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Why Is Health Care Not Free in The U.S.?

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Why Is Health Care Not Free in The U.S.?

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Healthcare cost is the total amount of money spent on medical services from treatments, medications, etc all medical expenses. Healthcare cost also includes insurance and the government pays for all health-related expenses.

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Universal Healthcare is a system in which all residents of a country have acess to medical services and coverage without needing to worry about affordability.

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Organizations that are the foundation of medical insurance in the U.S. advocate specific healthcare agendas and legislative changes. They represent the healthcare industry.

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People in the Medical community, such as doctors, nurses, etc, are going to be concerned about the chance of reduced income and autonomy. They do not agree with universal healthcare but more for self-opportunity.

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Health Insurance is the contract that provides coverage for all kinds of medical expenses. . Healthcare is an essential part of the U.S. health system. The money is used to pay for medical services, administrative costs, research, etc.

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Why can’t the U.S. change its current insurance policies to universal insurance policies, what's stopping it from making the change that could help so many individuals?

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Why can’t the U.S. change its current insurance policies to universal insurance policies, what's stopping it from making the change that could help so many individuals?

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There are multiple parts on why the U.S. hasn’t changed its current insurance to universal insurance. A few reasons are political opposition, economic concerns, and the influence of interest groups. These aspects are all vital to the U.S. and hold them back from changing to universal insurance like most other countries around the world. These factors need to be agreed upon and others need to be exposed and their corruption needs to be justified.

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How has the historical development of the U.S. healthcare system contributed to the current model where healthcare isn’t free?

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How has the historical development of the U.S. healthcare system contributed to the current model where healthcare isn’t free?

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The Healthcare system in the U.S. isn’t free because of how it started during World War 2 and well the so-called Job-Based Insurance. Even though Medicare and Medicaid came later they unfortunately didn't cover everyone. The U.S. in general likes to have private insurance but it is also a messy system. During the Cold War citizens of the U.S. didn't want everyone to get equal healthcare. Americans never thought about the bigger picture such as the right healthcare for everyone. The companies who control creating medicine and insurance have influence and make it hard to change things people believe are wrong. These are some of the reasons why historically the U.S. doesn’t have free Healthcare.

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What ethical considerations such as the right to health, social justice, and moral obligation to society contribute to the reason why healthcare should be free in the U.S?

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What ethical considerations such as the right to health, social justice, and moral obligation to society contribute to the reason why healthcare should be free in the U.S?

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Free healthcare is a right and a principle of fairness, health care should be an equitable resource for all. Everyone should have the right to get the medical attention they need no matter their financial status. It’s a moral obligation and it’s something that should be a human right. There is no reason for a who seeking help not to get provided the services they need. This concept revolves around equal opportunity for healthcare. It is morally correct to help all those in need and cannot help themselves just because they don’t have enough money.

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Most Americans don't want free healthcare because of popular individualism is in the U.S.

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Why should someone who pays more for healthcare get the same treatment as someone who hasn't paid. Just because healthcare is free doesn't mean it'll be the best.

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Interest group influence

Ideological differences

Anti-communism

Anti-socialism

Fragmentation of public policy

Enterpreneruail character

American voluntarism

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https://www.linkedin.com/pulse/pros-cons-universal-healthcare-aim%C3%A9e-jordan#:~:text=In%20conclusion%2C%20universal%20healthcare%20coverage,of%20care%2C%20and%20high%20taxes

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The Pros and Cons of Universal Healthcare

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Universal healthcare coverage is a system where a country provides access to necessary medical services for all of its citizens, regardless of their financial status. While this type of healthcare system has its benefits, there are also drawbacks that are important to consider.

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https://news.gallup.com/poll/468401/majority-say-gov-ensure-healthcare.aspx#:~:text=WASHINGTON%2C%20D.C.%20%2D%2D%20A%2057,than%20run%20by%20the%20government

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Story Highlights

57% say government should ensure health coverage for all in U.S.

53% favor health system based on private insurance; 43%, a government-run one

72% of Democrats, 13% of Republicans support government-run system

WASHINGTON, D.C. -- A 57% majority of U.S. adults believe that the federal government should ensure all Americans have healthcare coverage. Yet nearly as many, 53%, prefer that the U.S. healthcare system be based on private insurance rather than run by the government. These findings are in line with recent attitudes about the government's involvement in the healthcare system, which have been relatively steady since 2015.

Majority in U.S. Say Healthcare Is Government Responsibility

In 2000, Gallup began tracking the public's views of whether it is the federal government's responsibility to ensure all Americans have healthcare coverage and has found considerable fluctuation. From 2000 through 2008, majorities ranging from 54% to 69% believed the federal government should ensure universal coverage in the U.S.

In 2009, then-President Barack Obama's administration worked with Congress to pass the Affordable Care Act (ACA), which expanded access to private health insurance via new government mandates and subsidies. The bill was ultimately signed into law in March 2010, and until 2012, the public was divided in their attitudes about the government's obligation for healthcare coverage in the U.S. From 2012 through 2014, clear majorities said this was not the government's responsibility.

In 2015, the tide again turned, and a slim majority felt healthcare coverage was a government obligation. Since then, between 51% and 57% of Americans have held this view. The latest findings, from Gallup's annual Health and Healthcare poll conducted Nov. 9-Dec. 2, 2022, show 57% think the government should be responsible to ensure coverage for all Americans, while 40% say it should not.

Partisans' views of the federal government's responsibility in ensuring healthcare for all Americans diverge sharply, as they have over the past two decades. Currently, 88% of Democrats and 59% of independents but just 28% of Republicans think the government is responsible.

While an average 79% of Democrats since 2001 have asserted the government's obligation to ensure healthcare for all in the U.S., an average 71% of Republicans over the same period have said the opposite. A 56% average of independents have said it is a governmental obligation.

Preference for Private Healthcare System Over Government-Run Persists

At the same time that Americans see a government role in ensuring universal U.S. healthcare coverage, they prefer that the nation's healthcare system be based on private insurance rather than run by the government. Currently, 53% of U.S. adults prefer a private system, while 43% support a government-run system. Since 2010, when the measure was first tracked, the public has consistently favored private insurance, with just one exception: In 2017, U.S. adults were evenly divided in their preferences.

Partisans' preferences for the U.S. healthcare system differ sharply, with 72% of Democrats in favor of a government-run system and 83% of Republicans a private system. Independents tilt slightly toward a private (50%) rather than a government-run (46%) system.

Over the past 13 years, the percentage of Republicans preferring private insurance has not fallen below 79%; it peaked at 91% in 2010, the year the ACA became law. At the same time, between 52% (in 2013) and 77% (in 2021) of Democrats have favored a government-run system.

Majorities of independents backed a private system from 2010 through 2015, but they have been more divided since then, reaching a consensus only once -- in 2021, when 55% favored private insurance.

Bottom Line

Americans continue to hold a nuanced view of the U.S. healthcare system, with a majority saying the government should ensure that all Americans have coverage but preferring that the system be funded privately. Partisans have fundamentally differing views on how healthcare should be delivered in the U.S., with Democrats indicating support for a system where the government not only guarantees coverage but provides healthcare, while Republicans remain wedded to the current system of private coverage and healthcare.

Notably, Democrats are more unified in their belief that government is responsible for ensuring all Americans have healthcare than in wanting a true public health system. Conversely, Republicans are more unified against such medical care than they are against the idea that it is government's job to make sure no American goes without healthcare.

To stay up to date with the latest Gallup News insights and updates, follow us on Twitter.
Learn more about how the Gallup Poll Social Series works. View complete question responses and trends (PDF download).

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Majority in U.S. Still Say Gov't Should Ensure Healthcare

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A majority of U.S. adults continue to think the federal government should ensure universal healthcare coverage, while they also prefer that the U.S. healthcare system be based on private insurance rather than government-run.

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https://study.com/learn/lesson/history-healthcare-u-s-timeline-evolution-impacts.html#:~:text=1950s%3A%20The%20cost%20of%20medical,COBRA

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1. In the 1910s’s The American Labor Legislation offered the idea of healthcare for low-class and working-class citizens

2. In the 1920s’s The predecessor of the Blue Cross was made.

3. In 1935 The Social Security Act was passed

4. In the 1950’s The cost of medical care doubled.

5. In the 1960s The extension of the Social Security Act gave the blueprint for Medicare and Medicaid

6. In 1973, The Health Maintenance Organization Act was passed.

7. In 1986 The Consolidated Omnibus Budget Reconciliation Act was passed

8. In the 1990s’s The Health Insurance Portability and Accountability was passed as well as the Children’s Health Insurance Program

9. In 2010 The Patient Protection and Affordable Act was passed

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factors that contribute to rising healthcare costs

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factors that contribute to rising healthcare costs

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Population Growth

Population Aging

Disease prevalence or incidence

Service utilization

Service price and intensity

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https://aspe.hhs.gov/reports/effects-health-care-spending-us-economy-0#:~:text=Overall%20Economy%20Rapidly%20rising%20health,positive%2C%20impact%20on%20the%20economy

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This report is available on the Internet at: http://aspe.hhs.gov/health/costgrowth

Printer Friendly Version in PDF Format

This background paper examines health care spending and the impact on the economy of the United States. In brief, the findings reported in this paper are:

The relationship between health care spending growth and the U.S. economy is inherently complex and multidimensional. Rising health care spending can be viewed as both a weight on broader economic growth and as a driver of sectoral and local prosperity.

Recent Trends Since the late 1990s, health care spending has increased at a faster rate of growth than has gross domestic product (GDP), inflation, and population. In the latest year data are available (2003), total national spending on health care rose to $1.67 trillion, or $5,670 per person.

Overall Economy Rapidly rising health care spending is considered to lower the rate of growth in GDP and overall employment, while raising inflation. However, some economists view increases in health care spending as a neutral, if not positive, impact on the economy. Increased health care spending, in this view, is seen as improving access to new health care technologies and treatments.

Employers 174 million Americans, or 60.4 percent of the population, had employment-based health insurance during 2003. A December 2004 survey of CEOs found that employee health care costs are the foremost cost concern in the minds of Americas business leaders.

Active Workers In 2004, employers contributed $3,137 for single coverage and $7,289 for family coverage on average across all plan types.

Retirees The 2004 Kaiser/Hewitt survey on retiree health benefits found that the total cost of providing health benefits to retirees from 2003 to 2004 increased by 12.7 percent, on average, for surveyed employers.

