canadians (Lalonde Report)

Led by Marc Lalonde, Canadian Minister of National Health and Welfare, this paper introduced the public health imperative and called for the prevention of illness and promotion of good health. It called for the expansion of the health-care system beyond disease-based medical care.

1979–80: Health Services Review

Led by Justice Emmett Hall, this review reported on the progress made since the 1964 commission and sought to determine whether provinces were meeting the criteria of the Medical Care Insurance Act. This inquiry identified widespread extra billing and user fees, and served as a catalyst for the Canada Health Act.

1991–96: Royal Commission on Aboriginal Peoples

The Commission investigated the evolution of the relationship between Aboriginal and non-Aboriginal people and governments in Canada. Major recommendations included the training of 10 000 health professionals over a 10-year period.

1993–97: Commission of Inquiry on the Blood System in Canada (Krever Inquiry )

Led by Justice Horace Krever, the Commission investigated the use of contaminated blood products that infected 2000 transfusion recipients with HIV and 30 000 with hepatitis C between 1980 and 1990. This Commission led to the creation of Canadian Blood Services in 1998.

1994–97: National Forum on Health

Commissioned by Prime Minister Jean Chrétien, this group of experts from across Canada focused on broad determinants of health and the need for enhanced emphasis on evidence-based care.

1999–2002: Standing Senate Committee on Social Affairs, Science and Technology Study on the State of the Health Care System in Canada (Kirby Committee)

Led by Senator Michael Kirby, this committee conducted a comprehensive review of Canadian health care. Recommendations included a call for enhanced federal oversight to ensure effective care and efficient resource use, and highlighted poor health human resource planning as a cause of geographical inequities.

2001–02: Commission on the Future of Health Care in Canada (Romanow Commission)

Led by former Saskatchewan Premier Roy Romanow, the Commission called for a renewed commitment to the values of equity, fairness, and solidarity. The report was the catalyst for the 2003 “Accords” and the establishment of the Health Council of Canada (defunded in 2014) to monitor progress on key objectives.

2003: National Advisory Committee on Severe Acute Respiratory Syndrome (SARS) and Public Health

Led by David Naylor, this committee was established to review the circumstances of the 2003 SARS outbreak. The report identified significant issues with public health in Canada and led to the creation of the Public Health Agency of Canada.

2008–15: Truth and Reconciliation Commission of Canada

Undertaken as part of holistic and comprehensive response to the systemic abuse suffered by Indigenous Canadians under the Indian Residential School system, the commission identified calls to action to advance reconciliation. Although not specifically focused on health care, the report highlighted substantial gaps in health care for Indigenous people and outlined the substantial impact of the trauma on mental and physical health.

2015: Advisory Panel on Healthcare Innovation

Led by David Naylor, the panel's Unleashing Innovation report highlighted the need for enhanced patient engagement, workforce modernisation, technological transformation, and improved scale-up of existing innovations.

The geographical challenges to Canada's health system are enormous. Approximately 18% of Canada's population lives in rural or remote communities dispersed throughout 95% of the area of the second largest country in the world ( table ). North of the densely inhabited Canada–USA border corridor, the need for remote primary care facilities and frequent medical transport to specialised centres renders health-care delivery both challenging and expensive ( figure 2 ). 46 The distribution of health-care providers and resources does not mirror need: only 13·6% of family physicians and less than 3% of specialists live in rural and remote areas of Canada. 47 Similar distributional imbalances exist for nurses and other regulated health-care professionals.

Population density and distribution of hospitals in Canada (and the UK)

The map shows the population density and wide geographical distribution of health-care delivery. For comparison, a map of the distribution of hospitals in the UK is shown inset. Hospital data for Canada are from DMTI Spatial, 2016, and population data for Canada are from Statistics Canada, 2016. UK hospital data are from the National Health Service, 2016, and UK population data are from Eurostat.

These realities have led to the emergence of high-performing regional networks for expensive specialty care, such as trauma services, cancer care, and organ transplantation. Telemedicine—in which local providers or patients receive specialist advice via telecommunication—has facilitated rapid access to emergency subspecialty assessment and follow-up, and is gradually expanding its role in chronic disease management. 48 New curricula and legislation have allowed rural nurses, nurse practitioners, pharmacists, and primary care physicians to broaden their scopes of practice into areas such as oncology or surgery. 49 , 50 Trainees across the regulated health professions are increasingly being trained in rural or remote communities to prepare them for careers outside major cities. 51

Despite these successes, Canadians living in remote areas must often travel long distances to access anything beyond the most basic forms of health care. 52 For example, in Nunavut, a northern and largely Indigenous territory, 58% of patients needing inpatient and outpatient hospital care are transported outside the territory. 53 These geographical complexities might change in the coming decades, as Canada continues to urbanise. Census data from 2016 show that almost 60% of Canadians now live in metropolitan areas, with one in three individuals living in Toronto, Montréal, or Vancouver. 54

Ethnocultural and linguistic diversity and migration

Migration has been and remains an important force shaping Canadian demography and identity ( figure 3 ). At present, more than one in five Canadians are foreign-born. 55 Canada welcomed nearly 325 000 immigrants and refugees in 2015, representing just under 1% of the total population. 56 Most immigrants and refugees settle in one of the country's three biggest cities—Toronto, Montréal, or Vancouver. 57

Map of Canada by country of birth

The map illustrates the population density and the proportion of provincial populations based on country of birth. For comparison, a map of the UK by country of birth is shown inset. Population data for Canada are from Statistics Canada, 2012, and population data for the UK are from the UK Office of National Statistics, 2016.

Despite the Canadian commitment to multiculturalism and a general historical pattern of strong immigrant integration into Canadian society, the health status of many migrant groups often differs from that of Canadian-born patients. 58 , 59 , 60 Newly arrived economic immigrants are typically healthier than the general population, but this so-called healthy immigrant effect declines over time, partly because of the stresses of integration, and it is not found across other classes of migrants. 61

Recent immigrants are twice as likely to have difficulty in accessing care than are Canadian-born women and men, and seek primary care less often than either established immigrants or the Canadian-born population. 62 , 63 However, with longitudinal data controlling for individual propensity to seek care, immigrants are no more likely to be without a regular doctor or report an unmet health-care need than is the Canadian-born population. 64 For refugees, challenges are more prevalent and complex. 65 Language is the most commonly cited reason for difficulty in accessing care among many categories of migrants, whether they are newcomers or established. 55 Availability of interpretation services and adequate use of those services, along with appropriate training for health-care providers and increased health and legal literacy for newcomers to Canada, would pave the way for improved access to context-sensitive care ( panel 4 ). 65 , 66

Health-care experiences of vulnerable groups in Canada

Vanessa: an Indigenous health story

Vanessa is a healthy 28-year-old First Nations woman pregnant with her third child. Her two previous deliveries were uncomplicated and her pregnancy is considered low risk. On her northern First Nations reserve, primary care services are provided by nurses in the community clinic and supported by a family physician who flies in once a month. The nearest community an hour away has a small hospital, but provides no intrapartum services.

