Universal Health Insurance
For anyone living in the United States of America in 2018 it is hard to imagine celebrating the birthday of your national health system. Yet that is exactly what occurred in the United Kingdom for the July 5, 2018, 70th birthday of the UK National Health Service (NHS). But despite being described as one of the nation’s most loved institutions, NHS is not without its critics.
With a founding principle of providing health care that is comprehensive, universal and free at point of delivery, funding during nearly a decade of austerity was inadequate to keep up with demand. As a result, metrics for timely delivery of services, such as emergency room waits, have not been met. While additional funding has been promised, outsourcing of some support services like housekeeping has been used to cut costs. The UK’s health system is socialized medicine. General taxation provides most of funding, with a smaller portion coming from a national insurance payroll tax. About 10% of the population purchase private health insurance to assure more rapid and convenient access to care.
According to the World Health Organization (WHO), the UK spent 9.9% of GDP on health care in 2015. Comparable figures were 11.1% for France, 11.2% for Germany, and 16.8% for the United States. Of 36 countries that make up the Organization for Economic Cooperation and Development (OECD), 32 have some form of universal health care following WHO criteria.
Health insurance in France is mandatory, available through non-profit funds largely financed through taxes. Public insurance covers 70-80% of costs. About 95% of the population also has voluntary health insurance which covers the remainder. Voluntary health insurance is employer-sponsored, with employees paying 50% of the cost.
Health insurance is also mandatory in Germany. About 86% of Germans get their coverage primarily through the statutory health insurance system, provided through competing, not-for-profit, non-governmental health insurance funds. Premiums for the public system are based on income and paid by employers and employees, on earnings up to about US$65,000. Federal taxes pay costs for low-income, for those with chronic illnesses and for children. Unsubsidized private insurance is available at government-regulated premiums; about 11% of the population, generally with higher incomes, choose coverage by one of 42 private companies, 24 of which are for-profit.
The closest the U.S. has to a universal system came with the 2010 passage of the Affordable Care Act, nicknamed Obamacare. Millions of people previously without health insurance became covered by Obamacare. In addition, the federal government-sponsored Medicaid and Medicare programs serve low income, disabled and elderly segments of the U.S. population; the Veterans Administration serves military veterans, including the only government-run hospitals. States have the option of participating in federally-subsidized expansion of Medicaid eligibility. Private insurance is regulated by the individual states. Over half the population receives private health insurance through their employers. Beyond the coverage provided by these four options, an estimated 24 to 28 million people are without health insurance.
| Selected Metrics Source: World Health Organization 2018 | Health Expenditure as % of GDP – 2015 | Life Expectancy at Birth – 2016 | Neonatal Mortality Rate – 2016 | Under 5 Mortality Rate – 2016 | Maternal Mortality Rate – 2015 |
| United Kingdom | 9.9 | 81.4 | 2.6 | 4.3 | 9 |
| France | 11.1 | 82.9 | 2.4 | 3.9 | 8 |
| Germany | 11.2 | 81.0 | 2.3 | 3.8 | 6 |
| United States | 16.8 | 78.5 | 3.7 | 6.5 | 14 |
While the medical system in the U.S. is dynamic and innovative, a comparison of health metrics among OECD countries raises questions. Is its higher expenditure justified? Why are outcomes relatively poor by standards of other major economies? Is the fragmented system inherently inefficient? And finally, why are the Brits celebrating, but not the Yanks?