Local Impacts, Health Sector The health sector is a significant source of employment for American workers, employing 6.3 million practitioners and technical workers, and 3.2 million Americans in health care support occupations in as of November, 2003.

Employees Workers with employer-sponsored health insurance will often experience reductions in real (after adjusting for inflation) wages reductions (or wage growth) in response to health care cost growth. The empirical evidence has tended to show that health care cost increases are offset by either direct wage reductions, increased employee cost sharing, or in instances where wages are fixed (i.e., unionized contracts), by increases in the number of hours worked.

Households In the latest available data (2002), the average household spent $2,350 a year, or 4.8 percent of its income, on health care. Roughly 20 million American families, or 43 million people, reported financial problems related to paying medical bills in 2003.

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In recent years, considerable attention has focused on aggregate health care spending increases. Emphasis has been given to identifying and examining the factors that have contributed to spending growth, and proposing policy solutions to reduce spending growth. Factors that contribute to spending growth encompass changes in health care utilization, population demographics, price inflation, and advances in medical technology.[1]

This background paper focuses on a somewhat broader topichow health care spending impacts the economy of the United States. The relationship between health care spending growth and the U.S. economy is inherently complex and multidimensional.

At an aggregate level, economists have cautioned that rising health care spending could lower economic growth and employment.[2]. A December 2004 survey of CEOs found that employee health care costs are the foremost cost concern in the minds of Americas business leaders (Figure 1).[3] Further, rising health care spending has a significant impact on the federal budget.[4] Many employers are seeking to limit their exposure to rising health care costs by requiring their employees to increase their contributions or by providing different forms of coverage, potentially reducing household available income finances as more costs are shifted from employers to employees.

Some economists note that rising health care spending has important benefits, often outweighing the increased costs.[5] When adjusted for improvements in quality, these economists found that the cost of medical care is in fact in decreasing. In this view, increased health care spending improves increases access to new technologies providing both new options of treatment (substitution) and treatment for a greater number of individuals (expansion).

Technology often leads to more spending, but outcomes improve by even more. [6]

At a local level, health care spending growth is more likely to be viewed as beneficial. It creates health care jobs, increases wages for health care workers, expands local tax revenues, and increases demand for related goods and services.

Source: Business Roundtable December 2004 CEO Survey.

The remainder of this paper is organized into five sections. The next section contains a brief overview of trends in health care spending. This is followed by four sections that contain discussions of the impacts of health care spending on 1) the overall economy, 2) employers, 3) employees, and 4) households.

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Total Spending

In the latest year for which data is available (2003) total national spending on health rose to $1.7 trillion, or $5,670 per person ( Table 1). By 2013, national health expenditures are projected to reach $3.4 trillion, or $10,709 per person. As a share of GDP, health spending is projected to reach 18.4 percent by 2013, up from its 2003 level of 15.3 percent.

Source: National Health Expenditures, Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce, Bureau of Economic Analysis; and U.S. Bureau of the Census.

Spending on outpatient hospital services and prescription drugs continued to outpace the rate of growth in overall health care spending as services move out of the hospital and into ambulatory settings. Since 1998, health care spending has increased at faster rate of growth than has gross domestic product (GDP), inflation, and population.[7]

Data Source: National Health Expenditures 2002. Centers for Medicare & Medicaid Services. NHE Tables.

Although the recently passed Medicare prescription drug benefit is not expected to have a large impact on overall national health spending, it is expected to cause sizable shifts in payment sources.[8] These shifts include from individuals and private payers to Medicare and from Medicaid to Medicare.

Sectoral Spending

In 2003, the private sector accounted for over half of national health expenditures, with private health insurance contributing the largest share ($600.6 billion or 36 percent) ( Figure 3). Individual out-of-pocket payments, part of private sector spending, accounted for $230.5 billion (or 14 percent of expenditures) in 2003.

Figure 3. The Nations Health Dollar Sources of Funding

Uses of Funding

Graphic Source: Charts, National Health Expenditures 2003. Centers for Medicare & Medicaid Services.

Footnotes: 1. "Other Public" includes programs such as workers' compensation, public health activity, Department of Defense, Department of Veterans Affairs, Indian Health Service, and State and local hospital subsidies and school health.

2. "Other Private" includes industrial in-plant, privately funded construction, and non-patient revenues, including philanthropy.

3. "Other Spending" includes dental services, other professional services, home health care, durable medical products, over-the-counter medicines and sundries, public health activities, research and construction.

Over half of the recent increase in out-of-pocket spending for health services was due to increases in spending for prescriptions drugs, reflecting new medicines, greater utilization, price increases, and the fact that seniors the age group that uses the most prescription drugs often pay 100% out-of-pocket today.

The public sector accounted for the remaining 46 percent of total health spending. The Medicaid and Medicare programs accounted for 16 percent ($267.0 billion) and 17 percent ($283.1 billion), respectively. Other government health spending on public health, veterans, military personnel, and school children comprised most of the remaining 12 percent of public sector health spending.[9]

Finally, the publics share of health spending has steadily increased. In 1990, public spending accounted for about 41 percent of total spending ( Figure 4). By 2002, the publics share had increased to 46 percent of total spending.

Data Source: National Health Expenditures 2002. Centers for Medicare & Medicaid Services. NHE Tables.

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The gap between the growth in health care spending of 9.3 percent and overall economic growth of 3.6 percent, which means a larger share of more resources are being devoted to health care relative to other goods, will impact the public and private sectors of the economy.[10] The public sector federal, state and municipal governments is faced with costs rising more rapidly than revenues, placing high scrutiny on all discretionary health care spending, especially health care. Companies with rising health care spending may cut other expenses, reduce wage increases, reduce health insurance benefits, or require employees to pay a greater share of the costs. As more costs are shifted to consumers, they will weigh the value of health care services will be more closely weighed against other purchases.

Some economists believe that rapidly rising health care spending lowers GDP and overall employment, while raising inflation. The effects of health care spending on interest rates and the relative impact on economic performance across industries depend upon the source of financing for federal health care spending. The results of one study using econometric models indicated that deficit financing disproportionately harms export and capital goods industries, and payroll tax financing disproportionately harms consumer service industries.[11]

It should be noted, however, that some economists view increases in health care spending as a neutral, if not positive, impact on the economy. Increased health care spending, in this view, is seen as a transfer.

One Americans rising medical spending is another Americans rising income.[12]

These transfers result in real employment growth and financial prosperity for companies that are largely American owned. The Congressional Budget Office (CBO) notes in a related viewpoint that as income rises, consumers may choose to assign a larger portion of their resources to health care services and a smaller portion to other goods and services.

Government Spending

Rising healthcare spending plays a central role in the fiscal health of the United States government.

In 1960, public funding accounted for about 25 percent of total health care spending. By 2002, this share nearly doubled to approximately 46 percent of total spending.[13] A large part of this increase is attributable to the introduction of the Medicare and Medicaid programs together with the aging of the population and expansion of program eligibility and benefits.

The primary impact of the increase in the governments share of health care spending is the burden it places upon the citizens to finance this spending namely increasing taxes, or increasing long-term borrowing. In addition to reducing the amount of income that firms and households would have for other activities, tax increases also create incentives to engage in activities to avoid the effects of these increases.[14]

Increased government borrowing to finance health care spending growth has a similar impact on the availability of resources for other activities. As interest rates increase due to government borrowing, the cost of capital to firms and households also increases, which would effectively crowd out investment in some activities that would otherwise been undertaken.

Finally, increased spending often results in greater intergenerational transfers of wealth from younger to older segments of the population.[15]

International Competitiveness

In theory, increasing health care costs could make U.S. goods and services less competitive in international markets.[16] Holding all other factors constant, increasing health care costs will have to be reflected in the final product costs, and depending upon how quickly health care costs are rising in other countries, could result in relatively more expensive goods and services.

Obtaining quantitative estimates of the degree to which health care costs have contributed to the US trade deficit (or other measures of interest), however, is a complex undertaking.

According to statistics from the Organisation for Economic Cooperation and Development (OECD), health care costs accounted for about 15 percent of US GDP in 2002. In contrast, for Switzerland (the next highest country) and the Slovak Republic (the lowest country in the comparison group) health care costs accounted for about 11 percent and 6 percent of GDP, respectively.[17] Although these simple statistics illustrate a sharp contrast across countries, converting these differences into relative product/service prices would entail accounting for differences in worker productivity, health cares share of total production costs, technology, and other factors that affect relative product prices between different countries.

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Many Americans receive part or all of their health insurance coverage through their employer during their years of active work and in retirement (174 million Americans, or 60.4 percent of the population, had employment-based health insurance during 2003).[18] In 2003, U.S. private employers spent an estimated $330.9 billion on employee health insurance.[19] Adjusting for participation in health insurance coverage by employers, it has been estimated that those who offered health insurance spent an average of $3.80 per hour for participating employees in 2003.[20]

Some employers now view rising health care costs as equally important to their profitability as energy costs and broader economic trends.[21],[22] Employers from large airlines to restaurant chains report double-digit increases in their health care spending, which erodes profits. Growth in health care spending has led employers to reduce, eliminate, or change this coverage.

Rising health care spending has the potential to lead some employers to curtail new hiring of full-time, benefit-eligible, employees. These increasing costs may also force companies perhaps most notably automakers with their large pool of unionized retirees to raise prices for their products. General Motors estimated in 2004 that providing health insurance for its workers and retirees added $1,400 to the price of cars built in the United States.[23]

Active Worker Coverage

Employers have seen their costs to insure active workers and dependents rise. In 2004, public and private employers surveyed by Kaiser/HRET contributed $3,137 for single coverage and $7,289 for family coverage on average across all plan types.[24] These costs have led to a small though statistically significant drop in the number of employers who offer health insurance to their active workers and dependents since 2001 (a decrease from 68 percent to 63 percent of all firms). A majority of employers in 2004 reported that they are likely to increase the amount that employees pay for health insurance.

Retiree Coverage

From 2003 to 2004, larger private sector employers providing retiree health insurance coverage saw their costs increase by an average of 12.7 percent.[25] As a consequence of these rising costs, a recent survey found that during the past year 79 percent of large private-sector firms increased retiree contributions to premiums and 45 percent increased cost-sharing requirements. Further, 8 percent of surveyed employers eliminated subsidized health benefits for future retirees. Since 1988, the share of large employers offering retiree health benefits declined from 66 percent to 36 percent. Retiree health insurance coverage has become a key factor in negotiations between employers and employees, and in bankruptcy proceedings.

