Don’t follow America on health care
March 28th, 2012
09:18 PM ET

Don’t follow America on health care

Editor's Note: Prabhat Jha is a professor of public health sciences at the University of Toronto. Dean Jamison is an economist and professor in the School of Medicine at the University of California, San Fransisco. This article was originally published by Project Syndicate. For more from them, visit their new website and follow it on Facebook and Twitter.

By Prabhat Jha and Dean T. Jamison, Project Syndicate

With the United States Supreme Court set to begin considering the Affordable Care Act (the historic health-care reform derided by opponents as “Obamacare”), it is worth noting that the number of Americans without health insurance reached an all-time high in 2010, the year the law was enacted. Roughly 50 million US residents (one in six) pay out-of-pocket for medical expenses.

The 2008 recession is not the only reason for this staggering figure; long-term political and policy choices are also to blame. Globally, but especially for rapidly growing economies, the lesson is simple: avoid America’s private health-care model.

The US is one of the few high-income countries that does not finance health care through a publicly funded prepaid system. On average, wealthier countries spend roughly 11% of their GDP on health, with more than 80% publicly financed and only 14% of spending taking place on a fee-for-service basis. Public finance (or, in some cases, government-regulated cooperative insurance funds that amount to public financing) pays for most discretionary medical services, with private insurance supplementing only minimal extra services.

Most rich countries choose to finance their health care publicly for several reasons. First, free-market health care is usually inequitable and inefficient. Individual needs vary significantly, and private companies are often unwilling to insure the very people who need the most care (such as those who are already ill, or who have conditions like diabetes, which predispose them to other health problems). Moreover, those who buy care – insurers and patients – are unlikely to have the information necessary to choose the safest and most effective treatments.

At the same time, public spending acts as a brake on overall spending, and prevents the rapid cost escalation to which America’s private insurance companies contribute. The US spends 1% of its GDP annually simply to administer its complex, unwieldy insurance system. Without reform of the type now before the Supreme Court, total US health expenditures will rise from 16% of GDP today to 25% by 2025.

The economic impact of the current system already is severe. The last US census showed a marked increase in the number of Americans living below the poverty line, a fact closely related to lack of health insurance, which in turn reflects over-reliance on employer-based insurance coverage.

In emerging-market economies, governments should bear in mind five considerations when devising health-care systems. First, investments in health provide an important safety net against poverty traps, especially in times of economic upheaval. For example, each year, 37 million uninsured Indians fall below the poverty line because of catastrophic health expenditures (generally defined as costs exceeding 10% of a household’s total expenditures).

Second, public financing of health care frees the poor to use their money to satisfy other needs. In low-income countries, half of all health-care spending (about 2.5% of GDP) is out-of-pocket (compared to 2% in middle-income countries). This spending consumes a large proportion of poorer households’ income, precludes more productive household investments, creates few jobs, and often remains untaxed, as doctors and hospitals are frequently paid under the counter.

Third, publicly financing health could increase overall employment. Canada’s provinces phased in national health insurance from 1961 to 1975. Employment and wages rose where the program was introduced, even though average working hours were unchanged. Provinces with high levels of private insurance coverage, on the other hand, had lower employment rates and slower wage growth. More recently, Canada beat the US in a bid for a new Toyota plant, in part because private health-insurance costs in the US add several thousand dollars to the cost of manufacturing a car there.

Fourth, existing national health-care systems in wealthier countries can serve as models for emerging-market economies that choose to adopt similar systems. Importantly, public finance need not mean only public delivery; private hospitals and clinics can sometimes deliver services more effectively. Taiwan initiated a single-payer system in 1995, significantly curbing health-care costs and improving the population’s quality of life. Mexico’s new universal health-insurance system was implemented first in the poorest parts of the country.

China, on the other hand, provides a sobering example of the consequences of withdrawing publicly financed health insurance. In the early 1980’s, market reforms left roughly 100 million rural citizens without insurance, almost overnight. Out-of-pocket costs skyrocketed, infant mortality rates stopped declining, and the disease surveillance system was weakened, which may have contributed to the SARS epidemic in 2002-2003, which took more than 900 lives worldwide and caused economic losses worth an estimated $60 billion. The Chinese government has acknowledged that the reforms were a flop, and has committed to spending several billion dollars on publicly financed health care.

Finally, following the principle, “everyone is covered, but not everything is covered,” governments must investigate which services are most cost-effective, and which should not be publicly financed, because they are both expensive and ineffective. The list of insured services can always grow in step with incomes and government revenues. In particular, higher tobacco taxes yield a double benefit: they reduce smoking, a leading cause of adult death, and raise revenue.

China, India, and South Africa have all committed to adopting national health insurance. Which country achieves this goal first will depend not only on revenue, but also on the political will to overcome vested interests. It will also depend on institutions’ ability to design rational health care, monitor delivery, and properly assess new treatments.

Health-care costs in the US are exorbitant, with low value for money. One can only hope that “Obamacare,” together with the models being implemented by the US’s future competitors, will nudge the US to adopt a long overdue universal, publicly financed health-care system.