Vanessa has access to prenatal care close to home. It is important for her that such care is given within the community, increasing the ease of access and sense of cultural safety. Her medical care and prenatal vitamins are covered through public health insurance plans, as is her transportation to medical appointments outside the reserve. She worries about her partner when she is away, particularly given the deep impact of a cluster of recent suicides in the community that included his teenaged sister. The community is affected by many preventable deaths, including suicides, and trauma, but no births—the circle of life feels incomplete.

At 34 weeks' gestation, Vanessa must travel to the city, where she sits in a motel room and waits to go into labour. Neither the timing of the baby's arrival nor the potential complications that can arise can be predicted, so Vanessa waits alone. As for most women in communities like hers, the birth will occur not with a midwife in her community, but in a hospital hundreds of kilometres away from her partner and children, compromising her much-needed sense of cultural safety. Her access to health-care services free at the point of care is critical, but she wishes her care could be connected to her home, her family, and her culture. If these defects in the system are addressed, perhaps Vanessa's next generation will grow up to expect access to such vital, culturally safe health care.

Mahmoud: a migrant health story

Mahmoud is a 52-year-old Syrian dental surgeon who arrived in Canada with his wife and four children in 2016, as a government-sponsored refugee family. The children started public school while both parents enrolled in the government-funded English-language training for the first months of settlement.

Despite having publicly funded health insurance immediately on arrival, Mahmoud does not access primary care for himself or his family for many reasons, including discomfort with the English language and a lack of knowledge of where to seek care. When he begins to feel unwell, after stalling for a long time, he goes to a local community clinic. An appointment is given for him to return with interpreter services for the following week.

Unfortunately, in the meantime, Mahmoud is admitted to hospital with uncontrolled blood sugars. He is started on oral hypoglycaemics. As a refugee, his medicines are covered, but when he transitions to regular provincial health insurance he will have to pay for his medicines out of pocket.

The process associated with recognition of Mahmoud's dental credentials and skills is complex and lengthy. To take care of his family, he takes up taxi driving. With his unpredictable hours, he finds it hard to comply with his prescribed regimen and starts missing follow-up appointments.

As the Ramadan period approaches, Mahmoud knows he will fast but does not consult with the health team at the local clinic, unsure whether he would be understood as he does not know how to get an interpreter. Despite the fact that there is an increasing sensitivity to the diversity of the Canadian population by the health-care professionals, who are also becoming increasingly diverse, more work is needed to improve communication and personalisation of care, especially at the primary care level.

Policy challenges

Three urgent issues.

Canadians have a life expectancy at birth of 82·14 years ( table ), which is longer than the OECD average. Canada also outperforms the USA, the UK, and Denmark in terms of amenable mortality (ie, deaths that should not occur in the presence of timely and effective health care), as measured through the Health Access and Quality (HAQ) Index. 13 But key observations from international comparisons point to a decades-long struggle with wait times for some elective care and inequitable access to services outside the traditional Medicare strength of hospitals and doctors. 67 Average life expectancy also masks variations in vulnerable groups, most notably Indigenous populations: First Nations people have a projected life expectancy of 73–74 years for men and 78–80 years for women; for the Inuit, living in the far north, life expectancy was 64 years for men and 73 years for women as of 2017. 68

What is most distressing to many observers of the Canadian system is the persistence of its problems over time. 69 Change in Canada is often slow and incremental, by contrast with the major and rapid transformations often observed in reforms of the UK's National Health Service. 70 It is thus most accurately described not as a system in crisis, but a system in stasis. 71 Within that context, and considering the complex needs of many segments of the Canadian population, three crucial problems require action.

Wait times for elective care are too long

Urgent medical and surgical care is generally timely and of high quality in Canada, as indicated by outcomes such as acute myocardial infarction mortality ( table ). However, the timeliness of elective care, such as hip and knee replacements, non-urgent advanced imaging, and outpatient specialty visits, is problematic. 72 The proportion of Canadians waiting more than 2 months for a specialist referral is 30% ( table ), which is far greater than any OECD comparator in the Commonwealth Fund's comparison of 11 countries. 67 Similarly, the proportion of Canadians waiting more than 4 months for elective non-urgent surgery is greatest at 18%.

Governments have experimented with wait-time guarantees, focused programmes, and targeted spending in priority areas such as cancer care, cardiac care, and diagnostic imaging, with varying degrees of success. For example, all provinces achieved wait-time benchmarks in radiation oncology in 2016, but long elective MRI wait times remain largely unchanged over the past decade, despite substantial growth in the number of machines purchased and scans done. 73 , 74

The high degree of physician autonomy in Canada does little to encourage doctors to join organised programmes to reduce wait times. Successful models exist, such as the Alberta Bone and Joint Health Institute in Calgary, which reduced wait times for consultation for hip and knee replacement from 145 days to 21 days through innovations including interprofessional teams and centralised referral. 75 However, physicians have competing responsibilities, and there is no systemic support for their involvement in system change. If a government or regional health authority wants physicians to participate in such an initiative, it must often rely on exhortation or simply pay its doctors more to gain their involvement. Poor federal–provincial–territorial collaboration also hinders the ability to scale up such successful responses to wait times across provincial borders, hence the characterisation of Canada by at least one former Minister of Health as a “country of perpetual pilot projects”. 76 , 77

Canada's reasonable performance on composite quality metrics such as amenable mortality suggests that these wait times for elective care do not necessarily translate to worse health outcomes. 78 However, for the Canadian public, long wait times for elective care are a lightning rod issue and threaten to undermine support for Medicare. Some groups have turned to the courts as a means of challenging the public–private payment divide. Relying on the constitutional Charter of Rights and Freedoms, major lawsuits in Quebec and British Columbia have argued that various provisions of provincial laws, including those that prevent privately financed care, are at the root of public wait times and threaten the right to security of the person. 79 , 80 , 81 , 82

Little more than a decade ago, the Quebec government responded to the Supreme Court of Canada's Chaoulli decision by allowing private insurance for a few types of surgical procedures, but this outcome did not create a viable private market for a health insurance duplicative of Medicare. 83 A more ambitious lawsuit impugning provincial Medicare laws was launched in British Columbia in 2016. 84 Unlike the Quebec trial, which sought only to overturn limits on private duplicative insurance, the plaintiffs in the Cambie Surgeries Corporation case in British Columbia seek to also overturn restrictions on user fees and on physician dual practice. 85

In the past decade, Canadian courts have made important judgments on several other major questions of health-care delivery, including the legalisation of safe injection sites, reinstatement of insurance coverage for refugee claimants, and legalisation of medical assistance in dying. 86 , 87 , 88 These decisions have generally increased access to care for vulnerable people. However, should the court in the Cambie Surgeries Corporation case establish a legal right for Canadians of means who wish to jump the public queue, this case could fundamentally reshape Medicare laws across the country and could threaten equitable access to care. If Canadians are unable to find ways to change the system from within through clinical and political leadership, there is a risk that changes will be forced by the courts, which are a blunt instrument for making policy change.

