Achieving Universal Health Coverage Solutions from Home and Abroad Issue Brief available at:

The Statistics 84 percent of Americans have some form of health insurance 45.7 million Americans lack health insurance ◦ One in three uninsured has a chronic illness ◦ One in four of this group has not seen a health provider in over a year ◦ The uninsured account for 18,000 excess deaths each year ◦ The cost to the nation of poorer health status of the uninsured is between $65 billion- $135 billion yearly ◦ The number of uninsured is expected to increase

The Triangle

The U.S. and Cost $1.86 trillion or $6401 per capita spent on healthcare in 2005 Cost drivers ◦ Constant stream of new technologies ◦ Maintaining highly trained workforce ◦ Increased consumption of healthcare services ◦ The health of Americans in general

The U.S. and Access Lack of insurance creates barrier to access ◦ 80 percent from working families ◦ The unemployed ◦ Those who don’t think they need it Geography can create a barrier HPSAs ◦ shortage of primary care physicians ◦ Declines in medical students choosing family practice

The U.S. and Quality U.S. enjoys excellent medical reputation U.S. fares relatively poorly in the W.H.O.’s health system performance rankings ◦ Nursing shortage ◦ Quality-neutral payment system (until very recently) ◦ Little quality information publicly available Differentiation between quality of healthcare services and general population health

Recent U.S. Quality Initiatives 2002: Nurse Reinvestment Act 2003: CMS Quality Reporting Program 2005: Hospital Compare Web site 2008: CMS and many private insurers refuse to pay for care resulting from medical errors Now: Pilot projects that tie reimbursement to quality outcomes

Healthcare Delivery Models The Beveridge ModelThe National Health Insurance (NHI) Model Used in the U.K., Scandinavia, Spain & New Zealand (and for American veterans) Used in Canada, Taiwan and South Korea (and for Americans with Medicare) Healthcare is delivered and paid for by the government All citizens pay into the healthcare system where the government is the sole payer The Bismarck ModelThe Out-of-Pocket Model Used in France, Belgium, Netherlands & Japan (and for Americans with employer-sponsored insurance) Used in poor nations without a nationwide health system such as rural Africa, India & China (and uninsured Americans) Funding for insurance is shared between employers & employees The poor cannot afford healthcare and they do not get it. The rich buy the care they need.

The United Kingdom Beveridge model- the government pays for the healthcare services of all of its citizens through taxes, including doctor care and hospital visits. Care coordinated through GP Low per-capita cost compared to U.S. Equal access to healthcare (though not perfect) ◦ Wait time ◦ Limiting types of services

Taiwan NHI model- One national, government run insurer that covers all citizens, all of whom are mandated to participate. Implemented in 1995 Low costs and high access achieved ◦ Single-payer model ◦ Smart Card ◦ Quality a lower priority

Germany Bismarck model- insurance is mandatory and is paid for by employers and employees Insurance companies nonprofit and administered by the state Quality a high priority High costs ◦ Abundant self-referral to specialists

Massachusetts health reform legislation passed known as Chapter 58 ◦ Individual Mandate for insurance coverage ◦ Expanded Medicaid to include children with families between % FPL ◦ Provided subsidies ◦ Imposed penalties on companies not offering insurance to their employees ◦ Created an insurance connector ◦ Included pay-for-performance measures

Vermont Health Care Affordability Act, 2006 ◦ Catamount Health Plan- affordable insurance plan open to all uninsured residents ◦ State offers subsidies to those 300% FPL for employer plan or Catamount plan ◦ Businesses assessed $365/employee not offered insurance ◦ Focus on chronic disease management with comprehensive Blueprint for Health initiative

Lessons Learned U.K. → Stress importance of primary care ◦ Pay general practitioners more generously ◦ Financial incentives for GPs to keep patients healthy Vermont→ Chronic disease management Massachusetts→ Payment incentives to eliminate ethnic/racial disparities Taiwan→ Health information technology Germany→ Excessive use of specialists

Conclusion Let’s first take a lesson from Taiwan, which may be the most important one of all. In response to its very poor healthcare system, Taiwan radically and fundamentally changed healthcare delivery. The lesson is, healthcare reform can occur.