Universal health care
Universal health care is health care coverage for all eligible residents of a political region and often covers medical, dental and mental health care. These programs vary in their structure and funding mechanisms. Typically, most costs are met via a single-payer health care system or national health insurance, or else by compulsory regulated pluralist insurance (public, private or mutual) meeting certain regulated standards. Universal health care is implemented in all but one of the wealthy, industrialized countries, with the exception being the United States. It is also provided in many developing countries and is the trend worldwide.
Universal health care is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards. Most implement universal health care through legislation, regulation and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis. Usually some costs are borne by the patient at the time of consumption but the bulk of costs come from a combination of compulsory insurance and tax revenues. Some programs are paid for entirely out of tax revenues. In some cases, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care.
Universal health care in most countries has been achieved by a mixed model of funding. General taxation revenue is the primary source of funding, but in many countries it is supplemented by specific levies (which may be charged to the individual and/or an employer) or with the option of private payments (either direct or via optional insurance) for services beyond that covered by the public system.
Almost all European systems are financed through a mix of public and private contributions. The majority of universal health care systems are funded primarily by tax revenue (e.g. Portugal). Some nations, such as Germany, France and Japan employ a multi-payer system in which health care is funded by private and public contributions.
A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency.
Universal health care systems are modestly redistributive. Progressivity of health care financing has limited implications for overall income inequality.
The term single-payer health care is used in the United States to describe a funding mechanism meeting the costs of medical care from a single fund. Although the fund holder is usually the government, some forms of single-payer employ a public-private system.
Some countries (notably the United Kingdom, Italy and Spain) have eliminated insurance entirely and choose to fund health care directly from taxation. Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation, either by directly paying their medical bills or by paying for insurance premiums for those affected.
This is usually enforced via legislation requiring residents to purchase insurance, though sometimes, in effect, the government provides the insurance. Sometimes there may be a choice of several funds providing a basic service (e.g. as in Germany) or sometimes just a single fund (as in Canada).
In some European countries where there is private insurance and universal health care, such as Germany, Belgium, and Holland, the problem of adverse selection (see Private insurance below) is overcome using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price and there is no advantage to eliminate people with higher risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but then mainly compete on price and service. In some countries the basic coverage level is set by the government and cannot be modified.
Ireland at one time had a "community rating" system through VHI, effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. This resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market which then made super profits at VHI's expense. The government later re-introduced community rating through a pooling arrangement and at least one main major insurance company, BUPA, then withdrew from the Irish market.
In some countries with universal coverage, private insurance often excludes many health conditions which are expensive and which the state health care system can provide. For example in the UK, one of the largest private health care providers is BUPA which has the following list of general exclusions.
Dental/oral treatment (such as fillings, gum disease, jaw shrinkage, etc); pregnancy and childbirth; temporary relief of symptoms; convalescence, rehabilitation and general nursing care; drugs and dressings for out-patient or take-home use; screening and preventive treatment; birth control, conception, sexual problems and sex changes; allergies or allergic disorders; chronic conditions; eyesight; physical aids and devices; *deafness; cosmetic, reconstructive or weight loss treatment ; ageing, menopause and puberty ; dialysis ; complications from excluded or restricted conditions/ treatment ; HRT and bone densitometry; learning difficulties, behavioural and developmental problems ; overseas treatment and repatriation ; AIDS/HIV ; pre-existing or special conditions ; experimental drugs and treatment ; sleep problems and disorders ; speech disorders
all of which (except overseas repatriation) are available for free or very low cost from the NHS. ( indicates that treatment may be provided in certain circumstances)
Where voluntary insurance (often private) is predominant, such as in the U.S., medical (health) insurance is subject to the well-known economic problem of adverse selection which may also be referred to as a market failure. Adverse selection in insurance markets occurs because those providing insurance have limited information with which to estimate the health risks on which they may need to pay future claims. In simple terms, those with poor health are more likely to apply for insurance and more likely to need treatments requiring high insurance company payouts. Those with good health may find the cost of insurance too high for the perceived benefit, and some will remove themselves from the risk pool. This adverse selection concentrates the risk pool, thereby further raising costs. In practical terms, the potential for adverse selection means that private insurers have an economic incentive to use medical underwriting to 'weed out' high cost applicants in order to avoid adverse selection. Among the potential solutions posited by economists are single payer systems as well as other methods of ensuring that health insurance is universal, such as by requiring all citizens to purchase insurance and limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.
Keep in Mind that there are no private dialysis centers in New Zealand