Services outside the Medicare basket are often inaccessible

Up to a third of working Canadians do not have access to employer-based supplemental private insurance for prescription medicines, outpatient mental health services provided by professionals such as social workers or psychologists, and dental care. 21 These individuals are more likely to be women, youths, and low-income individuals. Public coverage of those services varies between provinces, but generally focuses on seniors and unemployed people receiving social assistance, leaving the working poor most vulnerable. 89 Thus, inequities in health outcomes driven by the social determinants of health are at risk of being compounded by the narrow but deep basket of publicly funded services.

Notably, Canada is the only developed country with universal health coverage that does not include prescription medications, and 57% of prescription drug spending is financed through private means. 18 , 90 Nearly one in four Canadian households reports that someone in that household is not taking their medications because of inability to pay. 91

Beyond prescription drugs, inequitable access to home-based care and institutional long-term care is pressing. In 2012, nearly 461 000 Canadians aged 15 years or older reported that they had not received help at home for a chronic health condition even though they needed it. 92 Because such layer two services receive inadequate public financing, Canadians aged 65 years or older have cited inability to pay as the main barrier to accessing the home and community care support they needed. 92 Some combination of inspired leadership, public financing, engaged governance, robust regulation, and intergovernmental cooperation seems to be needed to protect the public interest and address inequities of access to layer two services.

Indigenous health disparities are unacceptable

As in other settler societies such as Australia, New Zealand, and the USA, Indigenous populations in Canada were colonised and marginalised. In the Canadian case, marginalisation took the forms of Indian Residential Schools, government-enforced relocation, and historically segregated Indian hospitals, to name a few. 93 , 94 Three distinct and constitutionally recognised groups—First Nations, Inuit, and Métis—constitute 4·3% of the Canadian population and experience persistent health disparities relative to the non-Indigenous population, including higher rates of chronic disease, trauma, interpersonal and domestic violence, and suicide, as well as lower life expectancy and higher infant mortality rates. 95 , 96 , 97 For example, Canada's infant mortality rate dropped by 80% from more than 27 deaths per 1000 livebirths in 1960, to five per 1000 livebirths on average in 2013. 98 However, the estimated rate in Nunavut (the northern territory in which approximately 85% of the population is Inuit) was more than three times the national rate at 18 deaths per 1000 livebirths in 2013. 98

Other far-reaching inequities exist in the social determinants of health that even the best health-care systems cannot redress. Indigenous Canadians face substantial wage gaps of up to 50% compared with non-Indigenous groups, after adjustment for education and age. 99 Persistent racism and social exclusion permeate not only the health-care but also the education and justice systems, with subsequent disparities in high school education rates, incarceration rates, and other factors often driving egregious health statistics. 100

These challenges are not evenly distributed: figure 3 illustrates the proportion of the population that is Indigenous by province and territory. Due in part to higher fertility rates in the Indigenous population than in the general population, by 2036, a projected one in five people will be an Indigenous person in the western provinces of Saskatchewan and Manitoba. 101

A dizzying array of services in the health-care system, including federal programmes, provincially provided services, and highly bureaucratised add-ons, together continue to fail to meet the needs and constitutional rights of Indigenous people. 102 Indigenous people are covered by provincial Medicare plans, but some on-reserve health-care services fall under federal jurisdiction, and many Indigenous people receive supplemental insurance through the federal government.

Canada is actively grappling with its colonial history. An unprecedented Truth and Reconciliation Commission (TRC) released a report 94 in 2015 that shared the stories of Indian Residential School survivors who lost connection to family, land, culture, and language through a process intended to assimilate them into western society. Seven of the 94 calls to action in the report refer directly to steps required to address the inequities in health. From recognising and valuing traditional Indigenous healing practices to training Indigenous doctors and nurses and setting measurable goals to close gaps in access to health-care services, the TRC calls to action address crucial themes, many of which are rooted in self-governance. The newly established First Nations Health Authority in British Columbia, which is self-governed and community-driven, is an example of the type of emerging model intended to address the demand for self-governance in the administration and delivery of culturally safe and responsive services for Indigenous people in Canada. 103 The remaining TRC calls to action, should they be implemented, would help to reduce disparities in the social determinants of health, leading to better health-care outcomes.

An opportunity to renew the social contract

The role of governments: federal, provincial, and indigenous.

As Canadians observe the 150th anniversary of Confederation in the face of these three important challenges, a renewed vision of the roles of governments, providers, and the public will be required to overcome the stasis of the present and achieve the potential of single-payer Medicare. Rather than continue the Canadian tradition of slow, steady, and incremental change, governments must step forward boldly and with proactive commitment to ensure a vital and sustainable system for all Canadians.

The predominant administrative and delivery responsibilities for health care in Canada will always lie with provincial and territorial governments. The work of reorganising resources, building infrastructure, and delivering programmes for an ageing population under fiscal constraints is theirs to lead. For wait times in particular, a focus on provincial implementation of successful projects using the available financial and policy levers is long overdue.

However, provincial and territorial governments cannot succeed alone. At a few key times in Canadian history, the federal government has overcome decentralisation and fragmentation by setting a national vision for health care and investing politically and financially in that vision. In an era in which Canada is reasserting its commitment to progressive values on the international stage, 7 health care represents a key domestic opportunity to recommit to the core Canadian values of equity and solidarity. 104

The movement to expand the scope of the public basket of services is at the heart of this approach, and we support mounting calls for universal prescription drug coverage 105 as well as expanded home care, 106 long-term care, 106 and mental health services 107 to be included in layer one of the financing system. Royal Commissions as far back as the 1964 Hall Commission 108 and as recent as the 2002 Romanow Commission 109 have clearly articulated the need for this expansion. In particular, debates about a so-called Pharmacare system are gaining needed momentum, as multiple economic evaluations have suggested that improved access through an expansion of public coverage is possible at lower overall costs. 110 As the Quebec experience illustrates, it is difficult for any one province to begin alone as Tommy Douglas did in Saskatchewan—federal cost sharing and stewardship will be required at an early stage to achieve the savings as well as the coverage and quality goals of Pharmacare. 111

With respect to wait times, solutions will continue to be based in local innovations, but the infrastructure for national spread and scale-up requires active federal involvement. One possible approach, recommended by a federally commissioned panel on health innovation, would be a Healthcare Innovation Fund intended to accelerate the spread and scale-up of promising innovations. 32

A constructive partnership between the federal government and Indigenous peoples could overcome one of Canada's most difficult challenges—the very poor health outcomes of Indigenous peoples. Newly established principles guiding the relationship between the Government of Canada and Indigenous peoples, as well as the launch of a new federal Ministry of Indigenous Services established in August, 2017, could set the tone for renewed terms of engagement. 112 This commitment to self-determination will mean supporting new models of self-governance within and beyond the health-care sphere, with a particular focus on healing from intergenerational trauma and a strengths-based, wellness-focused approach to enhancing the social determinants of health. Canada's considerable experience with decentralised models of health-care delivery should allow for such innovation, and the opportunity must be seized with more urgency.

