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Universal health care

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Universal health care, or universal healthcare, is health care coverage which is extended to all citizens, and sometimes permanent residents, of a governmental region. Universal health care programs vary widely in their structure and funding mechanisms, particularly the degree to which they are publicly funded. Typically, most health care costs are met by the population via compulsory health insurance or taxation, or a combination of both.

Universal health care systems require government involvement, typically in the forms of enacting legislation, mandates and regulation. 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.

In the 1880s, most citizens in Germany became covered under the mandatory health care system championed by Otto von Bismarck. The National Health Service (NHS), established in the United Kingdom in 1948, was the world's first universal health care system provided by government. Universal health care is provided in most developed countries and in many developing countries. According to the Institute of Medicine of the National Academy of Sciences, the United States is the only wealthy, industrialized nation that does not provide universal health care.[1][2]

Implementation

Main article: Health care systems

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. Most countries 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 but are subsidized by taxation and compensated to the patient by the government. Many programs utilize some form of compulsory insurance to accomplish this goal. Other programs are paid for entirely out of tax revenues and provide automatic coverage for every citizen or resident.[3]

Europe

Virtually all of Europe has publicly sponsored and regulated health care. Countries include Austria, Belgium, Bosnia, Bulgaria, Croatia, Czech Republic, Denmark, Finland, Estonia, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Italy, Malta, the Netherlands, Norway, Latvia, Liechtenstein, Luxembourg, Poland, Portugal,[4] Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland and the United Kingdom.[5]

Finland

Finland has a highly decentralized three level socialized system of health care and alongside these, a much smaller private health care system. Responsibility for health care is devolved to the municipalities (local government), Primary health care is obtained from district health centers employing general practitioners and nurses that provide most day-to-day medical services. The general practitioners are also gatekeepers to the more specialized services in the secondary and tertiary care sectors. Secondary care is provided by the municipalities through district hospitals where more specialist care is available. Finland also has a network of five university teaching hospitals which makes up the tertiary level. These contain the most advanced medical facilities in the country and they are where Finnish doctors learn their profession. These are funded by the municipalities, but national government meets the cost of medical training. These hospitals are located in the major cities of Helsinki, Turku, Tampere, Kuopio, and Oulu.

There is a high level of co-operation between the various sectors with almost all having access to computerised patient data. Since the 1980s, the planning system for basic health care has been extended and now plans not just health care services but also care homes for the elderly and day care for children creating a fairly seamless cradle to grave system.

The private health care system is very small. Between 3 and 4 per cent of hospital in-patient care is provided by the private health care system and the remainder by the public or socialized system. Physiotherapy, dentistry and occupational health services are the main areas where the private sector is most used, although the municipalities by law also have to provide basic dental services. Employers are obliged by law to provide occupational health care services for their employees, as are educational establishments for their students as well as their staff. Only about 10 per cent of the income of private sector income comes from private insurance. Most is paid for out of pocket, but a significant share of the cost is reclaimable from the National Insurance system KELA. Spectacles, however, are not publicly subsidized.

A Patient’s Injury Law gives patients the right to compensation for unforeseeable injury that occurred as a result of treatment or diagnosis. Health care personnel need not be shown to be legally responsible for the injury thus avoiding the development of a litigious blame culture and the development of defensive medical practices. To receive compensation, it is sufficient that unforeseeable injury as defined by law occurred. A law on patients’ status and rights, the first such law in Europe, ensures a patient’s right to information, to informed consent to treatment, the right to see any relevant medical documents,and the right to autonomy. Legislation also lays down the time frame in which a person must be ensured access to necessary medical care and defines the small percentage of treatments that are to be considered as non-urgent. Doctors comply with care guidelines set by medical experts, but these are just guidelines and doctors are free to decide independently how to treat patients. The government does not dictate how doctors may treat their patients.

Finland's health care services are more highly socialized than the European average. The quality of service in Finnish health care is considered to be good and according to a survey published by the European Commission in 2000, Finland's is in the top 4 of EU countries in terms of satisfaction with their hospital care system: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[6] Finnish health care expenditures are below the European average.

Overall, the municipalities (funded by taxation, local and national) meet about two thirds of all medical care costs and the remaining one third by the national insurance system (nationally funded), and private finance (either employer funded or met by patients themselves). There are caps on total medical expenses that are met out of pocket for drugs and hospital treatments. All necessary costs over these caps are paid for by the National Insurance system. Public spending on health care in 2006 was 13.6 billion euros, equivalent to 2,586 euros (US$ 1,616) per person annually. The increase over 2005 at 8.2 per cent was below the OECD average of 9 percent. Household budgets directly met 18.7 per cent of all health care costs. [7]

Main sources: Finland report on Health Care Systems in Transition (WHO) and Health care in Finland (Ministry of Social Affairs and Health publication)

Germany

Germany has the world's oldest universal health care system, with origins dating back to Otto von Bismarck's Health Insurance Act of 1883. As mandatory health insurance, it originally applied only to low-income workers and certain government employees, but has gradually expanded to cover virtually the entire population.[8] Currently 85% of the population is covered by a basic 'Statutory Health Insurance' plan, which provides the standard level of coverage. The remainder opt for private health insurance, which frequently offers additional benefits. According to the World Health Organization, Germany's health care system was 77% government-funded and 23% privately funded as of 2004.[9]

The government's role is chiefly regulatory.[citation needed] It convenes representatives of consumers, employers, health care professionals, workers unions, and the insurance industry annually to set national standards and reimbursement levels for particular services.[citation needed] Although the government regulates the process, it is administered by myriad health insurance providers and is financed chiefly by a combination of employer and employee contributions.[citation needed] The government also subsidizes the cost of Statutory Health Insurance for the unemployed.[citation needed] It partially reimburses the costs for low-wage workers, whose premiums are capped at a predetermined value. Higher wage workers pay a premium based on their salary. They may also opt for private insurance, which is generally more expensive, but whose price may vary based on the individual's health status.[10]

In Germany, most hospital care is provided by salaried physicians and nurses in public non-profit hospitals.[citation needed] A smaller number of private non-profit (e.g., church-owned) hospitals exist, but private hospitals are rare.[citation needed] Ambulatory care is generally provided by physicians in individual or small-group practices.[citation needed] Ambulatory care physicians may not be simultaneously employed by hospitals.[citation needed] Reimbursement is on a fee-for-service basis, but the number of physicians allowed to accept Statutory Health Insurance in a given locale is regulated by the government and professional societies.

