A Necessity: The Healthcare Systems Abroad and at Home

BY INDIRA FLORES

On January 30, 2018, Trump delivered his first State of the Union address. Prior to the speech, 82% of registered voters in one poll stated that improving the healthcare system was important for the president to discuss, making it their most highly prioritized topic.¹ To the disappointment of these many Americans, one topic that was noticeably absent from Trump’s address was that of the future of healthcare; he only ever mentioned the term two times in passing throughout the entire duration of his ninety-minute-long speech.² Perhaps the reason why Americans were hoping that Trump would address the healthcare situation is that they are unhappy with the current system, or possibly that the details of the current system are unclear and have left many Americans confused. The American healthcare system has in fact left many people, including those outside of the United States, puzzled because it is quite different from many of the systems of comparable Western nations. 

The Organization for Economic Cooperation and Development (OECD) is a group of 35  international governments that collaborate with the intent of “promot[ing] policies that will improve the economic and social well-being of people around the world”.³ Membership includes such countries as Australia, Japan, Sweden, Israel, Germany, Mexico, Turkey, and the United States.⁴ Of the 35 member countries, 32 have introduced systems of universal healthcare; the US is not one of them.⁵ This idea of universal health coverage is generally defined as a system that provides everyone with equal access to quality healthcare services while ensuring that people are also protected against extreme financial risk from utilizing these services.

One of the earliest adopters of some form of national health coverage was Germany. Starting with a law instituted in the late 1800s and intended for industrial workers, the nation’s healthcare system has evolved to cover all fields of work and social sectors.⁶ Today, the German state establishes the conditions of medical care, and legally designated self-governing bodies within the healthcare system, most notably the Federal Joint Committee, determine the specifics of individual medical services-from setup, to financing, to organization. All German citizens are required to have statutory health insurance if their gross income is under a certain threshold. If they are above this, they may instead elect to have private health insurance. Funding for individuals’ healthcare plans comes from a combination of employee salaries, employer payments, and surplus tax revenue. The amount individuals must pay for health insurance coverage in Germany is also dependent on income — the wealthy pay higher premiums than the poor.⁷ 

Though its beginnings do not extend as far back as Germany’s, the Swedish form of universal healthcare is arguably the most comprehensive of any other contemporary nation. There, health coverage is “universal and automatic”.⁷ In 2013, 84% of all health expenditures in Sweden were publicly financed, and private health insurance accounted for less than one percent of all expenditures.⁷ To finance these services, municipalities and county councils tax their constituents proportionally to income. Sweden’s public health coverage does not have defined limits; everything from primary care to prescription drugs to emergency services to mental health care is covered by the system. This widespread access to healthcare is likely a significant factor that has contributed to Sweden having one of the highest life expectancies in the world at 82.10 years.⁸

Wealthier, Western nations are not the only ones transitioning to universal healthcare. Many low- and middle- income countries, including India, Mexico, and Turkey, are also on the path towards universal health coverage.⁴ The United States, however, has not joined that bandwagon. Seventy percent of all health insurance holders in the US are covered by private insurers. In 2010, the US began taking steps towards making healthcare more accessible with the institution of the Affordable Care Act, commonly called Obamacare. Under this system, all Americans were required to have health insurance or else be penalized with a fine, and subsidies were available to help citizens afford the insurance. The legislation also required businesses to offer health insurance if they had more than fifty full-time employees, banned insurance companies from discriminating against people with pre-existing conditions when giving coverage, and expanded the range of people eligible for Medicaid, the government-run health coverage program. This legislation, which remains mostly intact as of the beginning of 2018, appears to be an excellent way of lowering the percentage of Americans without coverage from the current estimate of 15% and slowly decreasing the rate of healthcare spending in the US, which is the highest in the world.¹⁰ 

