How American Cultural Assumptions Keep Us From Having Universal Health Care
American attitudes dissuade citizens from having a universal health care system (UHC). Those beliefs have outweighed considering the health benefits gained from providing affordable health coverage to every citizen.
However, since the Affordable Care Act was passed, there has been greater acceptance of moving our nation’s health standards to what citizens enjoy in other economically developed democracies. Still, two beliefs continue to resist universal health care.
The first belief is that America is the greatest nation in the world, and hence our health care is better than anywhere else. Second, collecting taxes makes for a big government to interfere in people’s private lives.
Those beliefs are not evil but are stopping our healthcare system from being universally accessible to all Americans. Consequently, let’s examine how each assumption is challenged by how our healthcare compares to other nations’ healthcare plans.
Being the Greatest Nation has limits
The belief that one’s country is a unique great nation is a sentiment other nations have also possessed. Britain, Russia, Germany, China, etc., sometimes believed they were the greatest. And each declined as they limited what they were willing to learn from other countries. We need not make that mistake.
We are the wealthiest nation in the world, measured by both GDP and per capita GDP. Moreover, our federal military and health budgets are roughly equal. However, compared to other developed democracies, our military’s performance is unmatched, while our health care is dismal.
Our politicians, for the most part, have shunned investigating how other nations have surpassed us in delivering health care. As a result, Americans are only aware of the difference from other countries once they experience receiving health care elsewhere. Of course, each person will have a different experience, but they will all be starkly different from how they are treated in the US. For example, you can read about the experience of two of my readers with universal health care (UHC) in Italy and Germany here. I invite others to submit their stories to me, and I’ll post them on my website under the tab Resources.
Measuring the Quality of a Nation’s Health Care
A nation’s cultural assumptions are dynamic in that political power energizes them to achieve objectives that benefit those who wield power. Nevertheless, despite this condition in other democracies, their societies have adopted (UHC) despite resistance from their established health industry. The results are evident when their health systems are compared to the US as measured by three indexes: Medical drug expenditures per capita, health expenditure per capita, and life expectancy. The detail for each index follows.
Cost of medical drugs – A study on Retail Rx spending per capita (1980–2015) showed that the US spent more than nine other high-income nations of similar population sizes. For example, Americans spent $1,011 annually, while Australia, Canada, France, Germany, and the United Kingdom spent considerably less. Germany came the closest to the US, spending $686 a year.
Findings concluded that Americans consume similar amounts of drugs as people in other countries, so the high US cost was not due to our greater demand.
Health expenditure per capita – The data is expressed in Purchasing power parities (PPPs) which equalize the purchasing power of different currencies. In 2021, the US had the highest expenditure at $12.3 thousand. This amount includes both public and private expenditures.
Of the nine other comparable developed democracies, seven in Europe and two in Asia, Germany, at $7.4 thousand, had the next highest per capita ranking. All the other countries had per capita amounts that ranged from six to four thousand dollars per capita.
Life expectancy – In the US, the average life expectancy is 79.11 years, which ranks at #46 out of 149 countries based on the latest United Nations Population Division estimates. We rank last among economically developed democracies. On average, citizens in the three nations with our closest cultural heritage, Canada, England, and Australia, live five years longer than Americans.
Although the public may need to become more familiar with these metrics, a 2019 survey by Statista revealed that only 33% of Americans were satisfied with our national health system. Compared to other economically developeddemocracies, the UK ranked highest with 53% satisfied, followed by Australia, France, Canada, Spain, Germany, South Korea, Japan, Italy, and the US. The Statista survey also showed that 43% of Americans were dissatisfied with our health system.
The Fear of Big Government is hurting us.