The TRC's calls to action must move from suggestions based on the courageous voices of survivors of the Indian Residential School system to non-negotiable tasks for all levels of government, all professional organisations, and all citizens. These tasks include: first, measurement and frank evaluations of health-care systems and programmes; second, creation of cultural safety and humility within a health-care system that needs to rebuild trust; and third, true representation of Indigenous Canadians within the ranks of providers and leaders of the health-care system. Mutual accountability here is essential.

The role of providers

Canadian hospital-based nurses, nurse practitioners, pharmacists, physiotherapists, and other health professionals are employed by health service delivery organisations and regional health authorities. As employees, these regulated health professionals have accountability for quality improvement and system reform, and their influence and importance in the system have been increasing steadily for decades. 113 The scope and availability of interprofessional and nurse-led care models continue to grow, as evidenced by policy outcomes such as the rapid increase in nurse practitioners in Quebec as part of that province's approach to primary care reform. 114 Given the importance of interprofessional teams in improvement of access to high-quality primary and specialty care, such teams must be accelerated to reduce wait times, work on disparities associated with social determinants of health, and improve care for vulnerable groups.

By contrast, Canadian physicians remain primarily self-employed, independent professionals. 115 Ongoing conflicts are fuelled by mounting pressure to alter this arrangement and increase professional accountability for and to the system. 116 Productive partnerships between physicians and governments at times exist, but co-stewardship of finite resources is not built into the structure of the system. The need for physician engagement, both at the individual and collective level, is crucial as Canada moves to address long wait times for elective care, because solutions so often involve the reorganisation of traditional referral models and the introduction of team-based care. Furthermore, expanded public coverage of prescription medications will necessitate a drive towards more evidence-informed and value-based prescribing. Canadian physicians are well situated to constructively contribute to such efforts to define value and help to shift behaviour. As founders of evidence-based medicine and important contributors to global medical research, Canadian physicians must help to lead the necessary research and debates on change within the health-care system. 117 They are critical partners in ensuring quality, consistency, and availability of services. 27 Medical associations in at least two provinces have recognised the importance of system stewardship in the practice of professionalism and have committed to health system reform in collaboration with governments. 118 , 119 The Canadian Medical Association's renewed strategic plan places patients at the core of its mission. 120 And leaders in medical education have embraced a social accountability mandate and are actively working to train the “right mix, distribution, and number of physicians to meet societal needs”. 121 This approach is a model with potential broad international application.

The role of the public: patients, taxpayers, and citizens

It is not yet clear what mechanisms will emerge to alter patient behaviours as the system evolves. An early example of patients being encouraged to engage directly in system stewardship is Choosing Wisely Canada. This clinician-led campaign to address overuse of tests and treatments is part of the international movement to reduce low-value care. 122 The campaign offers four questions that patients can ask to start a conversation with their health-care provider about whether a test, treatment, or procedure is necessary. 123 Users of services will also need to be willing to participate in new models of care delivery that have been shown to successfully reduce waits for specialty care. These models will include those that are more team focused than physician focused, and models centred in comprehensive primary care with expanded scopes of practice.

Public engagement and participation in health-care policy require engagement with people as taxpayers, who want value for money, and as citizens, who continue to believe in the principle of equitable access to services. At times, governments have assessed public support for various reform options through the public consultations of independent Royal Commissions or external advisory panels, many of which are listed in panel 3 . National Royal Commissions are independent inquiries, invited through the power of the Crown to investigate matters of national importance and characterised by extensive consultations with the public. 124 , 125

Such commissions produce reports that are often accused of gathering dust, but at times they can be transformative in terms of public views and judgment, eventually having a profound effect on government policy. Some commissions even produce immediate change. Despite admirable efforts by health-care providers on the ground in Ontario and British Columbia to contain the outbreak of severe acute respiratory syndrome (SARS) in 2003, a subsequent review highlighted long-ignored flaws plaguing the system that were unmasked by the outbreak and led to formation of the Public Health Agency of Canada 1 year later. 126 , 127

As in the rest of the world, other models of citizen engagement in public policy are being explored, but the value of such initiatives is not yet known. 128 Citizens' panels are becoming more common, such as one on national Pharmacare in 2016. 129 Public support for and participation in values-based, evidence-informed decision making will be crucial to ensure financial sustainability and to mitigate the risks of overprescribing in the area of pharmaceutical policy.

Public engagement in health research—as seen, for example, in the Canadian Institutes of Health Research-funded Canada's Strategy for Patient-Oriented Research— incentivises each province and territory to identify research priorities in collaboration with patients, and must continue. 130 Public input of this kind should be nurtured, since it can help policy makers to balance the need for health system investment against other social priorities.

Canadian lessons for a global world

Canada's most important accomplishment by far has been the establishment of universal health coverage, which is free at the point of care, for medical and hospital services. The preservation and enhancement of Medicare are due largely to Canadians' pride in caring for one another—an expression of equity and solidarity that runs core to Canadian values. Hinging on a social consensus of equitable access to health care, the simplicity of the system—no variable coverage, no means testing, and no co-payments—is easy for Canadians to understand and support.

But universal health coverage is an aspiration, not a destination. All countries must continuously consider the depth and scope of coverage that is politically achievable and fiscally feasible. In Canada, that necessary work has not been done for more than 40 years. The Canadian experience thus offers a cautionary tale on incrementalism. In the absence of bold political vision and courage, coverage expansion can be very difficult to achieve, with the result that the Canadian version of universal health coverage is at risk of becoming outdated.

A powerful mechanism such as a single-payer insurance system is only as good as the willingness of system leaders to use it for reform. In turn, reform requires a willingness on the part of governments to pursue change, rather than simply managing the status quo. Clear mechanisms are lacking to consistently realign resources to meet population needs, promote evidence-based care, reduce variation, and contain costs. Health care is ultimately a local affair, and no patient or provider wants the payer in the examination room. However, much of the potential benefit of a single-payer structure is lost when institutions are independent, with little accountability. The potential of the system is further limited by the fact that physicians function alongside but outside the system, rather than as accountable participants through employment or other contractual means. Co-stewardship and accountability should be recognised as integral parts of payment systems rather than avoided or grafted on afterwards.