Local Impacts, Health Sector Employers

Health spending impacts at the local market level are typically viewed more favorably. As the health sector becomes a greater portion of GDP, employment and related activities in the health sector also grow. According to the Bureau of Labor Statistics, the health sector employed 6.3 million practitioners and technical workers as of November 2003.[26] Coupled with the 3.2 million Americans employed in health care support occupations, the health sector is a significant source of employment for American workers. For example, hospitals account for over $1.3 trillion in economic activity annually.[27] By state, hospitals as a percent of total non-farm employment range from 4.1 percent in Nevada to 13.3 percent in North Dakota.

Though health care costs are a significant burden to all levels of government, at the metropolitan level, that spending represents a substantial economic asset and potential leverage for improving job growth and wages.[29]

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Most economists combine wages and benefits when examining employee compensation and the dynamics of the labor market. Firms that continue to offer health insurance will focus on the total compensation, and when paying higher benefit costs may reduce wages (or wage growth) in an attempt to keep total worker compensation (wages and benefits) the same.[30] The empirical evidence has tended to show that health care cost increases are indeed offset by either direct wage reductions, increased employee cost sharing, or in instances where wages are fixed (i.e., unionized contracts), by increases in the number of hours worked.[31]

Finally, to the extent that firms are unable to offset cost increases via wage reductions or hour increases, work force reductions could result in layoffs, not replacing employees who quit, and/or increasing the number of part-time and temporary workers. Recent statistics support this understanding of the impact of health care spending on staffing decisions. While the overall labor force grew by 1 percent from July 2003 to July 2004, the number of individuals employed in temporary positions grew by 9 percent during the same time period.[32] Evidently, employers are choosing to differentially fill positions with temporary workers who do not have the attendant rising health care costs of full-time, benefit-eligible employees.

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In 2002 the most recent year for which data are available the average household spent $2,350 a year, or 4.8 percent of its income, on health care. This is an increase from 1999, when the average household health expenditure was $1,959, or 4.5 percent of income.

Households may also benefit from increased health spending through improved health status, increased access to care, wage and employment growth in the health care sector, and improved local economic activity. Improvements in health status may have a positive economic impact on households through increased productivity, reduced absenteeism, and enhanced independence.

As health care coverage costs increase, fewer individuals and families may afford private coverage and some of those with coverage may find it challenging to cover their out-of-pocket costs. In 2003, roughly 20 million American families, or 43 million people, reported financial problems paying medical bills.[33]

Rising health costs affect household finances. Income and savings that would otherwise be used for purchasing consumer goods, or put toward savings for financing future educational costs or retirement, must be used to cover health care services. For less affluent households, this could result in forcing tradeoffs between health care and other normal necessities of living. For example, a 2003 survey found that 63 percent of families that reported problems with paying medical bills also had problems paying for other household necessities, such as food, clothing, and rent.[34]

Low-income households without access to government or private sector charity programs may be particularly impacted by rising health care costs. A recent study reported that between 2001 and 2003 the proportion of insured low-income individuals with chronic conditions that spent more than five percent of their income on health care rose from 28 percent to 42 percent. Almost half of the uninsured low-income chronically ill have reported problems in paying medical bills, which has likely contributed to delaying or foregoing medical care.[35] In line with these cost-related health care choices, increased spending on health care led almost 6 million Americans to seek complimentary and alternative medicine (CAM) treatments in 2002 as a more affordable option compared to traditional medical care.[36]

Finally, increasing public sector health care spending will indirectly impact households. As indicated above, public sector financing requirements might result in increases in taxes, borrowing, or some combination of the two. Such increases would impact households via direct reductions in disposable income or increases in the cost of borrowing.

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[1] See The Lewin Group, Inc., Drivers of Healthcare Costs Associated with Physician Services, October 16, 2002, or Newhouse, J.P., Medical Care Costs: How Much Welfare Loss?, Journal of Economic Perspectives, 6(3):3-21, 1993.

[2] R M Monaco and J H Phelps Health care prices, the federal budget, and economic growth Health Affairs, Summer 1995; 14(2): 248-259.

[3] Business Roundtable. December 2004 CEO Economic Outlook Survey. http://www.businessroundtable.org/newsroom/Document.aspx?qs=5866BF807822...

[4] R M Monaco and J H Phelps Health care prices, the federal budget, and economic growth Health Affairs, Summer 1995; 14(2): 248-259.

[5] D M Cutler and M McClellan, Is technological change in medicine worth it? Health Affairs, September/October 2001; 20(5): 11-29.

[6] D M Cutler and M McClellan, Is technological change in medicine worth it? Health Affairs, September/October 2001; 20(5): 11-29.

[7] Mark V. Pauly, Should We Be Worried About High Real Medical Spending Growth In The United States? Health Affairs Web Exclusive, January 8, 2003

[8] Health Spending Projections Through 2013. Health Affairs Web Exclusive. Stephen Heffler, Sheila Smith, Sean Keehan, M. Kent Clemens, Mark Zezza, and Christopher Truffer, 11 February 2004.

[9] Highlights, National Health Expenditures 2002 and 2003. CMS. www.cms.hhs.gov/statistics/nhe/historical/highlights.asp

[10] Highlights, National Health Expenditures 2002 and 2003. CMS. www.cms.hhs.gov/statistics/nhe/historical/highlights.asp

[11] R M Monaco and J H Phelps Health care prices, the federal budget, and economic growth Health Affairs, Summer 1995; 14(2): 248-259.

[12] Mark V. Pauly, Should We Be Worried About High Real Medical Spending Growth In The United States? Health Affairs Web Exclusive, January 8, 2003

[13] Centers for Medicare & Medicaid, Office of the Actuary, National Health Expenditures, various years,

[14] Pauly, M., Should We Be Worried About High Real Medical Spending Growth in the United States, Health Affairs, January, 2003.

[15] Pauly, ibid.

[16] Carmakers Face Huge Retiree Health Care Costs. Danny Hakim. New York Times. September 15, 2004.

[17] www.oecd.org/dataoecd/13/13/31963469.xls, as accessed on December 9, 2004.

[18] Uninsured Rose in 2003 as Number of Americans With Employment-Based Health Benefits Declined. Employee Benefit Research Institute. October 2004. Vol. 25, No. 10.

[19] EmploymentTrends. August 3, 2004. Employer Health Insurance Costs Continue to Rise. Employment Policy Foundation.

[20] EmploymentTrends. August 3, 2004. Employer Health Insurance Costs Continue to Rise. Employment Policy Foundation.

[21] Business Roundtable. December 2004 CEO Economic Outlook Survey.

[22] Companies Feel Pinch of Rising Health Costs. Dow Jones News Service. 07/17/2002

[23] Rising Cost of Health Benefits Cited as Factor in Slump of Jobs. Eduardo Porter. New York Times. August 19, 2004.

[24] Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2004.

[25] Current Trends and Future Outlook for Retiree Health Benefits: Findings from the Kaiser/Hewitt 2004 Survey on Retiree Health Benefits

[26] U.S. Department of Labor, Bureau of Labor Statistics, http://www.bls.gov/oes/current/oes290000.htm

[27] TrendWatch, The Economic Contribution of Hospitals. The Lewin Group and American Hospital Association. May 2004.

[28] The Economic Impact of Hospitals in Washington State in the Year 2001, William B. Beyers, Department of Geography, University of Washington

[29] The Other Side of the Ledger: Federal Health Spending in Metropolitan Economies, by Daniel Gitterman,Joanne Spetz, and Matthew Fellowes, September 2004, The Brookings Institution.

[30] See Summers,. L.H., Some Simple Economics of Mandated Benefits, American Economic Review Papers and Proceedings, 99:177-183, 1989 or S.A. Woodbury, Substitution Between Wage and Nonwage Benefits, American Economic Review, 73:166-182, 1983.

[31] See Goldman, D.P., N. Sood, and A. Leibowitz, The Reallocation of Compensation in Response to Health Insurance Premium Increases, NBER working paper no. 9540, March 2003, or Cutler, D.M. and B.C. Madrian, Labor Market Responses to Rising Health Insurance Costs: Evidence on Hours Worked, National Bureau of Economic Research Working Paper 5525, April, 1996, or Gruber, J. and A. Krueger, The Incidence of Mandated Employer-Provided Insurance: Lessons from Workers Compensation Insurance, in D. Bradford, ed, Tax Policy and the Economy, V. 5, (Cambridge MA: MIT Press, 1991).

[32] Rising Cost of Health Benefits Cited as Factor in Slump of Jobs. Eduardo Porter. New York Times. August 19, 2004.

[33] Tough Trade-offs: Medical Bills, Family Finances and Access to Care, Center for Studying Health System Change, Issue Brief No. 85, June 2004

[34] May, J.H. and P.J. Cunningham, Tough Trade-offs: Medical Bills, Family Finance: and Access to Care, Center for Studying Health System Change, Issue Brief No. 85, June 2004.

[35] Tu, H.T., Rising Health Costs, Medical Debt and Chronic Conditions, Center for Studying Health System Change, Issue Brief No. 88, September 2004.

[36] High Cost of Medical Care Prompts Consumers to Seek Alternatives, Center for Studying Health System Change, Data Bulletin No. 28, December 2004, Ha T. Tu, J. Lee Hargraves.

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Effects of Health Care Spending on the U.S. Economy

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Effects of Health Care Spending on the U.S. Economy This report is available on the Internet at:http://aspe.hhs.gov/health/costgrowth Printer Friendly Version in PDF Format

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(Transcribed from a talk given by Karen S. Palmer MPH, MS in San Francisco at the Spring, 1999 PNHP meeting)

Late 1800's to Medicare

The campaign for some form of universal government-funded health care has stretched for nearly a century in the US On several occasions, advocates believed they were on the verge of success; yet each time they faced defeat. The evolution of these efforts and the reasons for their failure make for an intriguing lesson in American history, ideology, and character.

Other developed countries have had some form of social insurance (that later evolved into national insurance) for nearly as long as the US has been trying to get it. Some European countries started with compulsory sickness insurance, one of the first systems, for workers beginning in Germany in 1883; other countries including Austria, Hungary, Norway, Britain, Russia, and the Netherlands followed all the way through 1912. Other European countries, including Sweden in 1891, Denmark in 1892, France in 1910, and Switzerland in 1912, subsidized the mutual benefit societies that workers formed among themselves. So for a very long time, other countries have had some form of universal health care or at least the beginnings of it. The primary reason for the emergence of these programs in Europe was income stabilization and protection against the wage loss of sickness rather than payment for medical expenses, which came later. Programs were not universal to start with and were originally conceived as a means of maintaining incomes and buying political allegiance of the workers.