Republican President Ronald Reagan gets credit for the best quote about fearing Big Government when he said, “The nine most terrifying words in the English language are: I’m from the Government, and I’m here to help. “
Since 1980, Republicans have opposed tax increases for expanding Medicare and Medicaid and enacting ACA. Providing more health care is a precursor to producing a big government with more bureaucracy and poorer service. Most countries with effective and affordable UHC heavily fund it through taxes. Tax-financed expenditures as a percentage of US national health expenditures were 65.7 % in 2020. That is in the high range for comparable nations but not unusual.
However, our private per capita health expenditure is the highest of all of them. It is 17% higher than what citizens spend in Australia, Canada, and South Korea, which spend the following highest amounts per capita. US tax dollars do not offset out-of-pocket costs that individuals must pay for health coverage, while citizens in nations providing UHC pay less out-of-pocket expenses. This discrepancy is not a problem of a big government; it is a problem of how our tax dollars are spent.
Nevertheless, a note of caution is necessary. First, of course, a national government must be involved in the planning or delivery of health services. However, a government declaring total coverage does not guarantee good health care. For instance, Brazil is the only country where any individual is eligible to receive free healthcare with no previous application. Consequently, one would expect them to have a health care system with the most satisfied citizens. But that’s not so.
Brazil is ranked 63 among nations in providing a sound quality health system. Meanwhile, the US is ranked 30 by the CEOWorld Magazine‘s Health Care Index. Also, 63% of Brazilians are dissatisfied with their health care system, a far higher percentage than Americans are dissatisfied with ours. Therefore, government involvement is critical for achieving an efficient UHC, but only if it is one of many. Comparable countries to the US with UHC involve private companies, hospitals, physicians, and non-profit organizations in some capacity of service delivery, cost sharing, and planning.
How UHC functions in other nations
All nations implementing universal health care (UCF) do so through regulation and taxation. The legislation directs what kind of care must be provided, subject to the ability to make a co-payment for a minimum amount for service or medications.
The following is a brief sampling of how comparable nations to the US have consistently rated among the top dozen nations providing the best health care to their citizens (Australia, Canada, France, Germany, Italy, Japan, Spain, and the United Kingdom’s England).
In looking across multiple nations, UHC can be described by how they address four common elements: Funding source, health costs, coverage provided, and how services are delivered. Remember that health plans reflect conditions over the past few years. Countries continuously adjust their plans as political and economic conditions impact the health of their citizens.
All the comparable countries have some national healthcare insurance that receives substantial tax revenue. That revenue comes from central and local governments through income, sales, and corporate taxes. Some have specific levies for national health insurance, like Australia, which has a 2% levy and a surcharge for people over 35 that don’t have private health insurance. Exemptions and reductions are available for low-income Australian earners.
Businesses in most of this sampling also pick up a significant portion of healthcare costs for their employees. For instance, German employers pay for half of their employees’ health insurance contributions, while self-employed workers pay the entire contribution themselves with some exceptions.
One of the critical tools employed is the government regulating health costs for medical procedures and prescription medicines and not leaving the profit-oriented marketplace to determine prices.
Japan has used a national uniform fee schedule for reimbursing health providers for decades. Canada determines physician fees through periodic negotiations between the ministry and provincial medical associations (the Canadian version of the American Medical Association). France sets the insurance premium levels to be charged related to income and determines the prices of goods and services refunded.
By the government influencing the costs, it can insert community social goals, such as access to health care based on need. For example, Germany calculates individual health insurance premiums based on income and not age or the number of dependents. Australia made hospitalization free for permanent residents; in France, only 3.7% of hospital treatment costs are reimbursed through private insurance.
Although these nations commit to providing affordable healthcare, it is not free of requiring copayments. For instance, the national insurance plans in Canada and Japan cover 70 percent of the costs. However, in the case of Canada, the 30 percent typically relates to services not covered or only partially covered by their national insurance, such as prescription drugs, eye care, and dentistry.
In Japan, the individual contribution percentage could drop to 10 or 20 percent, depending on the family’s income and the insured’s age. Seniors who are covered by Japan’s national Senior Insurance plan only pay 10% out of pocket.