These steps towards universal healthcare in the United States have not been universally popular. Republicans and conservatives have generally been opposed to the Affordable Care Act since its inception. This is due to a combination of both party loyalty and the increased constraints the legislation places upon businesses. The Affordable Care Act has also led to an increase in the average cost of insurance premiums- by approximately 25% in 2017.¹⁰ This was predicted by even the Democrats and is a result of health insurance companies being mandated to provide coverage to any American, including those with pre-existing conditions. These pre-existing conditions are common throughout the population and can include anything from chronic back pain to asthma to cancer.¹¹ These individuals may require more financial assistance for medical services than do healthy individuals, but health insurance companies do not want to lose their profits. Instead, they push the additional cost of insuring these individuals onto the general population of insurance holders and force them to all shoulder the difference. Similar events, such as dramatic increases in drug prices (consider the Daraprim case), can also lead to higher insurance premiums as a way for the insurance companies to avoid losing any profits.¹²

From the time he began running for office, Trump has spoken of plans to completely repeal the Affordable Care Act. However, coming up with a better healthcare plan must have proven to be more complicated than anticipated, as he has yet to take any major action towards this. Republicans in Congress have made several attempts at new healthcare legislation throughout the past year, including the American Health Care Act and Better Care Reconciliation Act, but all of these failed.¹³ The primary changes proposed by these plans include the ability for states to waive out of current protections for individuals with pre-existing conditions, blocking funding for Planned Parenthood for at least one year, ending the subsidies made available by the government to help make health insurance premiums and deductibles more affordable, and eliminating penalties for being uninsured to effectively repeal the mandate. 

Although no new healthcare bills have been passed in the United States, Trump and the Republicans did find another, more subtle way to alter the healthcare system. One of the two times Trump mentioned healthcare in passing during his State of the Union Address was to say, “[w]e repealed the core of disastrous Obamacare”.² Here, he was referring to the elimination of that individual health insurance mandate. The Republican tax bill that was recently passed in December of 2017 sparked discussion for many reasons, most of which related to tax cuts for the rich. However, one aspect of the tax bill that many Americans do not realize was included is that the individual mandate will end in 2019.¹⁴ Without having a replacement plan set up, this is actually expected to cause another rise in health insurance premiums, this time because insurance companies will be losing customers and thus want to make up the profit by, again, pushing additional costs onto the insurance holders that remain. Republicans have expressed their desire to make more changes to the healthcare system before that happens in 2019, but at the rate things went last year, this seems unlikely to happen.

The one aspect of the healthcare field that Trump spent more time elaborating on during his address was the price of prescription drugs. He proudly stated that the “FDA approved more new and generic drugs and medical devices than ever before in our history” and that his administration will work on lowering the price of prescription drugs so they are not as overpriced when compared to the cost of the same drugs in other countries.² If he could accomplish this, this would be one method of potentially causing a decrease in the cost of health insurance since the insurers would not have to pay as much for their holders to purchase these drugs and could in turn lessen the burden on the general holder population. However, again, these things are easier said than done. Trump may especially have difficulty passing this type of legislation if he wants to regulate the way pharmaceutical companies set their pricing because his fellow Republicans are often opposed to such governmental regulation of business.

Many Americans are unhappy with the current state of the healthcare system. The best type of system is likely some form of universal healthcare, as is very common throughout Europe as well as in several transitioning developing countries. Unfortunately, the necessary legislation to enact such a system is, clearly, difficult to pass in the United States. Party loyalty and the fear of socialism often get in the way of moving towards universal health coverage. It is therefore important that the government continue pressing forward with small actions that will shape the healthcare system, but in ways that are likely to decrease the cost of insurance and make it more accessible to all, rather than increase it again.

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References:

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11. Secretary, H. O., & Assistant Secretary for Public Affairs (ASPA). (2017, January 31). Pre-Existing Conditions. Retrieved from https://www.hhs.gov/healthcare/about-the-aca/pre-existing-conditions/index.html 
12. Flores, Indira. “Turing Pharmaceuticals: A Price Raise, a Name Change, and an Outrage.” Yale Global Health Review, vol. 5, no. 1, 2018, pp. 22–24. 
13. Desjardins, L. (2017, September 19). What’s in the new GOP health care bill, in one (simple) chart. Retrieved from https://www.pbs.org/newshour/politics/whats-new-gop-health-care-bill-one-simple-chart 
14. Long, H. (2017, December 15). Analysis | The final GOP tax bill is complete. Here’s what is in it. Retrieved from https://www.washingtonpost.com/news/wonk/wp/2017/12/15/the-final-gop-tax-bill-is-complete-heres-what-is-in-it/?utm_term=.5e0754b71a34