In a seeming paradox, the British and German systems were developed by the more conservative governments in power, specifically as a defense to counter expansion of the socialist and labor parties. They used insurance against the cost of sickness as a way of "turning benevolence to power".

US circa 1883-1912, including Reformers and the Progressive Era:

What was the US doing during this period of the late 1800's to 1912? The government took no actions to subsidize voluntary funds or make sick insurance compulsory; essentially the federal government left matters to the states and states left them to private and voluntary programs. The US did have some voluntary funds that provided for their members in the case of sickness or death, but there were no legislative or public programs during the late 19th or early 20th century.

In the Progressive Era, which occurred in the early 20th century, reformers were working to improve social conditions for the working class. However unlike European countries, there was not powerful working class support for broad social insurance in the US The labor and socialist parties' support for health insurance or sickness funds and benefits programs was much more fragmented than in Europe. Therefore the first proposals for health insurance in the US did not come into political debate under anti-socialist sponsorship as they had in Europe.

Theodore Roosevelt 1901 - 1909

During the Progressive Era, President Theodore Roosevelt was in power and although he supported health insurance because he believed that no country could be strong whose people were sick and poor, most of the initiative for reform took place outside of government. Roosevelt's successors were mostly conservative leaders, who postponed for about twenty years the kind of presidential leadership that might have involved the national government more extensively in the management of social welfare.

AALL Bill 1915

In 1906, the American Association of Labor Legislation (AALL) finally led the campaign for health insurance. They were a typical progressive group whose mandate was not to abolish capitalism but rather to reform it. In 1912, they created a committee on social welfare which held its first national conference in 1913. Despite its broad mandate, the committee decided to concentrate on health insurance, drafting a model bill in 1915. In a nutshell, the bill limited coverage to the working class and all others that earned less than $1200 a year, including dependents. The services of physicians, nurses, and hospitals were included, as was sick pay, maternity benefits, and a death benefit of fifty dollars to pay for funeral expenses. This death benefit becomes significant later on. Costs were to be shared between workers, employers, and the state.

AMA supported AALL Proposal

In 1914, reformers sought to involve physicians in formulating this bill and the American Medical Association (AMA) actually supported the AALL proposal. They found prominent physicians who were not only sympathetic, but who also wanted to support and actively help in securing legislation. In fact, some physicians who were leaders in the AMA wrote to the AALL secretary: "Your plans are so entirely in line with our own that we want to be of every possible assistance." By 1916, the AMA board approved a committee to work with AALL, and at this point the AMA and AALL formed a united front on behalf of health insurance. Times have definitely changed along the way.
In 1917, the AMA House of Delegates favored compulsory health insurance as proposed by the AALL, but many state medical societies opposed it. There was disagreement on the method of paying physicians and it was not long before the AMA leadership denied it had ever favored the measure.

AFL opposed AALL Proposal

Meanwhile the president of the American Federation of Labor repeatedly denounced compulsory health insurance as an unnecessary paternalistic reform that would create a system of state supervision over people's health. They apparently worried that a government-based insurance system would weaken unions by usurping their role in providing social benefits. Their central concern was maintaining union strength, which was understandable in a period before collective bargaining was legally sanctioned.

Private insurance industry opposed AALL Proposal

The commercial insurance industry also opposed the reformers' efforts in the early 20th century. There was great fear among the working class of what they called a "pauper's burial," so the backbone of insurance business was policies for working class families that paid death benefits and covered funeral expenses. But because the reformer health insurance plans also covered funeral expenses, there was a big conflict. Reformers felt that by covering death benefits, they could finance much of the health insurance costs from the money wasted by commercial insurance policies who had to have an army of insurance agents to market and collect on these policies. But since this would have pulled the rug out from under the multi-million dollar commercial life insurance industry, they opposed the national health insurance proposal.

WWI and anti-German fever

In 1917, the US entered WWI and anti-German fever rose. The government-commissioned articles denouncing "German socialist insurance" and opponents of health insurance assailed it as a "Prussian menace" inconsistent with American values. Other efforts during this time in California, namely the California Social Insurance Commission, recommended health insurance, proposed enabling legislation i
n 1917, and then held a referendum. New York, Ohio, Pennsylvania, and Illinois also had some efforts aimed at health insurance. But in the Red Scare, immediately after the war, when the government attempted to root out the last vestiges of radicalism, opponents of compulsory health insurance associated it with Bolshevism and buried it in an avalanche of anti-Communist rhetoric. This marked the end of the compulsory national health debate until the 1930's.

Why did the Progressives fail?

Opposition from doctors, labor, insurance companies, and business contributed to the failure of Progressives to achieve compulsory national health insurance. In addition, the inclusion of the funeral benefit was a tactical error since it threatened the gigantic structure of the commercial life insurance industry. Political naivete on the part of the reformers in failing to deal with the interest group opposition, ideology, historical experience, and the overall political context all played a key role in shaping how these groups identified and expressed their interests.

The 1920's

There was some activity in the 1920's that changed the nature of the debate when it awoke again in the 1930's. In the 1930's, the focus shifted from stabilizing income to financing and expanding access to medical care. By now, medical costs for workers were regarded as a more serious problem than wage loss from sickness. For a number of reasons, health care costs also began to rise during the 1920's, mostly because the middle class began to use hospital services and hospital costs started to increase. Medical, and especially hospital, care was now a bigger item in family budgets than wage losses.

Next came the Committee on the Cost of Medical Care (CCMC). Concerns over the cost and distribution of medical care led to the formation of this self-created, privately funded group. The committee was funded by 8 philanthropic organizations including the Rockefeller, Millbank, and Rosenwald foundations. They first met in 1926 and ceased meeting in 1932. The CCMC was comprised of fifty economists, physicians, public health specialists, and major interest groups. Their research determined that there was a need for more medical care for everyone, and they published these findings in 26 research volumes and 15 smaller reports over a 5-year period. The CCMC recommended that more national resources go to medical care and saw voluntary, not compulsory, health insurance as a means to covering these costs. Most CCMC members opposed compulsory health insurance, but there was no consensus on this point within the committee. The AMA treated their report as a radical document advocating socialized medicine, and the acerbic and conservative editor of JAMA called it "an incitement to revolution."

FDR's first attempt - failure to include in the Social Security Bill of 1935
Next came Franklin D. Roosevelt (FDR), whose tenure (1933-1945) can be characterized by WWI, the Great Depression, and the New Deal, including the Social Security Bill. We might have thought the Great Depression would create the perfect conditions for passing compulsory health insurance in the US, but with millions out of work, unemployment insurance took priority followed by old age benefits. FDR's Committee on Economic Security, the CES, feared that inclusion of health insurance in its bill, which was opposed by the AMA, would threaten the passage of the entire Social Security legislation. It was therefore excluded.

FDR's second attempt - Wagner Bill, National Health Act of 1939
But there was one more push for national health insurance during FDR's administration: The Wagner National Health Act of 1939. Though it never received FDR's full support, the proposal grew out of his Tactical Committee on Medical Care, established in 1937. The essential elements of the technical committee's reports were incorporated into Senator Wagner's bill, the National Health Act of 1939, which gave general support for a national health program to be funded by federal grants to states and administered by states and localities. However, the 1938 election brought a conservative resurgence and any further innovations in social policy were extremely difficult. Most of the social policy legislation precedes 1938. Just as the AALL campaign ran into the declining forces of progressivism and then WWI, the movement for national health insurance in the 1930's ran into the declining fortunes of the New Deal and then WWII.

Henry Sigerist

About this time, Henry Sigerist was in the US He was a very influential medical historian at Johns Hopkins University who played a major role in medical politics during the 1930's and 1940's. He passionately believed in a national health program and compulsory health insurance. Several of Sigerist's most devoted students went on to become key figures in the fields of public health, community and preventative medicine, and health care organization. Many of them, including Milton Romer and Milton Terris, were instrumental in forming the medical care section of the American Public Health Association, which then served as a national meeting ground for those committed to health care reform.

Wagner-Murray-Dingell Bills: 1943 and onward through the decade

The Wagner Bill evolved and shifted from a proposal for federal grants-in- aid to a proposal for national health insurance. First introduced in 1943, it became the very famous Wagner-Murray- Dingell Bill. The bill called for compulsory national health insurance and a payroll tax. In 1944, the Committee for the Nation's Health, (which grew out of the earlier Social Security Charter Committee), was a group of representatives of organized labor, progressive farmers, and liberal physicians who were the foremost lobbying group for the Wagner-Murray-Dingell Bill. Prominent members of the committee included Senators Murray and Dingell, the head of the Physician's Forum, and Henry Sigerist. Opposition to this bill was enormous and the antagonists launched a scathing red baiting attack on the committee saying that one of its key policy analysts, I.S. Falk, was a conduit between the International Labor Organization (ILO) in Switzerland and the United States government. The ILO was red-baited as "an awesome political machine bent on world domination." They even went so far was to suggest that the United States Social Security board functioned as an ILO subsidiary. Although the Wagner-Murray-Dingell Bill generated extensive national debates, with the intensified opposition, the bill never passed by Congress despite its reintroduction every session for 14 years! Had it passed, the Act would have established compulsory national health insurance funded by payroll taxes.

Truman's Support

After FDR died, Truman became president (1945-1953), and his tenure is characterized by the Cold War and Communism. The health care issue finally moved into the center arena of national politics and received the unreserved support of an American president. Though he served during some of the most virulent anti-Communist attacks and the early years of the Cold War, Truman fully supported national health insurance. But the opposition had acquired new strength. Compulsory health insurance became entangled in the Cold War and its opponents were able to make "socialized medicine" a symbolic is
sue in the growing crusade against Communist influence in America.

Truman's plan for national health insurance in 1945 was different than FDR's plan in 1938 because Truman was strongly committed to a single universal comprehensive health insurance plan. Whereas FDR's 1938 program had a separate proposal for medical care of the needy, it was Truman who proposed a single egalitarian system that included all classes of society, not just the working class. He emphasized that this was not "socialized medicine." He also dropped the funeral benefit that contributed to the defeat of national insurance in the Progressive Era. Congress had mixed reactions to Truman's proposal. The chairman of the House Committee was an anti-union conservative and refused to hold hearings. Senior Republican Senator Taft declared, "I consider it socialism. It is to my mind the most socialistic measure this Congress has ever had before it." Taft suggested that compulsory health insurance, like the Full Unemployment Act, came right out of the Soviet constitution and walked out of the hearings. The AMA, the American Hospital Association, the American Bar Association, and most of then nation's press had no mixed feelings; they hated the plan. The AMA claimed it would make doctors slaves, even though Truman emphasized that doctors would be able to choose their method of payment.