While some of these eight nations have no-cost emergency medicine and general doctor visits, individual co-pays are common in all the countries. Often it does not apply to public health needs; instead, it applies to specialties like dental and eye work. Italy has a small parallel private healthcare system specializing in dentistry and optometry health needs.
Even with universal health coverage, some items still need to be covered. For instance, Australia does not cover the cost of ambulance services, most dental care, glasses, contact lenses, or hearing aids. However, most of these are covered by state and territory governments or under private health insurance.
How Services Are Delivered
Surprisingly nations adopting UHC have not created large central bureaucracies. As a result, the decision-making and delivery of services are more decentralized than expected.
In the UK, which has one of the most extensive UHCs, responsibility is divided among geographical areas through strategic health authorities. And within each of the UK’s states (England, Scotland, Wales, and Northern Ireland), their legislatures make changes that address their citizens’ concerns.
Italy permits considerable variation in the quality and outcomes of care by region. For example, when measured at their Local Health Authority level, the results varied between 5% and more than 60%. And Australia’s state and territory governments regulate and administer the significant elements of healthcare, such as doctors, public hospitals, and ambulance services.
Germany has a unique arrangement where the Federal Joint Committee executes its healthcare system, making binding regulations and routine decisions. The Committee consists of representatives of public health insurance, hospitals, doctors, and dentists and three impartial members. In addition, on a local level, regional groups of sickness funds negotiate with regional doctors’ and dentists’ associations for payment for ambulatory and dental care.
Canada has a single payer system operated by a third-party payer responsible for paying health care providers for medical services. The government generally doesn’t own hospitals or employ doctors directly, and health services are delivered through provincial and territorial systems.
Each nation has a different way of planning and delivering health services. But they all manage to provide health coverage more cost-effectively and equitably than what the US is accomplishing.
To Move Forward, We Must Question our Assumptions.
President Biden said, in a New York Times guest editorial, that “he will make Medicare “solvent beyond 2050 without cutting a penny in benefits.” Biden knows that adults 65 and older with Medicare coverage (94%) report being very satisfied or satisfied with the quality of their medical care and the availability of specialists.
Conservatives and portions of the health industry are attacking his suggestion to raise funds through fees and taxes. They are tapping into two cultural assumptions hindering America from moving forward: taxes produce a big ineffective government, and America has nothing essential to learn from other nations.
Opponents of Biden’s plan fear a more significant trend, support for a public health insurance option now winning over 80% of Democrats and 56% of Republicans. Having the opportunity to choose public or private insurance is one of the critical elements of the comparable nations’ universal health care plans.
Biden needs to use his executive authority to begin a year-long process to evaluate how other developed democracies serve their citizens’ health needs compared to what we are providing to ours. He should invite both houses to pursue this effort with him. He should also reach out to health medical professionals and providers.
This discussion must be debated openly, not with ominous predictions or utopian promises, but with facts gathered from the leaders and users of UHC in other nations. Let them explain how it works to our citizens. Let them talk not just in DC but in forums around the US.
Those forums should be held in at least the seven states that approved Medicaid expansion by ballot measure, Idaho, Maine, Missouri, Nebraska, Oklahoma, South Dakota, and Utah. They should also appear in Florida and Wyoming, the only remaining states that have rejected expanding Medicaid but can expand it by ballot initiative. All these states except Maine voted for Donald Trump in 2020, who campaigned to eliminate ACA.
The US will never adopt UCF, Medicare for All plan, or a public insurance option until Senators and Congressional Representatives from those and similar red states are pushed to support it by their residents. Until then, Congressional Republicans will block the creation of any national health insurance plan.
Nick Licata is author of Becoming A Citizen Activist, and has served 5 terms on the Seattle City Council, named progressive municipal official of the year by The Nation, and is founding board chair of Local Progress, a national network of 1,000 progressive municipal officials.