As in many countries, rising health care costs have been a cause of concern and have led to a number of changes or reforms in the health care system.[citation needed] Capitated care, such as that provided by health maintenance organizations, has been prohibited since the 1930s, but has been recently reconsidered as a cost containment mechanism.[11] Copayments were introduced in the 1980s in an attempt to prevent overutilization. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).[12][13] Part of the difference is that the chief consideration for hospital reimbursement is the number of hospital days as opposed to procedures or diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. However, because of the relative simplicity and universality of the reimbursement mechanisms the administrative costs are low, at 160 euro per capita.[citation needed] Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[14]

Hungary

The Hungarian health care system is universal and the revenues come from income tax. Recently, Prime Minister Ferenc Gyurcsány and his Hungarian Socialist Party proposed a change to the system which would include small "visit fees" when seeing a doctor. The reform required a vote from the people and on March 17, 2008, the visit fee bill was defeated.

The next move for Hungary could be privatized health care. Ferenc Gyurcsány also proposes moving Hungary into the hands of private health care insurers but was vetoed by President László Sólyom. President Sólyom, not a socialist but rather an independent, cited the fact that no country in the world has benefited from private health care. The veto is not yet the end of private health care in Hungary, as the bill can be put back into the vote. Opponent Viktor Orbán, part of the Fidesz (conservative) party and former prime minister, argues the need for universal health care. Viktor says his party will win in the next election and in the event the health care system is given to the private insurance companies, he vows to not only put back the universal health coverage but to force the insurance companies to pay for the costs of switching back.

As for the Hungarian people they have been anything but quiet concerning the threat of losing their universal health care system. Transportation workers have gone on strike, people have demonstrated and passed around petitions against the government, and even in some cases produced riots. It is common to see free viewing of the movie Sicko by Michael Moore in towns and villages.

The Netherlands

Main article: Health care in the Netherlands

The Netherlands has a dual-level system. All primary and curative care (i.e. the family doctor service and hospitals and clinics) is financed from private compulsory insurance. Long term care for the elderly, the dying, the long term mentally ill etc. is covered by social insurance funded from taxation. According to the WHO, the health care system in the Netherlands was 62% government funded and 38% privately funded as of 2004.[9]

Insurance companies must offer a core universal insurance package for the universal primary, curative care which includes the cost of all prescription medicines. They must do this at a fixed price for all. The same premium is paid whether young or old, healthy or sick. It is illegal in The Netherlands for insurers to refuse an application for health insurance, to impose special conditions (e.g. exclusions, deductables, co-pays etc or refuse to fund treatments which a doctor has determined to be medically necessary). The system is 50% financed from payroll taxes paid by employers to a fund controlled by the Health regulator. The government contributes an additional 5% to the regulator's fund. The remaining 45% is collected as premiums paid by the insured directly to the insurance company. Some employers negotiate bulk deals with health insurers and some even pay the employees' premiums as an employment benefit). All insurance companies receive additional funding from the regulator's fund. The regulator has sight of the claims made by policyholders and therefore can redistribute the funds its holds on the basis of relative claims made by policy holders. Thus insurers with high payouts will receive more from the regulator than those with low payouts. Thus insurance companies have no incentive to deter high cost individuals from taking insurance and are compensated if they have to pay out more than might be expected. Insurance companies compete with each other on price for the 45% direct premium part of the funding and try to do negotiate deals with hospitals to keep costs low and quality high. The competition regulator is charged with checking for abuse of dominant market positions and the creation of cartels that act against the consumer interests. An insurance regulator ensures that all basic policies have identical coverage rules so that no person is medicially disadvantaged by his or her choice of insurer.

Hospitals in the Netherlands are also regulated and inspected but are mostly privately run and for profit, as are many of the insurance companies. Patients can choose where they want to be treated and have access to information on the internet about the performance and wait times at each hospital. Patients dissatisfied with their insurer and choice of hospital can cancel at any time but must make a new agreement with another insurer.

Insurance companies can offer additional services at extra cost over and above the universal system laid down by the regulator, e.g. for dental care. The standard monthly premium for health care paid by individual adults is about 100€ per month. Persons on low incomes can get assistance from the government if they cannot afford these payments. Children under 18 are insured by the system at no additional cost to them or their families because the insurance company receives the cost of this from the regulator's fund.

United Kingdom

Main article: Healthcare in the United Kingdom

Each of the countries of the United Kingdom has a public health service that provides healthcare to all UK permanent residents that is free at the point of need and paid for from general taxation. However, since Health is a devolved matter, considerable differences are developing between the systems in the different countries.[15] Though commonly referred to as the NHS across the UK, in fact the National Health Service just covers England with separate 'National Health Services' in the other parts of the UK. For details of public healthcare in each country, see:

England
Main article: Healthcare in England

The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services.

