In light of the GOP’s fresh assault on our fragile first steps toward universal health coverage, it’s worth asking: what is it that scares Americans so deeply about a universal system? I’m not talking about Republican politicians – their objections are rooted in an unwillingness to allow government to administer any major sectors of the economy. I’m talking about ordinary voters, who often support the idea of universal healthcare in the abstract, but don’t like any of the ways politicians propose to provide it. I think the answer lies in the ubiquitous statements by older voters who want Congress to keep its government hands off their Medicare. Americans don’t understand that many of them are already receiving state-run healthcare, and therefore they are afraid of what the experience of healthcare would be like in systems that provide universal coverage. I think American opposition to universal healthcare proposals is largely based in a fear of the unknown. Therefore, I will be publishing a series of articles by and interviews with doctors and patients from countries with universal systems, including those found in Britain, France, Germany, and New Zealand. Hopefully they will be able to provide a personal window into how the healthcare experience feels when government funding is involved, as opposed to just a dry explanation of policy. Nevertheless, it’s still important to understand what we mean when we say “universal healthcare,” so let’s do a quick review of how the systems work.
Is there only one type of universal healthcare coverage?
Republicans aren’t the only Americans who unaware of all the routes we could take to achieve universal coverage. Politicians like Bernie Sanders, who favors a single payer system, often conveniently neglect to mention that countries like Germany and Austria provide excellent universal health coverage to their citizens without a single payer system. Consequently, many on the left confidently argue that if we can’t enact a single payer system, we will never provide healthcare for all Americans. Well, that just isn’t true. There are two primary types of universal healthcare systems: single payer, which can be found in Britain, Canada, Denmark and Norway, and insurance mandate, which can be found in Germany, Austria, and Japan.
Sometimes the government picks up the whole tab
A single payer system operates on the principle that the government should be the sole or primary provider of healthcare for its citizens. Sometimes, as in the UK, this means hospitals and other health facilities are owned by the government and doctors and nurses are government employees. Other times, as in Canada, it takes the form as basic government-provided health insurance, which patients use at privately owned doctor’s offices. In many countries, including Britain and Canada, private supplemental insurance policies are available. In Britain, these reduce wait times and sometimes make serious care more comfortable. In Canada, they cover needs like dental and pharmaceutical care, which are not considered “basic.” The key idea is that the government provides basic care without any contribution from citizens.
And sometimes the government makes you buy insurance
The insurance mandate system evolved from Otto von Bismarck’s welfare state, which he instituted when the modern German nation-state was founded in the late 19th century (many will note that there was a Holy Roman Empire in Germany for about 900 years, but since they spent much of the time murdering one another and definitely did not have universal healthcare, let’s stick with the modern date.) Insurance mandate systems like Germany‘s require that all citizens be covered by insurance. Most of those citizens are covered by non-profit, government regulated insurance providers. In Germany, citizens who earn less money are enrolled in the nonprofit coverage; those who earn more can substitute private insurance options. All employed Germans contribute a portion of their wages toward the sickness funds, as do their employers. The key takeaways from insurance mandate systems are that citizens must pay some portion of their insurance, and most facilities are privately owned. Insurance mandate systems are more complex and have more moving parts, but they can also be more flexible and provide greater choice for consumers, because there are so many different participants in the insurance market. Obamacare tried to take us down this road, but lost a crucial component on the way: a publicly funded nonprofit insurance option.
Read about all systems and make your own decisions
There are a number of ways to achieve universal healthcare. If you’d like to read more about how other industrialized countries have implemented universal care, take a look at this excellent survey by the Commonwealth Fund. No country has gotten it 100% right, and the US has the opportunity to look at all of the countries that have created systems before us and take the best from each. So I encourage everyone to read as much as you can, make your own decisions, and keep an open mind about both types of universal coverage as you read the upcoming stories of how universal care works from the inside.