When Tommy Douglas first established public health insurance in Saskatchewan in the late 1940s, his goal was to begin by creating insurance models that would eliminate the financial barriers to care. He intended to follow that with a second reform of health service delivery that would focus on population health needs, with an emphasis on the reform of delivery models and on the social determinants of health. 131 His government, and subsequent governments, provincially and federally, managed to overcome fragmented institutional structures and decentralisation of power to make the first stage of his vision a reality, but not yet the second. To achieve that second stage in the 21st century, determined action on the social determinants of health and a joint effort by governments, health-care providers, and the public in achieving health system reform will be needed. With bold political vision and courage, this ambitious goal is within reach. 132

Acknowledgments

We acknowledge funding from the McGill Observatory on Health and Social Services Reforms and from the Canada Research Chair in Policies and Health Inequalities (AQ-V) for maps developed by Tim Elrick and Ruilan Shi at the McGill Geographic Information Centre, Montréal, QC, Canada. We thank Ian McMillan and Leah Kelley for assistance with references, formatting, and submission; Karen Palmer for assistance with copy edits, critical review of the manuscript, and expertise regarding the British Columbia court case; and Meb Rashid for his expertise regarding migrant and refugee health issues.

Contributors

All authors contributed to the formulation of the ideas in the manuscript and the writing of initial drafts. All authors contributed to the literature search and editing of the manuscript. APM, DM, and AQ-V contributed to the figures. All authors reviewed and approved the final manuscript before submission.

Declaration of interests

DM is currently an external adviser to the Government of Canada on a review of pan-Canadian health organisations. NRC is a consultant for the cancer strategy of British Columbia's First Nations Health Authority and co-director of the Centre for Excellence in Indigenous Health, University of British Columbia (Vancouver, BC, Canada). GPM was executive director of the Romanow Commission. We declare no other competing interests.

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Guest Essay

I Studied Five Countries’ Health Care Systems. We Need to Get More Creative With Ours.

By Aaron E. Carroll

Dr. Carroll is the chief health officer of Indiana University and writes often on health policy.

Although we just experienced a pandemic in which over one million Americans died, health care reform doesn’t seem to be a top political issue in the United States right now. That’s a mistake. The American health care system is broken. We are one of the few developed countries that does not have universal coverage. We spend an extraordinary amount on health care, far more than anyone else. And our broad outcomes are middling at best .

When we do pay attention to this issue, our debates are profoundly unproductive. Discussions of reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a private system or we move toward a single-payer system like Canada’s. That’s always been an odd choice to me because true single-payer systems like that one are relatively rare in the world, and Canada performs almost as poorly as we do in many international rankings.

Moreover, no one has a system quite as complicated as ours.

A more productive debate might benefit from looking around the world at other options. Many people resist such arguments, however. They think that our system is somehow part of America’s DNA, something that grew from the Constitution or the founding fathers. Others believe that the health care systems in different countries couldn’t work here because of our system’s size.

I think those are bad excuses. Our employer-based insurance system is the way it is because of World War II wage freezes and I.R.S. tax policy, not the will of the founders. And much of health care is regulated at the state level, so our size isn’t really an outlier. We could change things if we wanted to.

In the first half of the year, I was privileged to visit five other countries and learn about their health care systems. In February I traveled to Britain and France with Indiana University’s Kelley School of Business and, more recently, with the Commonwealth Fund and AcademyHealth to New Zealand, Australia and Singapore.

Australia and New Zealand are two other countries with single-payer systems out there, although their systems differ greatly from Canada’s and from each other’s. Unlike our neighbor to the north, they allow private insurance for most care, which can be applied to pay for faster access with more bells and whistles. In addition, Australia’s system has fairly high out-of-pocket payments, in the form of deductibles and co-pays.

France’s system is close to a single-payer one because almost everyone gets insurance from one of a few collective funds, mostly determined by employment or life situations. They also have out-of-pocket payments and expect most people to pay upfront for outpatient care, to be reimbursed later by insurance. That’s something even the United States system doesn’t do.

Britain , on the other hand, has no out-of-pocket payments for almost all care. Private insurance is optional, as it is in other countries, to pay for care that may come faster and with more amenities. Relatively few people purchase it, though.

As I’ve written about before , Singapore has a completely different model. It relies on individuals’ personal spending more than almost any other developed country in the world, with insurance really available only for catastrophic coverage or for access to a private system that, again, relatively few use.

America could learn a thing or two from these other countries. We could take inspiration from them and potentially improve access, quality and cost. However, it’s important to frame our examination correctly. Focusing on these countries’ differences misses the point. It’s what they have in common — and what we lack — that likely explains why they often achieve better outcomes than we do.

Universal coverage matters, not how we get there.

The pandemic should have been an eye-opener in terms of how much work we need to do to repair the cracks in our health care foundation. Unfortunately, we seem to have moved on without enough focus on where we fall short and what we might do about it. It’s outrageous that the health care system hasn’t been a significant issue in the 2024 presidential race so far.

Even if we did have that national conversation, I fear we’d be arguing about the wrong things. We have spent the last several decades fighting about health insurance coverage. It’s what animated the discussions of reform in the 1990s. It’s what led to the Affordable Care Act more than a decade ago. It’s what we are still arguing about. The only thing we seem able to focus on concerns insurance — who provides it and who gets it.

No other country I’ve visited has these debates the way we do. Insurance is really just about moving money around. It’s the least important part of the health care system.

Universal coverage matters. What doesn’t is how you provide that coverage, whether it’s a fully socialized National Health Service, modified single-payer schemes, regulated nonprofit insurance or private health savings accounts. All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care.

But the United States can’t decide on a universal coverage scheme, and not only does it leave too many people uninsured and underinsured; it also distracts us from doing anything else. We have all types of coverage schemes, from Veterans Affairs to Medicare, the Obamacare exchanges and employer-based health insurance, and when put together, they don’t work well. They are all too complicated and too inefficient, and they fail to achieve the goal of universal coverage. Our complexity, and the administrative inefficiency that comes with it, is holding us back.

When I was younger, I was more of a single-payer advocate, until I realized how many systems perform better than Canada’s. More recently, I favored the tightly regulated, entirely private insurance system of Switzerland because it performs exceptionally well using a private scheme I thought would be more palatable to many Americans. Today, though, I really don’t care how we get to universal coverage.

If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services.

Public delivery systems are essential, but so are private options.

What separates the countries I traveled to from the United States is that they largely depend on public delivery systems. Most people get their hospital care from a government-run facility. However, each country also has a private system that serves as a release valve. If people don’t like the public system, they can choose to pay more, either directly or indirectly, through voluntary private health insurance, to get care in a different system.