In 1946, the Republicans took control of Congress and had no interest in enacting national health insurance. They charged that it was part of a large socialist scheme. Truman responded by focusing even more attention on a national health bill in the 1948 election. After Truman's surprise victory in 1948, the AMA thought Armageddon had come. They assessed their members an extra $25 each to resist national health insurance, and in 1945 they spent $1.5 million on lobbying efforts which at the time was the most expensive lobbying effort in American history. They had one pamphlet that said, "Would socialized medicine lead to socialization of other phases of life? Lenin thought so. He declared socialized medicine is the keystone to the arch of the socialist state." The AMA and its supporters were again very successful in linking socialism with national health insurance, and as anti-Communist sentiment rose in the late 1940's and the Korean War began, national health insurance became vanishingly improbable. Truman's plan died in a congressional committee. Compromises were proposed but none were successful. Instead of a single health insurance system for the entire population, America would have a system of private insurance for those who could afford it and public welfare services for the poor. Discouraged by yet another defeat, the advocates of health insurance now turned toward a more modest proposal they hoped the country would adopt: hospital insurance for the aged and the beginnings of Medicare.

After WWII, other private insurance systems expanded and provided enough protection for groups that held influence in American to prevent any great agitation for national health insurance in the 1950's and early 1960's. Union-negotiated health care benefits also served to cushion workers from the impact of health care costs and undermined the movement for a government program.

Why did these efforts for universal national health insurance fail again?

For may of the same reasons they failed before: interest group influence (code words for class), ideological differences, anti-communism, anti-socialism, fragmentation of public policy, the entrepreneurial character of American medicine, a tradition of American voluntarism, removing the middle class from the coalition of advocates for change through the alternative of Blue Cross private insurance plans, and the association of public programs with charity, dependence, personal failure and the almshouses of years gone by.

For the next several years, not much happened in terms of national health insurance initiatives. The nation focussed more on unions as a vehicle for health insurance, the Hill-Burton Act of 1946 related to hospital expansion, medical research and vaccines, the creation of national institutes of health, and advances in psychiatry.

Johnson and Medicare/caid

Finally, Rhode Island congressman Aime Forand introduced a new proposal in 1958 to cover hospital costs for the aged on social security. Predictably, the AMA undertook a massive campaign to portray a government insurance plan as a threat to the patient-doctor relationship. But by concentrating on the aged, the terms of the debate began to change for the first time. There was major grass roots support from seniors and the pressures assumed the proportions of a crusade. In the entire history of the national health insurance campaign, this was the first time that a ground swell of grass roots support forced an issue onto the national agenda. The AMA countered by introducing an "eldercare plan," which was voluntary insurance with broader benefits and physician services. In response, the government expanded its proposed legislation to cover physician services, and what came of it were Medicare and Medicaid. The necessary political compromises and private concessions to the doctors (reimbursements of their customary, reasonable, and prevailing fees), to the hospitals (cost plus reimbursement), and to the Republicans created a 3-part plan, including the Democratic proposal for comprehensive health insurance ("Part A"), the revised Republican program of government subsidized voluntary physician insurance ("Part B"), and Medicaid. Finally, in 1965, Johnson signed it into law as part of his Great Society Legislation, capping 20 years of congressional debate.

What does history teach us? What is the movement reacting to?

1. Henry Sigerist reflected in his own diary in 1943 that he "wanted to use history to solve the problems of modern medicine." I think this is, perhaps, a most important lesson. Damning her own naivete, Hillary Clinton acknowledged in 1994 that "I did not appreciate how sophisticated the opposition would be in conveying messages that were effectively political even though substantively wrong." Maybe Hillary should have had this history lesson first.

2. The institutional representatives of society do not always represent those that they claim to represent, just as the AMA does not represent all doctors. This lack of representation presents an opportunity for attracting more people to the cause. The AMA has always played an oppositional role and it would be prudent to build an alternative to the AMA for the 60% of physicians who are not members.

3. Just because President Bill Clinton failed doesn't mean it's over. There have been periods of acquiescence in this debate before. Those who oppose it can not kill this movement. Openings will occur again. We all need to be on the lookout for those openings and also need to create openings where we see opportunities. For example, the focus on health care costs of the 1980's presented a division in the ruling class and the debate moved into the center again. As hockey great Wayne Gretzky said, "Success is not a matter of skating to where the puck is, it is a matter of skating to where the puck will be."

4. Whether we like it or not, we are going to have to deal with the persistence of the narrow vision of middle class politics. Vincente Navarro says that the majority opinion of national health insurance has everything to do with repression and coercion by the capitalist corporate dominant class. He argues that the conflict and struggles that continuously take place around the issue of health care unfold within the parameters of class and that coercion and
repression are forces that determine policy. I think when we talk about interest groups in this country, it is really a code for class.

5. Red-baiting is a red herring and has been used throughout history to evoke fear and may continue to be used in these post Cold War times by those who wish to inflame this debate.

6. Grass roots initiatives contributed in part to the passage of Medicare, and they can work again. Ted Marmor says that "pressure groups that can prevail in quiet politics are far weaker in contexts of mass attention - as the AMA regretfully learned during the Medicare battle." Marmor offers these lessons from the past: "Compulsory health insurance, whatever the details, is an ideological controversial matter that involves enormous financial and professional stakes. Such legislation does not emerge quietly or with broad partisan support. Legislative success requires active presidential leadership, the commitment of an Administration's political capital, and the exercise of all manner of persuasion and arm-twisting."

7. One Canadian lesson - the movement toward universal health care in Canada started in 1916 (depending on when you start counting), and took until 1962 for passage of both hospital and doctor care in a single province. It took another decade for the rest of the country to catch on. That is about 50 years all together. It wasn't like we sat down over afternoon tea and crumpets and said please pass the health care bill so we can sign it and get on with the day. We fought, we threatened, the doctors went on strike, refused patients, people held rallies and signed petitions for and against it, burned effigies of government leaders, hissed, jeered, and booed at the doctors or the Premier depending on whose side they were on. In a nutshell, we weren't the sterotypical nice polite Canadians. Although there was plenty of resistance, now you could more easily take away Christmas than health care, despite the rhetoric that you may hear to the contrary.

8. Finally there is always hope for flexibility and change. In researching this talk, I went through a number of historical documents and one of my favorite quotes that speaks to hope and change come from a 1939 issue of Times Magazine with Henry Sigerist on the cover. The article said about Sigerist: "Students enjoy his lively classes, for Sigerist does not mind expounding his dynamic conception of medical history in hand-to-hand argument. A student once took issue with him and when Dr. Sigerist asked him to quote his authority, the student shouted, "You yourself said so!" "When?" asked Dr. Sigerist. "Three years ago," answered the student. "Ah," said Dr. Sigerist, "three years is a long time. I've changed my mind since then." I guess for me this speaks to the changing tides of opinion and that everything is in flux and open to renegotiation.

Acknowledgements:

Special thanks to medical historians and PNHP colleagues Corinne Sutter-Brown and Ted Brown for background information, critical analysis, and editing.

References:

Much of this talk was paraphrased/annotated directly from the sources below, in particular the work of Paul Starr:

1. Bauman, Harold, "Verging on National Health Insurance since 1910" in Changing to National Health Care: Ethical and Policy Issues (Vol. 4, Ethics in a Changing World) edited by Heufner, Robert P. and Margaret # P. Battin, University of Utah Press, 1992.

2. "Boost President's Plan", Washington Post, p. A23, February 7, 1992.
Brown, Ted. "Isaac Max Rubinow", (a biographical sketch), American Journal of Public Health, Vol. 87, No. 11, pp. 1863-1864, 1997

3. Danielson, David A., and Arthur Mazer. "The Massachusetts Referendum for a National Health Program", Journal of Public Health Policy, Summer 1986.

4. Derickson, Alan. "The House of Falk: The Paranoid Style in American House Politics", American Journal of Public Health", Vol. 87, No. 11, pp. 1836 - 1843, 1997.

5. Falk, I.S. "Proposals for National Health Insurance in the USA: Origins and Evolution and Some Perspectives for the Future', Milbank Memorial Fund Quarterly, Health and Society, pp. 161-191, Spring 1977.

6. Gordon, Colin. "Why No National Health Insurance in the US? The Limits of Social Provision in War and Peace, 1941-1948", Journal of Policy History, Vol. 9, No. 3, pp. 277-310, 1997.

7. "History in a Tea Wagon", Time Magazine, No. 5, pp. 51-53, January 30, 1939.

8. Marmor, Ted. "The History of Health Care Reform", Roll Call, pp. 21,40, July 19, 1993.

9. Navarro, Vicente. "Medical History as a Justification Rather than Explanation: Critique of Starr's The Social Transformation of American Medicine" International Journal of Health Services, Vol. 14, No. 4, pp. 511-528, 1984.

10. Navarro, Vicente. "Why Some Countries Have National Health Insurance, Others Have National Health Service, and the United States has Neither", International Journal of Health Services, Vol. 19, No. 3, pp. 383-404, 1989.

11. Rothman, David J. "A Century of Failure: Health Care Reform in America", Journal of Health Politics, Policy and Law", Vol. 18, No. 2, Summer 1993.

12. Rubinow, Isaac Max. "Labor Insurance", American Journal of Public Health, Vol. 87, No. 11, pp. 1862 - 1863, 1997 (Originally published in Journal of Political Economy, Vol. 12, pp. 362-281, 1904).

13. Starr, Paul. The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry. Basic Books, 1982.

14. Starr, Paul. "Transformation in Defeat: The Changing Objectives of National Health Insurance, 1915-1980", American Journal of Public Health, Vol. 72, No. 1, pp. 78-88, 1982.

15. Terris, Milton. "Crisis and Change in America's Health System", American Journal of Public Health, Vol. 63, No. 4, April 1973.

16. "Toward a National Medical Care System: II. The Historical Background", Editorial, Journal of Public Health Policy, Autumn 1986.

17. Trafford, Abigail, and Christine Russel, "Opening Night for Clinton's Plan", Washington Post Health Magazine, pp. 12, 13, 15, September 21, 1993.