The outsourcing of medical services and support to the private sector is a recent innovation. Hospitals may have both medical services (such as "surgicentres"),[16] and non-medical services (such as catering) provided under long-term contracts by the private sector. Capital projects such as new hospitals have been privatized through the Private Finance Initiative, enabling the public sector borrowing requirement to be circumvented, at least in the short term.

Northern Ireland
Scotland
Main article: Healthcare in Scotland

NHS Scotland was founded by the National Health Service (Scotland) Act 1947 (since repealed by the National Health Service (Scotland) Act 1978) which came into effect on the same day as the NHS in England and Wales but has always been a separate organisation.

Wales
Main article: Healthcare in Wales

NHS Wales was originally formed as part of the same NHS structure created by the National Health Service Act 1946 but powers over the NHS in Wales came under the Secretary of State for Wales in 1969[17].

Americas

Argentina, Brazil, Canada (see below), Chile, Costa Rica, Cuba and Uruguay all have public health care provided.

Mexico is planning to launch its own universal health care network.[18]

United States

Further information: Health care in the United States and Health care reform in the United States

The United States is the only wealthy, industrialized nation that does not have a universal health care system.[1] The government directly covers a little over one-quarter of the population[19] through health care programs for the elderly, disabled, military service families and veterans, children, and some of the poor.[20][21] Federal law ensures public access to emergency services regardless of ability to pay.[22] However, this unfunded mandate has contributed to a health care safety net that some analyses say is increasingly strained.[23] Certain types of medical spending and particularly health insurance benefit from significant tax subsidies; in particular, employer-sponsored health insurance is a non-taxable benefit. In all, government spending accounted for 45.1% of total health spending in the U.S. in 2005.[24]

Current estimates put U.S. health care spending at approximately 15% of GDP, the highest in the world.[25] Despite this, only an estimated 84.2% of citizens have some form of health insurance coverage, either through their employer, purchased individually, or through government sources. The number of uninsured increased from 44.8 million to 47.0 million from 2005 to 2006.[19] One study estimates that about 25% of the country's uninsured, or roughly another 11 million people, are eligible for government health care programs but unenrolled. However, assuring adequate financing to cover those who are eligible remains a challenge.[26]

In 2003, approximately 61 million adults, or 35 percent of individuals ages 19 to 64, had either no insurance, sporadic coverage, or insurance coverage that exposed them to high health care costs.[27] Employers that do provide insurance, on average, spend between 4.6 and 8.7% of their payroll in health insurance premiums. The cost of health care premiums is rising much faster than the general rate of inflation or employee wages. Since 2001, premiums for family coverage have increased 78%, while inflation has risen 17% and wages have risen 19%, according to a 2007 study by the Kaiser Family Foundation.[28]

In lieu of a national program, supporters of universal health care have sought implementation of such programs at the state and municipal level. The Commonwealth of Massachusetts is implementing a near-universal health care system by mandating that residents purchase health insurance by July 1, 2007.[29] The City of San Francisco is also undertaking a universal health care system for uninsured residents.[30][31] California, Maine, Vermont and Hawaii are also considering or seeking to implement universal or near-universal systems.[32] Recently, a California State Senate committee voted on a bi-partisan basis against a plan to help establish a $14 billion fund to subsidize medical insurance for 5 million uninsured Californians. [10]

There have been numerous proposals to stimulate the current system into extending coverage more universally, rather than through a more comprehensive restructuring. For example, since most Americans with private coverage receive it through employer-sponsored plans, many have suggested employer "pay or play" requirements as a way to increase coverage levels. However, one study suggests that current pay or play proposals are limited in their ability to increase coverage among the "working poor".[33] The study's criticisms of these proposals included the observations that they generally exclude small firms, do not distinguish between individuals who have access to other forms of coverage and those who do not, and increase the overall compensation costs to employers. One study that examined several such market-based reform packages concluded that if market-oriented reforms are not implemented on a systematic basis with appropriate safeguards, they have the potential to cause more problems than they solve.[34]

Others have proposed premium subsidies to help individuals purchase their own health insurance as a way to increase coverage rates. Research confirms that consumers in the individual health insurance market are sensitive to price. Estimates of the demand elasticity in this market vary, but generally fall in the range of -0.3 to -0.1. It appears that price sensitivity varies among population subgroups, and is generally higher for those at younger ages and lower incomes. However, research also suggests that subsidies alone are unlikely to incentivize more people to get coverage. [35][36]

Canada

Main article: Health care in Canada

In 1984, the Canada Health Act was passed, which prohibited extra billing by doctors on patients while at the same time billing the public insurance system. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."[37]

The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises or private corporations, although most hospitals are public. Most doctors do not receive an annual salary, but receive a fee per visit or service.[38] About 30% of Canadians' health care is paid for by the private sector or individuals.[39] This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and vision care.[40] Many Canadians have private health insurance, often through their employers, that cover these expenses.[41]

The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine.[42][43] The legality of the ban was considered in a decision of the Supreme Court of Canada which ruled in Chaoulli v. Quebec that "the prohibition on obtaining private health insurance, while it might be constitutional in circumstances where health care services are reasonable as to both quality and timeliness, is not constitutional where the public system fails to deliver reasonable services." The appellant contended that waiting times in Quebec violated a right to life and security in the Quebec Charter of Human Rights and Freedoms. The Court agreed, but acknowledged the importance and validity of the Canada Health Act, and at least four of the seven judges explicitly recognized the right of governments to enact laws and policies which favour the public over the private system and preserve the integrity of the public system. But not if the public system fails to deliver reasonable service as to quality or timeliness, as the court found in this case.[44]

Asia and Africa

Brunei, China[45], Hong Kong SAR, India, Kuwait, Qatar, UAE, Saudi Arabia, Israel[46] Japan, Malaysia, South Korea, Seychelles, Sri Lanka,[47] Taiwan[48] and Thailand have universal health care.