The care delivered in these public systems is often just as good, in terms of outcomes, as what is delivered in the private system. The same doctors often work in both settings. What is different is the speediness of care and the amenities that come with it. If you choose to get care in a public system, you often have to wait in line. Most often, the wait doesn’t lead to worse outcomes, and people accept it because it’s much cheaper than paying for private hospital care. Those who don’t want to wait, or feel they can’t, can pay more to jump the queue.

In fact, explicit tiering is a feature, not a bug, of all of these other systems. Those who want more can get more, even in Singapore’s public system. But more isn’t better care; it’s more choice in terms of physicians, private rooms, fancier food and even air conditioning. (While many Americans see the latter as a necessity, most people in Singapore — where it’s much hotter — don’t agree.)

In the United States, on the other hand, most care is provided by private hospitals , either for-profit or nonprofit. Even nonprofit systems compete for revenue, and they do so by providing more amenity-laden care. This competition for more patient volume leads to higher prices, and while we don’t explicitly ration care, we do so indirectly by requiring deductibles and co-pays, forcing many to avoid care because of cost . Our focus on what pays — acute care — also leads us to ignore primary care and prevention to a larger extent.

I’m convinced that the ability to get good, if not great, care in facilities that aren’t competing with one another is the main way that other countries obtain great outcomes for much less money. It also allows for more regulation and control to keep a lid on prices.

I’m not arguing it would be easy to expand the number of public hospitals in the United States. It would be politically difficult to expand the government’s role in delivering health care, directly or indirectly. But allowing people to choose whether to accept cheaper care delivered by a public system or to pay more for care in a private system might make this much more palatable. By doing so, we could make sure that good care is available to all, even if better care is available to some.

Strong social policies matter.

I have been to Singapore twice now to learn about the country’s health care system, and twice I’ve watched my hosts spend significant time showcasing their public housing apparatus. More than 80 percent of Singaporeans live in public housing , which involves more than one million flats that were built and subsidized by the government. Almost all Singaporeans own their own homes, too, even publicly subsidized ones; only about 10 percent of them rent.

Because of government subsidies, most people spend less than 25 percent of their income on housing and can choose between buying new flats at highly subsidized prices or flats available for resale on an open market.

This isn’t cheap. It’s possible, though, because the government is only spending about 5 percent of G.D.P. on health care. This leaves a fair amount available for other social policies, such as housing.

Other social determinants that matter include food security, access to education and even race. As part of New Zealand’s reforms, its Public Health Agency, which was established less than a year ago, specifically puts a “greater emphasis on equity and the wider determinants of health such as income, education and housing.” It also seeks to address racism in health care, especially that which affects the Maori population .

In Australia I met with Adam Elshaug, a professor in health policy at the Melbourne School of Population and Global Health. When I asked about Australia’s rather impressive health outcomes, he said that while “Australia’s mortality that is amenable to or influenced by the health care system specifically is good, it’s not fundamentally better than that seen in peer O.E.C.D. countries, the U.S. excepted. Rather, Australia’s public health, social policy and living standards are more responsible for outcomes.”

Addressing these issues in the United States would require significant investment, to the tune of hundreds of billions or even trillions of dollars a year. That seems impossible until you remember that we spent more than $4.4 trillion on health care in 2022. We just don’t think of social policies like housing, food and education as health care.

Other countries, on the other hand, recognize that these issues are just as important, if not more so, than hospitals, drugs and doctors. Our narrow view too often defines health care as what you get when you’re sick, not what you might need to remain well.

When other countries choose to spend less on their health care systems (and it is a choice), they take the money they save and invest it in programs that benefit their citizens by improving social determinants of health. In the United States, conversely, we argue that the much less resourced programs we already have need to be cut further. The recent debt limit compromise reduces discretionary spending and makes it harder for people to get access to government programs like food stamps. As Mr. Elshaug noted, doing the opposite would lead to better outcomes.

We are already doing what other countries can’t.

These other countries’ systems are not perfect. They face aging populations, expensive new technologies and often significant wait times — just like ours. Those problems can make some people quite unhappy, even if they’re not more unhealthy.

When I asked experts in each of these countries what might improve the areas where they are deficient (for instance, the N.H.S. has been struggling quite a bit as of late), they all replied the same way: more money. Some of them lack the political will to allocate those funds. Others can’t make major investments without drawing from other priorities.

Singapore might, though. With its rapidly aging population, it likely needs to spend more than the around 5 percent of G.D.P . Jeremy Lim, the director of the country’s Leadership Institute for Global Health Transformation and an expert on its health care system, said that while Singapore will need to spend more, it’s very unlikely to go above the 8 percent to 10 percent of G.D.P. that pretty much all developed countries have historically spent.

That is, all of them except the United States. We currently spend about 18 percent of G.D.P. on health care. That’s almost $12,000 per American . It’s about twice what other countries currently spend.

With that much money, any of these countries could likely solve the issues it faces. But spending substantially more on health care is something they feel they cannot do. We obviously don’t have that issue, but it’s intolerable that we get so little for what we spend.

We cannot seem to do what other countries think is easy, while we’ve happily decided to do what other countries think is impossible.

But this is also what gives me hope. We’ve already decided to spend the money; we just need to spend it better.

Source photograph by Oli Scarff via Getty

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow The New York Times Opinion section on Facebook , Twitter (@NYTopinion) and Instagram .

Aaron E. Carroll  is the chief health officer  for and a distinguished professor of pediatrics at Indiana University. His show and podcast on health research and policy is “ Healthcare Triage .” @ aaronecarroll

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Universal Health Care: Persuasive Speech Outline

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Published: Mar 20, 2024

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Introduction, i. equality, ii. public health, iii. financial burden.

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A Different Framework to Achieve Universal Coverage in the US

• 1 Harris School of Public Policy, University of Chicago, Chicago, Illinois
• 2 Harvard Business School, Harvard University, Cambridge, Massachusetts
• 3 Harvard School of Government, Harvard University, Cambridge, Massachusetts

The US spends substantially more on health care per capita than other high-income countries yet leaves a greater share of the population uninsured. Traditional economic models—and common sense—point to the benefit of having at least some health insurance, if only for financial protection. In addition, ample evidence has shown that health insurance provides greater access to beneficial care and can improve health and save lives. 1 - 3 Many people also place social value on others’ access to health care as part of a social safety net that also includes access to food, housing, and education.

Why, then, are so many in the US uninsured? Understanding the underlying causes sheds light on different options for expanding insurance. The first explanation may be that insurance is expensive and many people simply cannot afford it. But this factor is not the only or main reason. About 40% to 50% of uninsured individuals likely qualify for no-cost insurance via Medicaid or an Affordable Care Act (ACA) exchange plan, 4 and many others qualify for heavily subsidized insurance. Although some populations fall into gaps for subsidized coverage—notably undocumented immigrants and low-income people in states that have not adopted Medicaid expansion—lack of eligibility for affordable coverage is not the only barrier.