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A Brief History: Universal Health Care Efforts in the US - PNHP

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(Transcribed from a talk given by Karen S. Palmer MPH, MS in San Francisco at the Spring, 1999 PNHP meeting) The campaign for some form of universal government-funded health care has stretched for nearly a century in the US On several occasions, advocates believed they were on the verge of success; yet each time they faced defeat.

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1. Interest groups in the U.S. do not want universal health care and influence the political process. They profit off the amount of insurance money Americans pay. They know that people have the “you never know mindset” so they charge outrageous prices for coverage.

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https://www.columbiamissourian.com/opinion/guest_commentaries/interest-groups-could-be-why-america-doesnt-have-universal-health-care/article_211efaee-8db6-11eb-bcc2-1762746cd974.html

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In 1948, a newly elected President Harry Truman set out to establish national health insurance in the United States. He quickly gained the support of the American public.

National health insurance was seen as a threat by the American Medical Association, which quickly launched a $1.5 million counter-campaign - about $16 million in today's dollars - suggesting that the plan would result in low-quality medical care.

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Interest groups could be why America doesn't have universal health care

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From the start, interest groups such as the AMA have had their thumb on the scale.

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Fee-for-Service (FFS) Model

Managed Care Model

Accountable Care Organization (ACO)

Patient-Centered Medical Home (PCMH)

Telehealth and Telemedicine

Retail Health Clinics

Integrated Care Model

Direct Primary Care (DPC)

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https://jamanetwork.com/journals/jama/fullarticle/2661579

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https://jamanetwork.com/journals/jama/fullarticle/2661579

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Policy Challenges in Achieving Universal Health Care:

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Policy Challenges in Achieving Universal Health Care:

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Risk Manag Healthc Policy. 2023; 16: 607-621.

Abstract

Background

Achieving universal health coverage (UHC) is critical for ensuring equity, improving health, and protecting households from financial catastrophe. The COVID-19 pandemic derailed the progress made across primary health targets. This article aims to review the policy challenges to achieve UHC in a post-pandemic world.

Methods

A narrative review of 118 peer reviewed and grey literature was conducted. A total of 77 published articles were identified using an electronic search in PubMed and Scopus and a bibliographic search of relevant literature. Another 41 Reports, websites, blogs, news articles, and data were manually sourced from international agencies (WHO, World Bank, IMF, FAO, etc.), government agencies, and non-government organizations.

Findings

The challenges were identified and discussed under five broad findings: i) weak public health care systems ii) challenges to building resilient health systems, iii) health care financing and financial risk protection, iv) epidemiological and demographic challenges, and v) governance and leadership.

Conclusion

LMICs in Africa and South Asia face significant challenges to achieving UHC by 2030. As countries recover from the pandemic's aftermath, significant investments and innovations are needed to ensure progress toward UHC. Efficient resource mobilization through internal accruals, international cooperation, and resource sharing is needed.

Keywords: COVID-19, health systems, healthcare financing, primary health care, universal health coverage

Introduction

The foundation of Universal Health Coverage (UHC) is based on an egalitarian view of health care as a fundamental human right, in the spirit of earlier unifying concepts such as Health for All and the Alma-Ata declaration. UHC presents a vision in which all citizens enjoy a robust and efficient health system that spans preventive and curative healthcare, affordable access, access to medicines, and sufficient healthcare human resources.1 UHC is defined by the World Health Organization (WHO) as "ensuring that all people obtain the health services they need, of good quality, without suffering financial hardship when paying for them".2 It covers the entire continuum of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course. The delivery of these services requires capable healthcare systems and healthcare workers with optimal skill mix, equitably distributed, and adequately supported with sustained financing and resilient healthcare infrastructure.

Improving human health and well-being (Goal 3) is central to achieving Sustainable Development Goals (SDGs).

"Achieving UHC including financial risk protection, access to quality essential healthcare services, and access to safe, adequate, quality, and affordable essential medicines and vaccines for all" (target 3.8)

is vital to achieving the third sustainable development goal. The political declaration of the United Nations (UN) general assembly's high-level meeting on UHC recognized that investments made at the 2019 level were insufficient to achieve SDG targets.3 The WHO 13th General Programme of Work (GPW 13) 2019-2023 estimated that in 2019, at least half of global population lacked access to essential health services.4 It recommended covering at least a billion more people every five years from 2015 to 2030 to attain the UHC target of SDG 3.8.4 Estimates indicate that in 2018 approximately 4.6 billion global population had UHC effective coverage, whereas 3.1 billion lacked the same in 2023, despite an addition of 388.9 million from 2018 to 2023.5

From 2010 to 2019, the annualised rate of increase in UHC effective coverage index in Sub-Saharan Africa (SSA) was 2.6%, 1.6 times greater than global average signifying a greater pace of progress.5 However, COVID-19 had a negating impact on the progress made till 2019. TB deaths increased for the first time in over a decade, primarily attributed to disruptions caused by COVID-19 in the diagnosis, treatment, and management of TB.6 COVID-19 pushed over 90 million people into poverty with a substantial increase in poverty in Sub-Saharan African countries.7 There was a profound impact on food security globally, with 368 million children missing out on school meals.8 Moreover, the impact of the pandemic on education, employment, and access to essential and emergency healthcare services has been well documented.9,10 In Nepal, during the months of COVID-induced lockdowns, the weekly institutional deliveries reduced by approximately 50%.11 Majority of Indian districts witnessed >50% of antenatal care and child immunization services disrupted during December 2019 to April 2020.12 From March to July 2020, COVID-19 led service disruptions in eight Sub-Saharan African countries (ie, Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia) resulted in a cumulative shortfall of 0.32 million doses of pentavalent vaccinations.13 Another study reported a decline in first antenatal visits ranging from 18% to 32% across LMICs.14

The UN SDG report 2022 urges sustained cooperative efforts to raise from the negating effects of the pandemic, tackle the ongoing and future global uncertainties, and ensure sustainable development of humankind.15 Governments augmented their health spending in response to the pandemic.16 While COVID-19 has decreased globally (barring a few countries), significant challenges exist concerning achieving SDG 3.

Achievement of UHC facilitates the attainment of crucial health targets, including but not limited to reducing maternal, neonatal, and child mortality, reducing the disease burden attributed to communicable and noncommunicable diseases (NCD), prevention and treatment of substance abuse, and ensuring access to sexual and reproductive healthcare services, etc.17 In LMICs, the pandemic erased years of development across most SDG-3 targets. The LMICs in Asia and Africa were adversely impacted and were a priority to ensure global progress towards attaining UHC targets. Asia and Africa together account for more than 75% of the global population. At pre-COVID levels, the average UHC service coverage in South Asia and Sub-Saharan Africa was 51.07, indicating a significant under coverage.18 More than 75% of the estimated 3.1 billion global population not having an effective UHC coverage in 2023 are from LMICs in South Asia, Southeast Asia, East Asia, and Sub-Saharan Africa.5

As 2030 draws down, it is vital to take giant leaps in policy to make substantial progress toward achieving the promise of improving health and well-being. However, it is far more challenging in the current global environment with geopolitical uncertainties, inflation, rising costs of borrowing, and risk for sovereign default.19,20 Through a narrative review of published literature, reports, and data; this article discusses some of the critical challenges for policy to achieving UHC by 2030. The objective of this review is to identify the policy challenges to achieve UHC in a global ecosystem recovering from the aftermath of the COVID-19 pandemic. The review focuses on the health systems, economic, epidemiological, and demographic challenges to realize the goals set for UHC. The review focuses on the challenges faced by LMICs.

Methods

This article employs a narrative review approach to address its objective. Narrative reviews are the evidence-informed argument of plausible truth and provide an opportunity for induction, interpretation, and critical reflection.21-23 Due to their comprehensive nature, narrative reviews may not always employ a systematic search to identify a body of literature evidence.21 Given the broader objective of this work, the limited availability of empirical studies, and the inclusion and integration of several data sources, a narrative review was identified as the most suitable method for this article.

Evidence from multiple sources was integrated into this review. Research articles, opinion pieces, commentary, and reviews discussing on challenges posed by COVID-19 and its implications on UHC were identified through an electronic literature search in PubMed and Scopus employing the generic keywords "Challenges" AND "COVID-19" AND "Universal Health Coverage" AND "Health Systems". The literature search was conducted from October 2022 to December 2022. The initial search yielded 92 journal articles published in between 2020 and 2022. After screening for relevant titles and removing duplicates, a total of 40 articles were selected from the initial database search. A subsequent bibliographic search, manual search of key articles, and expert opinions identified another 37 journal articles. Additionally, datasets (n = 3), blogs/webpages (n = 21), reports (n = 15), news reports/policy documents (n = 2) were manually sourced from the websites of WHO, World Bank, OECD, FAO, ILO, Government organizations, and internationally renowned news agencies. For the data metrics, estimates for the latest available year were considered to draw interpretations.

The sourced evidence was analyzed and presented as findings under the broader dimensions of i) Weak primary health care systems ii) Challenges to building resilient health systems, iii) Health care financing and financial risk protection, iv) Epidemiological and demographic challenges, and v) Governance and leadership. This broader classification of challenges is based on the WHO global health observatory's key health data indicators and specific indicators on SDG target 3.8.24,25

Findings

Weak Primary Health Care Systems

Primary health care (PHC) is at the heart of achieving SDGs and UHC. PHC itself is estimated to account for more than 75% of the projected health gains associated with attaining SDGs and more than 90% of health services under comprehensive UHC.26 PHC is agreed upon as a vital and cost-effective means to attain universal health coverage.27 However, evidence indicates that primary health care systems are weak and not prioritised in a majority of LMICs.

Robust primary healthcare systems were able to continue the provision of essential healthcare services despite the disruptions caused due to COVID-19 pandemic.27,28 The key principles of primary health care (PHC) ie, i) community participation, ii) inter-sectoral coordination, iii) appropriate technology, and iv) support systems, are at the center to enabling health systems to achieve UHC.27,29 Weak PHC systems facing a shortfall of health workers, infrastructural shortcomings, lack of diagnostic facilities, asymmetric distribution of healthcare facilities, and inadequate financing were documented to be drivers of outbreaks like Ebola.30,31 During the COVID-19 pandemic, non-adherence to key PHC components resulted in the fragmentation of health systems, lack of coordination, infrastructural challenges, and inadequate investments, which further compromised health system preparedness to tackle COVID-19 in LMICs.32-34 Inadequacies in PHC resulted in a substantially higher burden of COVID-19 and its financial implications on households with high socioeconomic vulnerability.35-37

Shortcomings in PHC translate into widening health inequities among LMICs.42 Shortfall in primary health care inputs (such as availability of health workers, hospital beds, sufficient financing of health care) can be seen to be resulting in underperformance across key healthcare performance indicators. A comparison of eight LMICs, which account for over 32% of the global population, reflects that among LMICs, those with limited investments in PHC-building blocks had higher levels of infant and maternal mortality and lower levels of Measles immunization and COVID-19 vaccine coverage (see Table 1 ).