China

Main article: Healthcare system reform in the People's Republic of China

Since the founding of the People's Republic of China, the goal of healthcare programs has been to provide care to every member of the population and to make maximum use of limited health-care personnel, equipment, and financial resources.

China is undertaking a reform on its universal health care system. The New Rural Co-operative Medical Care System (NRCMCS) is a new 2005 initiative to overhaul the healthcare system, particularly intended to make it more affordable for the rural poor. Under the NRCMCS, the annual cost of medical cover is 50 yuan (US$7) per person. Of that, 20 yuan is paid in by the central government, 20 yuan by the provincial government and a contribution of 10 yuan is made by the patient. As of September 2007, around 80% of the whole rural population of China had signed up (about 685 million people). The system is tiered, depending on the location. If patients go to a small hospital or clinic in their local town, the scheme will cover from 70-80% of their bill. If they go to a county one, the percentage of the cost being covered falls to about 60%. And if they need specialist help in a large modern city hospital, they have to bear most of the cost themselves, the scheme would cover about 30% of the bill.[49]

Singapore

Singapore has a highly privatized universal health care system with an emphasis on individual fiscal responsibility. Overall spending on health care amounts to only 3% of annual GDP. Of that, 66% comes from private sources.[9] Singapore currently has the lowest infant mortality rate in the world (equaled only by Iceland) and among the highest life expectancies from birth, according to the World Health Organization.[50] Singapore has "one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes," according to an analysis by global consulting firm Watson Wyatt.[51] Singapore's system uses a combination of compulsory savings from payroll deductions (funded by both employers and workers) a nationalized catastrophic health insurance plan, and government subsidies, as well as "actively regulating the supply and prices of healthcare services in the country" to keep costs in check; the specific features have been described as potentially a "very difficult system to replicate in many other countries." Many Singaporeans also have supplemental private health insurance (often provided by employers) for services not covered by the national programs.[51]

Thailand

Thailand introduced universal coverage reforms in 2001, becoming one of only a handful of lower-middle income countries to do so. Means-tested health care for low income households was replaced by a new more comprehensive insurance scheme — originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card which allows them to access services in their health district, and, if necessary, be referred for specialist treatment elsewhere. The bulk of finance comes from public revenues, with funding allocated to Contracting Units for Primary Care annually on a population basis. According to the WHO, 65% of Thailand's health care expenditure in 2004 came from the government, 35% was from private sources.[9] Although the reforms have received a good deal of critical comment, they have proved popular with poorer Thais, especially in rural areas, and survived the change of government after the 2006 military coup. The then Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the UC scheme free. It is not yet clear whether the scheme will be modified further under the coalition government that came to power in January 2008.[52][18][53]

India

India has partial universal health care system run by the local governments. The "government hospitals", some of which are among the best hospitals in India,[54] provide treatment at taxpayer cost. Selected drugs are offered free of charge in some hospitals. In 1946 a Health Survey and Development Committee in India put forward a plan for a universal health care system. According to India today, the country has not lived up to their outlined plan. As of 2007, the hospitals contain only a tenth of the recommended ratio of hospital beds; there are only 70 beds for every 100,000 people.[55] According to the WHO, India's health care system is 83% privately funded, with 17% of health care expenditure coming from the government as of 2004.[9]

Oceania

Australia

File:Medicare-brand.png
Medicare logo
Main article: Medicare (Australia)

Medicare was introduced by the Whitlam Labour Government on 1 July 1975 through the Health Insurance Act 1973. The Australian Senate rejected the changes multiple times and they were passed only after a joint sitting after the 1974 double dissolution election. Yet Medicare has been supported by subsequent governments and became a key feature of Australia’s public policy landscape. The exact structure of Medicare, in terms of the size of the rebate to doctors and hospitals and the way it has administered, has varied over the years. The original Medicare program proposed a 1.35% levy (with low income exemptions) but these bills were rejected by the Senate, and so Medicare was originally funded from general taxation. In October 1976, the Fraser Government introduced a 2.5% levy. The program is now nominally funded by an income tax surcharge known as the Medicare levy, which is currently set at 1.5% with exemptions for low income earners.[56] In practice the levy raises only a fraction of the money required to pay for the scheme. If the levy was to fully pay for the services provided under the medicare banner then it would need to be set at about 8%.[citation needed] There is an additional levy of 1.0%, known as the Medicare Levy Surcharge, for those on high annual incomes ($50,000) who do not have adequate levels of private hospital coverage. This was part of an effort by the previous Coalition Federal Government to encourage takeup of private health insurance. According to the WHO, government funding covered 67.5% of Australia's health care expenditures in 2004; private sources covered the remaining 32.5% of expenditures.[9]

New Zealand

As with Australia, New Zealand's healthcare system is funded through general taxation. According to the WHO, government sources covered 77.4% of New Zealand's health care costs in 2004; private expenditures covered the remaining 22.6%.[9]

Economics

Main article: Health care economics

Funding models

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.

Most all European systems are financed through a mix of public and private contributions.[57] The majority of universal health care systems are funded primarily by tax revenue (e.g. Portugal[57]). Some nations, such as Germany, France[5] and Japan[58] 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.[59]

Compulsory insurance

This is usually enforced via legislation. 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.[60]

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.

Taxation

Some countries (notably the UK) 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.

Single-payer

This term is used in the U.S. debate to describe a funding mechanism meeting the costs of medical care from a single fund. Although the fund holder is sometimes assumed to be the government allocating funding from taxation, its proponents do not rule out the possibility of some other mechanism. It is therefore as yet undetermined whether a future U.S. single-payer universal health care system would be funded from taxation, from compulsory insurance or a mixture of both.