Other explanations point to market failures that make health insurance a bad deal for some people. Health insurance markets suffer from serious information failures—for example, insurers’ limited information about enrollees’ existing health needs and enrollees’ limited information about the potential plan’s quality and comprehensiveness of care—and from a lack of competition that drives up health care prices and insurance premiums in many areas. But these factors do not explain why many people do not take advantage of benefits available to them at no cost. Evidence shows that individuals’ behavioral biases and frictions, including the complexities of Medicaid and ACA exchange enrollment processes, may pose barriers. 5 - 7

The growing body of research on these barriers often encourages incremental policy approaches to expanding coverage: correcting each market failure and implementing nudges and administrative simplification to increase enrollment. Indeed, the ACA itself and more recent policies to amend it 8 take just such an approach. The result is a patchwork of insurance policies that are incomplete and expensive in terms of the cost to administer them and the health consequences of inconsistent coverage and care. Tweaks to the existing system also perpetuate other shortcomings, such as job lock that comes from employment-based coverage, regressive financing mechanisms, and limited incentives for investing in population health.

Instead, it may be advantageous to begin with a policy that sets a social floor or basic policy that would be available to everyone. Starting with this premise would force explicit decisions about crucial tradeoffs that are already faced implicitly in the current system. The existing implicit social floor in the form of uncompensated care, 9 emergency department visits, and free clinics 8 is inefficient, unpredictable, and highly variable. Implementing a publicly financed basic policy with automatic enrollment could facilitate a move toward universal coverage in a financially sustainable way that ensures access to care with substantial health benefits.

We recently outlined how such an approach might work. 10 First, this approach requires defining the floor to which everyone will be automatically entitled: How much insurance and health care access does society want to make universally available? Should publicly financed insurance cover all care, regardless of how low the health benefits or how high the costs, or should there be limits? We suggest that coverage decisions be grounded in how much health benefit a service generates, ensuring access to high-value care for all. High-value care is not the same as low-cost care: some very expensive treatments with dramatic health benefits are high-value care, and some cheap treatments with negligible health benefits are low-value care. Similar tradeoffs arise in deciding how much to pay health care professionals, which determines how many and which types of physicians and hospitals will accept basic coverage, as in Medicaid today.

The second step is determining who decides how much to pay for which services and for which patients? To mitigate concerns about the flexibility and innovation generated by one-size-fits-all public programs, public subsidies can be coupled with choice among plans, as in market-based social health insurance in the Netherlands and Switzerland as well as in Medicare Advantage and the ACA Marketplace plans in the US.

Third, decisions must be made about whether and how individuals can use private funds to buy additional coverage. For example, should people be able to opt out of the public system and replace it with separate private insurance as occurs in Germany ? Or should they be allowed to “top up” the public insurance with supplemental private insurance that covers more treatments or reduces patients’ cost sharing, similar to supplemental policies in England and Canada that cover a wider set of clinicians and hospitals? These decisions have economic as well as ethical and distributional implications. Allowing additional coverage means that those with higher incomes are likely to have more health care and better outcomes than those with lower incomes. But this policy also enables people to find insurance that more closely matches their preferences and priorities. Furthermore, the presence of private market choices can drive innovation and quality. Lessons can be learned from the experiences of other countries, many of which have some version of a universal basic system, although with different answers to these fundamental questions. Almost all universal systems include options for supplemental coverage.

Beyond these fundamental questions, moving to such a system raises real concerns about disruption to clinical relationships, the risk of having the government as a monopsonist payer setting prices that are too low for access and medical innovation, and myriad logistical challenges. Despite these challenges, few would argue that the current US health care system is serving the nation well; the system surely spends too much on health care that delivers too little benefit to too few people. Reconceptualizing universal coverage to ensure that public resources are devoted to care with high health benefit offers the opportunity to provide universal access to innovative care in an affordable system.

Published: February 2, 2023. doi:10.1001/jamahealthforum.2023.0187

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Baicker K et al. JAMA Health Forum .

Corresponding Author: Katherine Baicker, PhD, Harris School of Public Policy, University of Chicago, 1307 E 60th St, Chicago, IL 60637 ( [email protected] ).

Conflict of Interest Disclosures: Dr Baicker reported serving on the board of directors for Eli Lilly; serving as a trustee for the Mayo Clinic, the Urban Institute, the Chicago Council on Global Affairs, and NORC at the University of Chicago; and serving on advisory boards for the National Institute for Health Care Management and the Congressional Budget Office. Dr Chandra reported serving as an advisor to the Analysis Group, HealthEngine, SmithRx, and the Congressional Budget Office; having stock options in Kyruus; and receiving travel reimbursement from the Davos Alzheimer’s Collaborative. Dr Shepard reported serving on a technical advisory panel for and receiving personal fees from the Congressional Budget Office.

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Baicker K , Chandra A , Shepard M. A Different Framework to Achieve Universal Coverage in the US. JAMA Health Forum. 2023;4(2):e230187. doi:10.1001/jamahealthforum.2023.0187

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Universal Health Care System in the US Speech Essay

Satisfaction, visualization (negative method), universal health care system in the us speech outline.

In 2020, a big crisis showed that the USA health care system is not efficient. This crisis is the COVID-19 pandemic. Madara (2020) notes that “the coronavirus pandemic presents a challenge unlike anything we’ve faced in this country for generations” (para. 1). According to Miller (2020), the current healthcare system’s failure in dealing with the pandemic has resulted in more than 300,000 people’s deaths. Moreover, he also notes that there were frequent shortages of such medical equipment as “beds, gowns, face masks, ventilators” medical equipment (Miller, 2020, para. 7). It is obvious that a reform of the universal health care system is needed.

It can be said that the voiced problems are only symptoms of a prolonged crisis of the current US health care system. The problem is characterized by two critical long-term issues, which are the unaffordability of health insurance and high health care costs. Heitkamp (2018) states that more than 28 million US citizens cannot afford medical insurance. Lyford and Lash (2019) note that many families cannot afford even primary health care services due to high prices. Miller (2020) claims the US federal government spends more than four trillion annually. Administrative costs alone are $ 300 billion and overall costs (Heitkamp, ​​2018). A promising solution to these fundamental problems is needed.

The current social and political climate presents a unique opportunity for those in power to design and implement healthcare a reformation plan. The most effective and appropriate approach would be to transform the current system, which consists of private and public areas, into a universal one. Heitkamp (2018) states that “universal health care is a single-payer health care system in which the government – not a private insurer – pays for health care” (p .15). Successful examples of such models are seen in many Western European countries, for example, France and Germany. The recent health care reform in Argentina explored by Rubinstein et al. is another successful example (2018). However, the universal health care system’s negative consequences could be a decline in the quality of medical services and an increased federal budget spending on health care.