Table 1

Indicator

India

Pakistan

Indonesia

Bangladesh

Ethiopia

Nigeria

Ghana

DRC

Epidemiological indicators
Cause of death, by communicable diseases and maternal, prenatal and nutrition conditions (% of total deaths)

24.17

33.15

18.93

22.61

44.65

65.21

45.24

56.18

Health care input indicators
UHC Service Coverage Index

61

45

59

51

38

44

45

39

Health care performance indicators
Infant Mortality Rate

25.5

52.8

18.9

22.9

34.3

70.6

32.6

62.4

Challenges to Building Resilient Health Systems

Health systems are at the core of achieving the target of UHC by ensuring equitable access to essential healthcare services and protecting households from CHE. WHO points to i) health service delivery, ii) health workforce, iii) health information systems, iv) access to essential medicines, v) health systems financing, and vi) leadership and governance as the core-building blocks of health systems.43 It is essential to build resilience across these critical dimensions.

Resilience can be defined as the health system's ability to anticipate, absorb, adapt, and recover from significant shocks and health emergencies.44 Climate change, emerging and re-emerging diseases, natural disasters, epidemics, and human-caused disasters highlight the need for resilient health systems which can withstand and adequately respond in-face of crisis events. Building resilience requires investments in the health workforce, infrastructure, processes, leadership, and governance backed by sustained healthcare financing.44,45 While the components of healthcare financing, leadership, and governance are discussed as separate findings, the challenges associated with rest four are discussed here. A recent OECD report indicates that a) protecting people's health, b) fortifying the foundations of health systems, and c) strengthening the health workforce is core to building resilient health systems.44,46

Poor health of populations can overrun healthcare systems and cripple health service delivery. Protecting population health provides breathing space for the health systems to build capacities for emergency response. Protecting health requires an uninterrupted continuance of the ongoing programs, prevention, and control of vaccine-preventable illnesses, maternal and neonatal mortality, and NCDs. The progress in protecting people's health was significantly derailed during the pandemic. Evidence points towards COVID-19-led disruptions in essential services, reducing average life expectancy by up to two years in some parts of the world.15 WHO advocates that at least 70% of the global population should receive COVID-19 vaccines by mid-2022.15 However, till early 2023, less than 50% of the population in developing countries across Africa were fully vaccinated against COVID, although majority of these countries were rated "high" to "very high" on INFORM COVID-19 risk index.47 Among the least developed countries in Africa, the three-year average prevalence of undernourishment increased from 23.04% to 24.28% during the pandemic years.48 While access to water and sanitation improved globally, in Africa alone, over 418 million individuals lack essential drinking water services, and 779 million lack sanitation services.49 Among the healthcare facilities in LMICs at least 35% lack access to a reliable water source and close to 20% lack adequate sanitation facilities.50 Malnutrition, vaccine-preventable diseases, contaminated water, and inadequate sanitation are the significant killers barring noncommunicable diseases, and a potential challenge to protect health and build resilience of health systems.

Healthcare infrastructure, policies, and processes are essential to ensure health systems' resilience. Eight of the 12 major countries with a population of 100 million or more have less than 11 hospital beds per 10,000 population (see Figure 1 ). During the first wave of the COVID-19 pandemic, WHO estimates indicated that 87% of the sub-Saharan African counties had less than 50 ventilators and a little over 120 ventilator beds per country.45 Hospital resource availability was a significant predictor for COVID-19 mortality across geographies.55-57 Despite the awareness that a chronic shortage of hospital beds could be a challenge in a primary health emergency, most healthcare systems are underprepared. Most African countries are net importers of essential medical and pharmaceutical supplies.45 Similarly, the healthcare infrastructure in LMICs is deficient, with a shortfall in built space, accessibility, and availability of technology. Building self-reliance in healthcare capacities, essential medical supplies, and consumables are essential for health system resilience.

Healthcare Financing and Financial Risk Protection

Given the role of insurance as a core strategy towards the financial risk protection component of UHC, there is a risk that countries overemphasize the insurance component in their health policies. Insurance, while essential, is not a quick fix for underfunded and understaffed primary healthcare systems. A quick look at the recent national health accounts of selected countries demonstrates that inpatient curative care (which is the main focus of health insurance) is approximately 30-40% of the current health expenditure.61-63 Outpatient care, preventive care, pharmaceuticals and medical goods, transportation, laboratory, and diagnostics accounted for the other 60% of health expenditure by healthcare functions.61 In developing economies, overemphasizing the insurance component alone without strengthening the grassroots primary healthcare systems can be demeaning. As witnessed during the COVID-19 pandemic, countries and regions with underprepared PHC systems faced significantly higher patient loads, stock out of medical supplies, and a spike in mortality rates.64,65 Moreover, expansion of health insurance, without strengthening the primary and preventive healthcare services, might be of little benefit to patients but profitable for private healthcare providers.66 High penetration of health insurance in the context of weak PHC could result in over-medicalization and proliferation of private medical practice. It might be of limited benefit in preventing OOPE.

It is essential to ensure that the grassroots primary healthcare systems are well-oiled to serve the population's health needs. Strengthening PHC involves increasing healthcare expenditures substantially, establishing facilities, ensuring access, investments in training and retaining the health workforce, and ensuring access to life-saving medicines and supplies. The prominence of strengthening healthcare systems is far more critical for Africa and South Asia countries where significant challenges remain to achieve UHC.67 The countries facing challenges to achieving UHC underperform in the UHC service coverage sub-index for service capacity and access.68 Moreover, it can be observed that over two decades (ie, from 2000 to 2019), the poor-performing countries have yet to show much progress, remained stagnant or decreased,68 reflecting that improving health service capacity and access is a significant challenge in these countries.

Concerning health insurance and social protection, a major challenge is the high percentage of the population working in the informal sector. The International Labour Organisation (ILO) estimates that 60% of the world's population work in the informal sector, ranging from 68% in Asia to 85.8% in Africa.69 Arranging health insurance cover for the large proportion of the population working in the informal sector is a financial hurdle as contributory mechanisms need to be more effective.70 Moreover, without a universal identification and record-keeping mechanism, the large portion of informal workers are effectively out of the system to be covered under social security. Informal workers are also worst hit during crisis events and are more likely to face health ramifications due to their socioeconomic vulnerabilities.71-73 Ensuring social protection during emergencies is critical to achieving SDGs.74 Tax-based financing mechanisms, equitable provision of social security and financial risk protection should be ensured to protect vulnerable population groups.75

Another emerging challenge is that a significant portion of the population is missing out on the benefits of health insurance. The global emphasis on UHC resulted in several countries initiating government-subsidized health insurance programs.76 However, a significantly large number of these health insurance programs are specifically designed for the population in the lower wealth quintiles. On another extreme, the population in the higher wealth quintiles has access to resources and health insurance. A significantly large population in the middle wealth quintiles (Q2-Q3) remains uncovered or under-covered as they are neither poor enough to be covered by government-subsidized health insurance nor rich enough to purchase private health insurance voluntarily.77 National Institution for Transforming India estimates that despite the launch of Ayushman Bharat-PMJAY, approximately 40.5% of the Indian population falls under the "missing middle." Kerala, known for its pioneering health and nutritional indicators, has only 51.5% of its households covered under a health insurance scheme, even after the launch of PM-JAY.78 The missing middle population in India and other LMICs is mainly constituted of self-employed individuals (including agriculture and non-agricultural workers), urban poor, individuals working in the informal sector, service workers, craftsmen, elementary workers, small business owners, and professionals.79,80 In high inflationary environments, private voluntary health insurance is unaffordable for most of these population groups.81 Moreover, given that the middle class is expected to grow to 1.15 billion global population by 2030,82 mechanisms are needed to ensure adequate health insurance coverage to the population who do not qualify for government social protection.

Epidemiological and Demographic Challenges

There is a paradigm shift in the disease burden with NCDs, injuries, and mental health issues accounting for the majority of the disability-adjusted life years (DALY) globally. The epidemiological transition is more rapid in LMICs, characterized mainly by a substantial rise in chronic noncommunicable diseases and a persistently high burden of communicable diseases. A paradox of high burden of NCDs, communicable diseases, maternal and child undernutrition, and vaccine-preventable illnesses is characteristically visible in LMICs. India, for example, was documented to have a differing disease pattern with southern states witnessing a rapid rise in noncommunicable diseases and northern states having a substantial burden of communicable, maternal, infant, and child health issues.83 In Sub-Saharan Africa, HIV/AIDS, Child and Maternal Undernutrition, and overweight/obesity were top three risk factors for mortality.84 A recent study of nationally representative surveys reported that 6.7% to 10.0% of women of reproductive age in India, Myanmar, and Nepal had both anaemia and obesity.85

Evidence points to LMICs lagging in both communicable and noncommunicable disease control. An illustration of the same can be made by comparing tuberculosis and diabetes, two indicator diseases targeted for control as part of SDG 3.86,87 In Figure 2 it can be noted that despite having a low base, the percentage reduction in tuberculosis incidence in the upper middle- and high-income countries was double that of low and lower-middle-income countries. On the contrary, the prevalence of diabetes increased by over 37% in low-income countries, whereas it only increased by 7% in their high-income counterparts. The dual challenge of communicable and noncommunicable diseases is to be factored into policies and programs to progress toward UHC. Moreover, emerging issues such as climate change and antimicrobial resistance (AMR) pose a significant epidemiological challenge. A recent Lancet study concluded that AMR is attributable to over 4.9 million deaths in 2019, with LMICs of South Asia and Sub-Saharan Africa accounting for over 65% of the total DALYs attributable to AMR.88 Moreover, climate change is documented to directly impact aggravating disease outbreaks associated with vector-borne and waterborne diseases.89,90 These challenges are further compounded by epidemic proportions of NCDs brought forward by rapidly aging populations.