See also: Single-payer healthcare and Publicly funded healthcare

Private insurance

In countries with universal coverage, private insurance is most often used as a supplement, covering what the core safety net service does not provide, Examples include elective cosmetic surgery and special comforts like private rooms. In some countries, people can use private insurance to obtain treatment more quickly than would otherwise be possible.

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.[61][62]

Politics

Main article: Health care politics

Health care systems throughout the world face sustainability challenges that may require far-reaching changes in national policy.[63] Over the last decade, health spending has been accelerating as a percent of Gross Domestic Product (GDP) among Organisation for Economic Co-operation and Development (OECD) countries.[63] Many industrialized countries have aging populations, with resulting increases in health care utilization, while others face rapid population growth. One recent study, by global consulting firm PriceWaterhouseCoopers, projected that global health care spending would triple in real dollars by 2020, consuming 21% of GDP in the U.S. and 16% of GDP in other OECD countries.[63]

United States

Main article: Health care reform in the United States

Whether a government mandated system of universal health care should be implemented in the U.S. remains a hotly debated political topic. Those in favor of universal health care, such as the non-partisan Institute of Medicine of the National Academies, which has called for the U.S. to implement universal health care by 2010, argue that the current rate of uninsurance creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality.[64] Americans have a lower average life expectancy than those in other industrialized nations with universal health care, such as Australia, the United Kingdom, Canada, and Sweden.[65] Infant mortality rates also remain higher in the U.S., despite declines in recent decades, and are higher than the average of the European Union.[66][67]

Critics of this argument note that there is very little correlation between life expectancy and infant mortality with the quality of health care, due to such factors as alternate causality and variations in the way countries collect their statistical data.[68] In fact, the U.S. led the world in life expectancy twenty years ago with virtually the same health system. Rather, many analysts attribute the lower life expectancy to a great surge in obesity rates.[69][70][71]

Opponents of government mandates or programs for universal health care, including libertarian think tanks such as The Cato Institute, argue that people should be free to opt out of health insurance[72] and that government programs would require higher taxes, increase utilization, and reduce health care quality. Opponents also claim that the absence of a market mechanism may slow innovation in treatment and research, and lead to rationing of care through waiting lists.[73] Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.[74][75]

Survey research shows that Americans see expanding coverage as a top national priority, and a majority express support for universal health care.[76] There is, however, much more limited support for tax increases to support health care reform.[76][77] Most Americans report satisfaction with their own personal health care. Confidence in government, and the willingness to support large expansions of government, have declined significantly since the 1960s. Support for a single-payer system is less than the level of dissatisfaction with the current system and desire for increased coverage might suggest.[77]

Debate in the United States

Template:MultiCol Common arguments forwarded by supporters of universal health care systems include:

  • Health care is a basic human right[78][74][79] or entitlement.[80]
  • Ensuring the health of all citizens benefits a nation economically.[81]
  • About 60% of the U.S. health care system is already publicly financed with federal and state taxes, property taxes, and tax subsidies - a universal healthcare system would merely replace private/employer spending with taxes. Total spending would go down for individuals and employers.[82]
  • A single payer system could save $286 billion a year in overhead and paperwork.[83] Administrative costs in the U.S. health care system are substantially higher than those in other countries and than in the public sector in the US: one estimate put the total administrative costs at 24 percent of U.S. health care spending.[84]
  • Several studies have shown a majority of taxpayers and citizens across the political divide would prefer a universal healthcare system over the current U.S. system[85][86][87]
  • Universal health care would provide for uninsured adults who may forgo treatment needed for chronic health conditions.[88]
  • Wastefulness and inefficiency in the delivery of health care would be reduced.[89]
  • America spends a far higher percentage of GDP on health care than any other country but has worse ratings on such criteria as quality of care, efficiency of care, access to care, safe care, equity, and wait times, according to the Commonwealth Fund.[90]
  • A universal system would align incentives for investment in long term health-care productivity, preventive care, and better management of chronic conditions.[91]
  • Universal health care could act as a subsidy to business, at no cost thereto. (Indeed, the Big Three of U.S. car manufacturers cite health-care provision as a reason for their ongoing financial travails. The cost of health insurance to U.S. car manufacturers adds between USD 900 and USD 1,400 to each car made in the U.S.A.)[92]
  • The profit motive adversely affects the cost and quality of health care. If managed care programs and their concomitant provider networks are abolished, then doctors would no longer be guaranteed patients solely on the basis of their membership in a provider group and regardless of the quality of care they provide. Theoretically, quality of care would increase as true competition for patients is restored.[93]
  • A 2008 opinion poll of 2,000 US doctors found support for a universal healthcare plan at 59%-32%, which is up from the 49%-40% opinion of physicians in 2002. These numbers include 83% of psychiatrists, 69% of emergency medicine specialists, 65% of pediatricians, 64% of internists, 60% of family physicians and 55% of general surgeons. The reasons given are an inability of doctors to decide patient care and patients who are unable to afford care.[94]
  • According to an estimate by Dr. Marcia Angell roughly 50% of healthcare dollars are spent on healthcare, the rest go to various middlemen and intermediaries. A streamlined, non-profit, universal system would increase the efficiency with which money is spent on healthcare.[95]
  • In countries in Western Europe with public universal health care, private health care is also available, and one may choose to use it if desired. Most of the advantages of private health care continue to be present, see also Two-tier health care.[96]
  • Universal health care and public doctors would protect the right to privacy between insurance companies and patients.[97]
  • Public health care system can be used as independent third party in disputes between employer and employee.[98]


| class="col-break " | Common arguments forwarded by opponents of universal health care systems include:

  • If universal health care is provided by federally mandated purchase of health insurance, it may be unconstitutional, since the Constitution does not give the federal government this right and reserves all non-mentioned rights to the States or the People.
  • Health care is not a right. [75][99] As such, it is not the responsibility of government to provide health care.[100]
  • Universal heath care would result in increased wait times, which could result in unnecessary deaths.[101]
  • Unequal access and health disparities still exist in universal health care systems.[102]
  • Universal health care would reduce efficiency because of more bureaucratic oversight and more paperwork, which could lead to fewer doctor-patient visits.[citation needed] Advocates of this argument claim that the performance of administrative duties by doctors results from medical centralization and over-regulation, and may reduce charitable provision of medical services by doctors.[99]
  • Many problems that universal health insurance is meant to solve are presumed caused by limitations on the free market. As such, free market solutions have greater potential to improve care and coverage.[103]
  • The federal Emergency Medical Treatment and Active Labor Act requires hospitals and ambulance services to provide emergency care to anyone regardless of citizenship, legal status or ability to pay. The health care safety net, which includes free medical clinics, charity care, nonprofits and government-run community hospitals, provides necessary care to the uninsured.
  • The widely quoted health care system ranking by the World Health Organization, in which the US system ranked below other countries' universal health care systems, used biased criteria, giving a false sense of those systems' superiority.[104]
  • Empirical evidence on the Medicare single payer-insurance program demonstrates that the cost exceeds the expectations of advocates.[105] As an open-ended entitlement, Medicare does not weigh the benefits of technologies against their costs. Paying physicians on a fee-for-service basis also leads to spending increases. As a result, it is difficult to predict or control Medicare's spending.[102] Large market-based public program such as the Federal Employees Health Benefits Program and CalPERS can provide better coverage than Medicare while still controlling costs as well.[106][107]
  • Universal health care systems, in an effort to control costs by gaining or enforcing monopsony power, sometimes outlaw medical care paid for by private, individual funds.[108]