The views expressed in this article are solely those Prabhat Jha and Dean T. Jamison.
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soundoff (100 Responses)
  1. Javier

    I live in Spain and in spite of crisis and reforms towards privatizing parts of the health care system, most of the people is very happy with universal healthcare.We have one of the best in Europe, as people from other EU countries come for "medical tourism".It also cost us a lot in taxes, so Government is looking to privatize parts of it.
    Altgouh you guys may not want this system, from what I read in the comments, there is something very wrong and out of control in your all private system.Insurance companies are crazy about profits and doctors scared of lawsuits

    March 29, 2012 at 7:29 pm | Reply
  2. Javier

    To end The post, you really need a reform and regulations. Don't you?

    March 29, 2012 at 7:30 pm | Reply
  3. Cunamara

    It is ironic in the extreme that the Republican's bitter refusal to consider a government financed universal health care system is actually anti-business, as the Toyota example demonstrates. America fails to compete with most of the developed world. Of course, the nearsighted short-term thinking of the Republicans is to simply offload all insurance premium costs onto the individual and exempt both the government and employers from providing health coverage.

    Can't afford the premiums? Don't get sick.

    Can't afford the treatments if you are sick? Then die.

    What is amazing to me is the 150 million Americans who keep voting for politicians who overtly hate them. The right wing has unfortunately decided to bamboozle Americans into believing that poverty + misery = freedom.

    March 29, 2012 at 7:41 pm | Reply
    • Sharon

      Yours is the best post by far. Agree with everything you've said.

      March 29, 2012 at 11:04 pm | Reply
      • habibi

        Yeah let's riot in the streets after mosque tonight, lets ga ng ra pe a few females or males or children, lets overturn cars and burn buses, lets kill a few non-believers...
        Oops wrong country!

        March 30, 2012 at 9:40 pm |
  4. Johan

    Europe, Canada, Australia-New Zealand and many other countries look since many years with horror at the US healthcare system, that has so many drawbacks, that no country, not even developing countries would mirror it.
    This for many reasons:
    1. The system is inequitable, good access to health care depending on the size of your wallet. There is a national reluctance to share the burden is a social system, as in almost any other first world country. yet, the US spends (wasts!) more than any other country oh healthcare.
    2. if one compares outcomes (mortality and morbidity), then it shows that US patients get no bang for all these bucks. More people die from very common disorders in the USA than in any country of the EU. The mortality caused by unnecessary interventions is higher than that of Indonesia !
    3. The quality of training for health care professions is low, apart from some pribiliged doctors/nurses that come from renowned training centres. When Us doctors travel to overseas hospitals, they feel how porrly they have been trained compared to their peers they have to work with. it is for this reason that US doctors are not very popular overseas.
    4. The system has a libiality culture built in where the fear for liability leads to over-investigation with all the related problems, like costs, side effects of unnecessary procedures etc. For doctors this creates a fearful and unhealthy working climate.
    5. In their arrogance, health care leaders are refusing to look at the rest of the world, where almost everywhere better healthcare is delivered to more patients for less costs.
    6. The pharmaceutical industry is so powerful in the USA that they manage to keep inflated prices on their products. This is a by-effect of poor legislation protecting industry, and working against the interest of patients. This is a society-problem. look at other powerful lobby-troublemakers like the NRA.
    7. In a money first and me-first culture there is no chance to develop a healthy, cost effective and equitable health system. The USA should look at countries where this works well since many decades, liike Canada, Australia, New Zealand, Europe and get rid of its adversary system that makes lawyers rich and patients sick and poor.

    March 29, 2012 at 7:51 pm | Reply
  5. pete

    "it is worth noting that the number of Americans without health insurance reached an all-time high in 2010, the year the law was enacted. Roughly 50 million US residents (one in six) pay out-of-pocket for medical expenses."

    Even with private insurance- you still payout of pocket. Maybe not full price, but you still pay something beyond premiums and co-pays for a good number of procedures and tests. Do they think we all have 'cadillac plans'?

    March 29, 2012 at 7:59 pm | Reply
  6. verylatenight

    Health care is a business and in business the primary goal is to take care of the customer. The customer is the one who typically pays. In the American system that would be the insurance companies. The patient is not the customer in this system but rather a commodity, much like mortgages became a commodity to trade. There is no basic incentive to drive the health care system to be more efficient to the customer. And patients usually choose to seek care based on location, rather than on quality and certainly not on price since patients rarely pay directly.

    March 29, 2012 at 10:16 pm | Reply
    • habibi

      Customers who do not typically pay are not customers–they are thieves.

      March 30, 2012 at 9:42 pm | Reply
  7. Hahahahahaha

    The GOP thinks that only rich people should have health care.

    March 30, 2012 at 9:27 am | Reply
    • habibi

      Is this where I say that this is a left or right or middle or sideway thing?
      I forgot what my imam said to say.

      March 30, 2012 at 9:45 pm | Reply
  8. Matt

    Americans spend more per GDP on health care because they're the only industrialized nation still conducting R + D. Let's not fudge the numbers.

    April 18, 2012 at 5:38 pm | Reply
    • Correction

      Right, first off can we please stop misinforming people on these comment sections. As if all other industrial nations don't have universities conducting R&D in medicine and biology, or even bio-engineering for that matter.

      Secondly, nothing is a larger threat to the United States then denial, and to say that treating the medical system like a business is ethical, well your either in denial or insane.

      April 24, 2012 at 4:58 pm | Reply
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    April 23, 2012 at 9:18 pm | Reply
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