If the announced measures are not taken, then a significant deterioration of the current problems is possible. The number of people who cannot afford health care services would continue to grow as well as budgetary costs. It is also apparent that failures in dealing with crises would continue to occur.

What can we do to help solve the problem that is relevant to all Americans? I urge you to educate yourself on the topic of healthcare as well as to participate in promotions dedicated to universal health care.

• The COVID-19 pandemic is a big crisis that showed that the United States’ health care system is not efficient.
• “The coronavirus pandemic presents a challenge unlike anything we’ve faced in this country for generations” (Madara, 2020, para. 1).
• The failure of the current health care system in dealing with the pandemic has resulted in more than 300,000 people’s deaths (Miller, 2020).
• Shortages of medical equipment (Miller, 2020).
• It is obvious that a reform of the universal health care system is needed.
• The issues pointed out are only symptoms of a prolonged crisis of the current US health care system.
• Two fundamental long-term problems, which are the unaffordability of health insurance and high health care costs.
• Heitkamp (2018) states that more than 28 million US citizens cannot afford medical insurance.
• A large number of families cannot afford even primary health care services due to high prices (Lyford & Lash, 2019).
• US federal government spends more than four trillion annually (Miller, 2020).
• An effective solution to these fundamental problems is needed.
• Reform is needed.
• The most effective and appropriate approach would be to a universal health care reform.
• “Universal health care is a single-payer health care system in which the government – not a private insurer – pays for health care” (Heitkamp, 2018, p .15).
• Western Europe is a successful example of universal health care.
• The recent health care reform in Argentina explored by Rubinstein et al. is another successful example (2018).
• Potential decline in the quality of medical services.
• Possibility of increasing federal budget spending on health care.
• More people without access to medical services and care.
• Higher budgetary costs on the current system.
• Failures in dealing with future crises.
• Educate yourself on the topic of healthcare.
• Participate in universal health care promotions.

Heitkamp, K. L. (2018). Universal health care . Greenhaven Publishing LLC.

Lyford, S., & Lash, T. A. (2019). America’s healthcare cost crisis . Generations, 43 (4), 7-12. Web.

Madara, J. L. (2020, July 20). America’s health care crisis is much deeper than COVID-19 . American Medical Association. Web.

Miller, J. W. (2020, May 29). Most Americans support universal health care. But can it actually happen? America – The Jesuit Review. Web.

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Memories of fishers reach beyond the data

Catch recollection of Brazilian fishers provide accurate reconstructions of fisheries counts in remote regions.

• David Fleming

16 Apr 2024

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On the coast of Brazil, generations of fishers have set out every day to fish for food that will provide a livelihood for their families and communities. Now, with increased fishing and declining fisheries stocks raising concerns about future access, there is a critical need to understand historical harvest totals in rural regions to gain a better picture of what a robust ecosystem would look like.

A research team led by College of Natural Resources and Environment Associate Professor Leandro Castello is turning to an unusual source to accomplish this goal: the memories of fishers who have made their livings harvesting the world’s oceans and rivers. A new paper published in Frontiers in Ecology and the Environment suggests that local knowledge of past harvests can provide an accurate – and affordable – depiction of historical fish stocks. Additionally, having community fishers participate in developing stock quota histories has the potential to increase participation in future conservation practices and approaches.

This research aligns with Virginia Tech’s pledge to address global challenges through extensive, diverse partnerships and interdisciplinary collaborations, a hallmark of the  Virginia Tech Global Distinction  commitment to elevate the university’s international efforts to act as a force for positive change.

Collecting data face-to-face

Funded by the Pew Charitable Trust, the first step of Castello’s research team was selecting regions in Brazil where there was robust scientific data on fishing hauls. With that data on hand, researchers conducted interviews with area fishers to see if their memories aligned with the available data.

“All in all, we were able to compile data from nearly 400 fishers from 24 coastal fisheries in Brazil,” said Castello, who teaches in the Department of Fish and Wildlife Conservation . “These are communities where they are harvesting sardines, mahi-mahi, and other fish species.

“On average, we found that the fishers were about 95 percent accurate,” said Castello, an affiliated faculty member of the Fralin Life Sciences Institute , the Global Change Center , and the Center for Coastal Studies . “What this research does is get at the concept of the wisdom of the crowd. We’re able to demonstrate that you can produce information that is useful in reconstructing the historical record at a fraction of the cost of trying to rely on large-scale fisheries data.”

This knowledge fills a crucial gap for researchers attempting to determine fisheries declines in regions where broadscale data currently is not being collected. While individual accounts of fish catch are invariable scattered, when a large enough sample is aggregated, the result is data that can accurately depict the extent of fisheries harvest declines going back nearly 50 years.

Local knowledge as a tool for change

This project was not the first time Castello utilized local knowledge to conduct fisheries research: He has an extensive research portfolio studying arapaima, a species of air-breathing river fish that is a critical resource for communities along the Amazon. He also has conducted catch assessment research on Congo River fisheries where there is little collected fisheries data.

“My research on arapaima in the Amazon and in the Congo shows that fishers can produce useful fish data just as well as the best scientific methods with two differences: The fishers are 200 times cheaper and they are much, much faster at providing data,” said Castello.

And there is a third benefit: Involving fishers directly in the process gives them a stake in trying to conserve declining fishing stocks.

“With this paper, we’re able to go back to these communities and show them the graphs,” said Castello. “In another context, one could even point out each of their names as data points. In our work in the Democratic Republic of Congo, we recently shared our findings and said, ‘This is the information you gave us and this is the statistical method we used. Do you question these results?’ When they said no, we asked if there was anything they wanted to do about these declines.”

The fishers – not merely the subject of research but participants and experts – expressed a greater willingness to consider conservation approaches that would protect fish stocks for future seasons and generations. For Castello, getting such buy-in is critical to promoting real change, because it aligns local communities with the global challenges of conserving fishing stocks in the world.

“Having cheaper access to data is important, but the more vital part of this research is giving rural communities the tools and the responsibilities to manage their resources,” Castello said. “The key difference with this approach is that we’re relying on the skills and knowledge of the fishers and not just coming in with fancy scientific information and results that have nothing to do with their lives.”

Castello recently presented on this research to policymakers in Brazil’s federally protected areas, who are considering pilot programs to incorporate fishers’ memories in strategies to improve fisheries management in the country.

Castello’s collaborators within Virginia Tech include Michael Sorice of the Department of Forest Resources and Environmental Conservation and Eric Smith of the Department of Statistics . External collaborators include the University of Northern British Columbia, Federal University of Pará in Brazil, Federal University of Rio de Janeiro, and other institutions. 

Krista Timney

540-231-6157

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