Template:EndMultiCol

See also

References

  1. ^ a b Insuring America's Health: Principles and Recommendations, Institute of Medicine at the National Academies of Science, 2004-01-14, accessed 2007-10-22
  2. ^ The Case For Single Payer, Universal Health Care For The United States
  3. ^ For an international comparison of ten different health care systems in ten developed countries - nine universal systems and one non-universal system (the U.S.) - and their relative costs and key health outcomes, see http://www.nao.org.uk/publications/Int_Health_Comp.pdf. For a wider international comparison of 16 countries, each with universal health care, see the World Health Organisation publication at http://www.euro.who.int/document/e85400.pdf.
  4. ^ Portugal: Bentes M, Dias CM, Sakellarides C, Bankauskaite V. Health Care Systems in Transition: Portugal. WHO are Regional Offices for Europe on behalf of the European Observatory on Health Systems and Policies, 2004.
  5. ^ a b Physicians for a National Health Program "International Health Systems".
  6. ^ http://ec.europa.eu/public_opinion/archives/ebs/ebs_283_en.pdf European Commission: Health and long-term care in the European Union
  7. ^ http://www.yle.fi/uutiset/kotimaa/oikea/id88679.html News item on healthcare costs in 2006 (in Finnish)
  8. ^ History of German Health Care System
  9. ^ a b c d e f g World Health Organization Statistical Information System: Core Health Indicators
  10. ^ Gesetzliche Krankenversicherungen im Vergleich(English Translation)
  11. ^ Capitation in Germany
  12. ^ Length of hospital stay, Germany
  13. ^ Length of hospital stay, U.S.
  14. ^ Borger C, et al. "Health spending projections through 2015: changes on the horizon." Health Affairs (2006)
  15. ^ NHS now four different systems BBC January 2 2008
  16. ^ "New generation surgery-centers to carry out thousands more NHS operations every year". Department of Health. 2002-12-03. Retrieved 2006-09-15.
  17. ^ Introduction to NHS Wales 1960's www.wales.nhs.uk
  18. ^ a b G20 Health Care: "Health Care Systems and Health Market Reform in the G20 Countries." Prepared for the World Economic Forum by Ernst & Young. January 3, 2006.
  19. ^ a b "Income, Poverty, and Health Insurance Coverage in the United States: 2006." U.S. Census Bureau. Issued August 2007.
  20. ^ Overview - What is Not Covered, U.S. Department of Health & Human Services
  21. ^ Centers for Medicare & Medicaid Services. CMS Programs & Information. Retrieved August 30, 2006.
  22. ^ Centers for Medicare & Medicaid Services. Emergency Medical Treatment & Labor Act. Retrieved August 30, 2006.
  23. ^ "Report Brief: America's Health Care Safety Net: Intact but Endangered" (PDF). Institute of Medicine, National Academies of Science. 2000-01-01. Retrieved 2007-10-22. In the absence of universal health insurance, a health care "safety net" is the default system of care for many of the 44 million low-income Americans with no or limited health insurance as well as many Medicaid beneficiaries and people who need special services. This safety net system is neither uniformly available throughout the country nor financially secure.
  24. ^ Briefing note for OECD Health Data 2007: How Does the United States Compare, OECD Health Data 2007, accessed 2007-10-28
  25. ^ "The World Health Report 2006 - Working together for health."
  26. ^ "Characteristics of the Uninsured: Who is Eligible for Public Coverage and Who Needs Help Affording Coverage?" (PDF). Kaiser Commission on Medicaid and the Uninsured. Retrieved 2007-07-19.
  27. ^ "Insured But Not Protected: How Many Adults Are Underinsured". The Commonwealth Fund. Retrieved 2007-07-27.
  28. ^ "Health Insurance Premiums Rise 6.1 Percent In 2007, Less Rapidly Than In Recent Years But Still Faster Than Wages And Inflation" (Press release). Kaiser Family Foundation. 2007-09-11. Retrieved 2007-09-13.
  29. ^ Fahrenthold DA. "Mass. Bill Requires Health Coverage." Washington Post; Wednesday, April 5, 2006; Page A01.
  30. ^ "Healthy San Francisco: About Us". City of San Francisco. Retrieved 2007-10-27.
  31. ^ Meredith, Adams. "San Francisco launches universal health care". Chicago Tribune. 2007-09-18. Retrieved on 2007-10-09
  32. ^ Steinhauer, Jennifer (2007-01-09). "California Plan for Health Care Would Cover All". New York times. Retrieved 2007-10-27.
  33. ^ Richard Burkhauser and Kosali Simon,"Who Gets What From Employer “Pay or Play” Mandates", Employment Policies Institute, Cornell University, November 2007
  34. ^ Linda J. Blumberg and Len Nichols, "Health Insurance Market Reforms: What They Can and Cannot Do," Urban Institute, November 1, 1995
  35. ^ "The Price Sensitivity of Demand for Nongroup Health Insurance," Congressional Budget Office, 2005
  36. ^ M. Susan Marquis, Melinda Beeuwkes Buntin, Jose J. Escarce, Kanika Kapur, and Jill M. Yegian, "Subsidies and the Demand for Individual Health Insurance in California," Health Services Research 39:5 (October 2004)
  37. ^ Government of Canada, Social Union, News Release, "A Framework to Improve the Social Union for Canadians: An Agreement between the Government of Canada and the Governments of the Provinces and Territories, February 4, 1999," URL accessed 20 December 2006.
  38. ^ Public vs. private health care. CBC, December 1, 2006.
  39. ^ Press release, "Health care spending to reach $160 billion this year", Canadian Institute for Health Information, November 13, 2007, accessed November 19, 2007
  40. ^ National Health Expenditure Trends, 1975-2007, Canadian Institute for Health Information, November 13, 2007, accessed November 19, 2007
  41. ^ Private Health Insurance in OECD Countries OECD Health Project, 2004, accessed November 19, 2007
  42. ^ Private Health Care in Canada, Robert Steinbrook, N Engl J Med, 354:1661-1664, April 20, 2006
  43. ^ Kraus, Clifford (2006-02-26). "As Canada's Slow-Motion Public Health System Falters, Private Medical Care Is Surging". New York Times. Retrieved 2007-07-16.
  44. ^ http://www.sgmlaw.com/PageFactory.aspx?PageID=488
  45. ^ Gadling
  46. ^ The Health Care System in Israel- An Historical Perspective Israel Ministry of Foreign Affairs. Retrieved June 7, 2006.
  47. ^ Ministry of Health and Nutrition, Sri Lanka
  48. ^ Bureau of National Health Insurance, Taiwan
  49. ^ The reform of the rural cooperative medical system in the People's Republic of China: interim experience in 14 pilot counties. Authors: Carrin G.1; Ron A.; Hui Y.; Hong W.; Tuohong Z.; Licheng Z.; Shuo Z.; Yide Y.; Jiaying C.; Qicheng J.; Zhaoyang Z.; Jun Y.; Xuesheng L. Source: Social Science and Medicine, Volume 48, Number 7, April 1999, pp.961-972(12) [1]
  50. ^ World Health Organization, "World Health Statistics 2007: Mortality", based on 2005 data.
  51. ^ a b John Tucci, "The Singapore health system – achieving positive health outcomes with low expenditure", Watson Wyatt Healthcare Market Review, October 2004.
  52. ^ The Universal Coverage Policy of Thailand: An Introduction