In the last seven decades, the global average life expectancy has more than doubled from 30 years over 70, primarily due to the prevention of mortality due to communicable, maternal, neonatal, and nutritional diseases (CMNND).91 The increased life expectancies also pose a potential longevity risk, as the healthcare systems are under-prepared to provide essential healthcare services to the growing geriatric population. Evidence indicates that LMICs, despite their comparatively higher fertility rate, are aging rapidly.92 The epidemiological transition in several developing countries closely follows the demographic transition, with NCDs such as Hypertension, Diabetes, Cardiovascular diseases, and Cancers rising substantially. For example, from 2011 to 2021, the prevalence of diabetes increased by 37% and 32%, respectively, in low-income and lower-middle-income countries, whereas the same was 7% in high-income countries (see Figure 2 ). The healthcare systems in LMICs have a limited preparedness to tackle the growing burden of NCDs. For example, for hypertension which is one of the most common NCDs, less than 45% of women and 33% of men in South Asia were aware that they have hypertension.93 Studies from developing countries reveal a sub-optimal level of diagnosis and higher case-fatality rates for NCDs.94-97 Despite evidence indicating a higher incidence and early age of onset of major cardiovascular events in population groups from developing countries,96 there is a limited health systems preparedness towards tackling NCDs in general and aging-specific issues in particular.

Around 14 of the 21 interventions proposed by the 2022 NCD 2030 countdown, collaborators require healthcare systems prepared to tackle NCDs.98 However, investments in NCD care have traditionally been poor and limited in LMICs. Estimates indicate that less than 1% of the global health funding is directed towards NCDs in LMICs. An Indian study reported that from 2012 to 2017, the NCD expenditure of the ministry of health and family welfare accounted for less than 0.04% of the country's GDP. In contrast, NCDs during the same time accounted for over 60% of all deaths.98,99 Another South-African study reported inadequacies in mainstreaming aging-friendly healthcare facilities, primarily due to budgetary constraints.100 Among the 12 most populous countries reported in Figure 1 , the NCD sub-index for UHC coverage averages 61.18, with rapidly aging countries such as China and the United States (US) scoring 62.7% and 61.1%, respectively.101 Vietnam despite scoring higher than China and USA on NCD sub-index is projected to miss the 2030 targets across most of NCD risk management and health service indicators.101,102 This evidence substantiates the argument that most of the world's population are not covered by essential NCD services. The significant under coverage of NCD services, coupled with the rapidly aging population could potentially deter the achievement of NCD-specific targets under SDG and require sustained efforts. Providing accessible, affordable, and comprehensive care for the prevention and control of NCDs and aging-associated health issues is imperative to achieving the goals of UHC.

Governance and Leadership

In addition to financial investments into healthcare systems, mechanisms are required to ensure efficient use of the available resources. Corruption in the governance architecture and healthcare systems is a significant challenge hindering UHC. A recent narrative synthesis of out-of-pocket expenditure among insurance beneficiaries across Sub-Saharan African countries indicates corruption within the system as a significant challenge to successfully implementing UHC.105 Governance issues and informal payments were documented to erode trust in the healthcare systems.106 Lack of accountability, poor health resource management, and unequal power in healthcare decision-making, negatively impacted progress toward UHC in low-income countries.107 Additionally, internal conflicts within the countries are known to have a significant impact on people's health and well-being. Civil wars are documented to have resulted in outbreaks of cholera, measles, diphtheria, and other vaccine-preventable diseases in South Sudan and Yemen.108,109 The recent economic crisis in Sri Lanka had a significant impact on access to essential medical supplies and adequate nutrition. It was documented to have a negative impact on the mental health of individuals.110 The health impact of the recent armed conflicts between the countries is well documented.111

Moreover, a significant challenge to achieving UHC is an unequal distribution of healthcare services to socially and economically vulnerable populations. Despite the longstanding awareness about the impact of social inequalities in influencing individual health status and access to healthcare, the priority given to social determinants is all but underwhelming. The pandemic responses in several South-Asian countries were documented to have a substantial negative impact on vulnerable households resulting in unemployment, poverty, and food insecurity.112 Moreover, the lack of financial protection further pushed the households into poverty caused by COVID-19-induced health expenditures.113 The recent crisis events have reflected the limited protection available to socio-economically weaker sections of the community. Across the world, the poorest countries and poorest households are witnessing a weaker recovery.114,115 While the countries increased the social-sector spending during COVID-19, evidence indicates declining spending in the social sector from 2022.116,117 Decreased spending could narrow the available social protection nets to disadvantaged groups.

Good governance strategies, including but not limited to leveraging technology, inter-sectoral coordination, context-specific health policy, equitable financing modalities, and increased transparency, are needed to improve progress toward UHC. Creating quality leadership within healthcare human resources will be a strategic investment in improving healthcare systems' long-term resilience and facilitate achieving UHC.

PHC an Essentiality in Achieving UHC

Strong primary health care systems are necessary for attaining UHC. Without PHC, unilateral interventions to achieve UHC through health insurance seem to have little success. A study based on nationally representative sample of older persons in India reported that enrollment in a public funded health insurance had no effect on OOPE or CHE, but accessing treatment from private health sector significantly increased OOPE.118 Similarly, in Ghana despite implementation of national health insurance scheme (NHIS), governance issues, poor financing, quality of care, and lack of stakeholder participation compromised its effectiveness.119

Strengthening primary health care systems require strategic investments towards strengthening its core pillars. Community participation, one of the main pillars of PHC played a key role in pandemic response. In India and other LMICS, local bodies, community-based organizations, volunteers, and civil society played a vital role in pandemic response.120,121 Millions of CHWs across LMICS were critical in ensuring delivery of essential health services to the last mile.122 CHWs played a central role in strengthening primary health care systems and tackling HIV/AIDS, Malaria, Tuberculosis, Maternal and Child Mortality.122,123 Despite their apparent contributions, community participation through civil society is troubled by bureaucratic challenges, limited recognition, and engagement. Similarly, CHWs continue to face challenges of limited training, poor supervision, inadequate financing, inefficient compensation mechanisms, and an overwhelming workload.124 It is essential to tackle the existing challenges and build on the strengths of community participation as an important component of PHC in realizing the goal of UHC.

Accessibility and availability of medical and non-medical technology will strengthen PHC. Shortcomings in health infrastructural capacities weakening the health care systems were discussed earlier. Focused interventions are required to ensure access and availability of essential medical supplies and technologies. Digital technologies played a central role in pandemic response across the countries and minimized the pandemic's social, economic and health impacts.125,126 Leveraging technology can enable bridging the gaps towards attainment of UHC in low and middle-income countries.127 Additionally, inter-sectoral coordination with a "health in all" approach, and equitable distribution of resources for health and development are essential achieving UHC in face of the challenges of economic inequities, global uncertainty, antimicrobial resistance, and climate change.75,128 In India, campaigns like "Eat right India", "Fit India", "Poshan Abhiyan", integration of digital health technologies through "Ayushman Bharat Digital Mission" and launch of "National Programme on Climate Change & Human Health" provide an opportunity for inter-sectoral coordination.

Sustained financing is crucial for the success of PHC approach. WHO advocates for an increase in PHC spending by at least 1% of the GDP to increase access to essential health services. The Lancet Global Health Commission on financing primary health care recommends for substantial increase in PHC spending in LMICs, through resources pooled from tax revenues and internal accruals.129 However, at current levels PHC spending is limited. An analysis of health accounts of 36 LMICs revealed that only 10% of current health expenditure is spent on preventive care or health systems governance.130 Estimates indicate that attainment of UHC requires at least a 2.6-fold increase in per capita PHC expenditure from 2020 to 2030 with incremental PHC costs accounting for up to 3.3% of gross domestic product (GDP).131 However, there is a limited progress with countries like India aiming to increase the government health spending on PHC up to 1.6% of the country's GDP.132,133 The mismatch in requirement and allotment needs to be revisited with a strategic "primary health care investment plan" based on the cost analysis and evidence-based projections on country's PHC expenditure.

Despite the challenges, there are proactive steps focused at improving PHC service delivery in LMICs. Under Ayushman Bharat Program, Indian government plans to strengthen its PHC with a network of more than 0.15 million Health and Wellness Centers (HWC) providing a package of comprehensive primary health care services.132,134 By building on the lessons learnt from National Health Mission (NHM), HWCs are designed to provide robust primary health care services.132,135 Similar strategic approaches to strengthening PHC built on the local needs and capacities are needed in LMICs.136,137 Across LMICs, challenges remain with regard to utilization of PHC, and building trust among the users. The perception of low quality of health care at PHC facilities is known to negatively impact service usage.138 Providing a i) broader package of services, ii) assured provision of services offered, iii) services ensuring continuity of care, iv) ensuring basic quality standards, v) appropriate mix of providers, and vi) strong information systems are known to improve effectiveness of primary health care services and their utilization.139,140

Conclusion

Over the decades, sustained underfinancing for primary health care has resulted in several lost opportunities. As countries recover from COVID-19, significant investments are needed to compensate for the lost progress and achieve the specific targets for UHC. LMICs with weak healthcare systems require concentrated efforts and investments. Building resilient healthcare systems capable of adapting to epidemiological transition is essential. The challenges persist in pooling the required economic resources and efficiently using them. As the GDP raise, the growing economic powers should be used to finance the healthcare infrastructure sustainably. Measures such as health taxes (ie, taxes imposed on products having an adverse health effect) and earmarking the proceeds towards healthcare spending could be beneficial in improving per-capita healthcare spending. While international funding accounts for a minor portion of the overall health expenditure across LMICs, it is impactful. However, health expenditure from external sources remained static in the five years preceding pandemic. As the COVID-19 pandemic proved our shared vulnerabilities to disease, international cooperation, and support are necessary to achieve the goals of UHC. In the context of global economic stagnation and a high inflationary environment, necessary aid and leverage to low-income countries can boost their progress.

Funding Statement

The author received no funding to undertake this work.

Data Sharing Statement

Data sharing does not apply to this article. All the data used in this article are available in the public domain.

Disclosure

The author has no conflict of interest.

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# data[].attributes.attachment_link.title
Achieving Universal Health Coverage in Low- and Middle-Income Countries: Challenges for Policy Post-Pandemic and Beyond

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Achieving universal health coverage (UHC) is critical for ensuring equity, improving health, and protecting households from financial catastrophe. The COVID-19 pandemic derailed the progress made across primary health targets. This article aims to review ...

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596027/#:~:text=Reid%20compared%204%20different%20health,out%2Dof%2Dpocket%20model.

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Technological Innovations in Universal Health Care:

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Technological Innovations in Universal Health Care:

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8645240/