  53. ^ Hughes, D. and Leethongdee, S. Universal coverage in the land of smiles: lessons from Thailand's 30 baht health reforms, Health Affairs 26(4):999-1008, 2007.
  54. ^ A list of the top rated hospitals in India. Several hospitals among these are government hospitals, Including AIIMS
  55. ^ Universal care - still miles to go
  56. ^ Australian Taxation Office (19th June, 2007). "What is the Medicare levy?". Retrieved 2008-02-15. {{cite web}}: Check date values in: |date= (help)
  57. ^ a b Bentes M, Dias CM, Sakellarides C, Bankauskaite V. Health Care Systems in Transition: Portuagal. WHO are Regional Offices for Europe on behalf of the European Observatory on Health Systems and Policies, 2004.
  58. ^ Chua, Kao-Ping. "Single Payer 101". February 10, 2006.
  59. ^ Sherry A. Glied, "Health Care Financing, Efficiency, and Equity," National Bureau of Economic Research Working Paper No. 13881, March 2008
  60. ^ Goliath - Research in Healthcare Financial Management - Industry & Business News Articles - Article, News, Research, Information
  61. ^ Michael Rothschild and Joseph Stiglitz, "Equilibrium in Competitive Insurance Markets: An Essay on the Economics of Imperfect Information," Quarterly Journal of Economics, November 1976 (90:629-649) (known as the Rothschild-Stiglitz Model)
  62. ^ Paulo Belli, How Adverse Selection Affects the Health Insurance Market
  63. ^ a b c "HealthCast 2020: Creating a sustainable future" (PDF). PriceWaterhouseCoopers (requires registration. Retrieved 2007-10-27.
  64. ^ "Insuring America's Health: Principles and Recommendations". Institute of Medicine of the National Academies. Retrieved 2007-10-27.
  65. ^ CIA World Factbook table of life expectancies by country
  66. ^ -see table
  67. ^ CIA World Factbook; Guide to Rank Order Pages[2] and the complete article on the United States [3]
  68. ^ National Center for Public Policy Analysis. [4] Retrieved August 8, 2007.
  69. ^ New England Journal of Medicine. [5] Retrieved August 8, 2007.
  70. ^ Journal of the American Medical Association. [6] Retrieved August 8, 2007.
  71. ^ Center for Disease Control and Prevention. [7] Retrieved August 8, 2007.
  72. ^ "No Health Insurance? So What?". The Cato Institute. 2002-10-03. Retrieved 2007-10-27.
  73. ^ [8]
  74. ^ a b Center for Economic and Social Rights. "The Right to Health in the United States of America: What Does it Mean?" October 29, 2004.
  75. ^ a b Sade RM. "Medical care as a right: a refutation." N Engl J Med. 1971 December 2;285(23):1288-92. PMID 5113728. (Reprinted as "The Political Fallacy that Medical Care is a Right.")
  76. ^ a b Thomas Bodenheimer, "The Political Divide In Health Care: A Liberal Perspective," Health Affairs, November/December 2005
  77. ^ a b Robert J. Blendon and John M. Benson, "Americans’ Views On Health Policy: A Fifty-Year Historical Perspective," Health Affairs, March/April 2001
  78. ^ United Nations, Universal Declaration of Human Rights, Adopted and proclaimed by General Assembly resolution 217 A (III) of 10 December 1948. Article 25 states: "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control."
  79. ^ National Health Care for the Homeless Council. "Human Rights, Homelessness and Health Care".
  80. ^ Kereiakes DJ, Willerson JT. "US health care: entitlement or privilege?." Circulation. 2004 March 30;109(12):1460-2.
  81. ^ Wilhelmine Miller, Elizabeth Richardson Vigdor, and Willard G. Manning, "Covering The Uninsured: What Is It Worth?", Health Affairs Web Exclusive, 2004-03-31, accessed 2008-05-09. This study estimated that the value of health forgone each year because of uninsurance in the U.S. was $65–$130 billion and concluded that this figure constituted "a lower-bound estimate of economic losses resulting from the present level of uninsurance nationally."
  82. ^ "Won’t this raise my taxes?" PHNP.org.
  83. ^ Public Citizen. "Study Shows National Health Insurance Could Save $286 Billion on Health Care Paperwork:" http://www.citizen.org.
  84. ^ http://content.healthaffairs.org/cgi/content/full/23/3/10 Reinhardt, Hussey and Anderson, "U.S. Health Care Spending In An International Context", Health Affairs, 23, no. 3 (2004): 10-25
  85. ^ Teixeira , Ruy. "Healthcare for All?" MotherJones September 27, 2005 .
  86. ^ CBSNews. "Poll: The Politics Of Health Care" CBSNews March 1, 2007 .
  87. ^ Blake, Aaron. "Poll shows many Republicans favor universal health care, gays in military" TheHill.com June 28, 2007.
  88. ^ http://covertheuninsured.org/media/docs/release050205a.pdf
  89. ^ Paul Krugman and Robin Wells, The Health Care Crisis and What to Do About It, New York Review of Books, 2006-03-23, accessed 2007-10-28
  90. ^ "Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care" by Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea Commonwealth Fund, May 15, 2007.
  91. ^ "The Best Care Anywhere" by Phillip Longman, Washington Monthly, January 2005.
  92. ^ "Detroit's big three seek White House help" Guardian Unlimited, November 15, 2006
  93. ^ Pajamas Media
  94. ^ http://in.reuters.com/article/health/idINN3143203520080331
  95. ^ Statement of Dr. Marcia Angell introducing the U.S. National Health Insurance Act, Physicians for a National Health Program, February 4, 2003. Accessed March 4, 2008
  96. ^ ""Uguali e diversi" davanti alla salute" (PDF) (in Template:It). Retrieved 2008-01-22.{{cite web}}: CS1 maint: unrecognized language (link)
  97. ^ "Il segreto professionale nella relazione medico-paziente" (PDF) (in Template:It). Retrieved 2008-01-22.{{cite web}}: CS1 maint: unrecognized language (link)
  98. ^ "LEGGE 20 maggio 1970, n. 300 (Statuto dei lavoratori)" (in Template:It). pp. ART. 5. and ART. 6. Retrieved 2008-01-22.{{cite web}}: CS1 maint: unrecognized language (link)
  99. ^ a b David E. Kelley, A Life of One's Own:Individual Rights and the Welfare State, Cato Institute, October 1998, ISBN 1-882577-70-1
  100. ^ Michael Tanner, "Individual Mandates for Health Insurance: Slippery Slope to National Health Care," Cato Institute, Policy Analysis No. 565, April 5, 2006
  101. ^ Cato-at-liberty » Depends on What the Meaning of “Universal” Is
  102. ^ a b Victor R. Fuchs and Ezekiel J. Emanuel, "Health Care Reform: Why? What? When?," Health Affairs, November/December 2005
  103. ^ [9]
  104. ^ Glen Whitman, WHO's Fooling Who? The World Health Organization's Problematic Ranking of Health Care Systems, Cato Institute Briefing Paper No. 101, 2008-02-08, accessed 2008-05-28
  105. ^ Sue Blevins, Universal Health Care Won't Work -- Witness Medicare, The Cato Institute, 2003-04-11, accessed 2007-10-28
  106. ^ Michael J. O’Grady, "Health Insurance Spending Growth - How Does Medicare Compare?," Joint Economic Committee, June 17, 2003
  107. ^ Jeff Lemieux, "Medicare vs. FEHB Spending: A Rare, Reasonable Analysis," Centrists.org, June 2003
  108. ^ Cato-at-liberty » Revolt Against Canadian Health Care System Continues

Support

Oppose

Neutral

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