Category: Health Care Policy

Public health in the Victorian era is a sharp contrast to what public health is today, majorly due to the healthcare practices and general public health sanitation conditions. The Victorian era refers to the period in the reign of Queen Victoria from June 20 1837 to her demise on January 22, 1901. This period was characterized by rapid economic and industrial growth but was also performing poorly in terms of healthcare and sanitation, due to the high mortality rates resulting from diseases. As the urban population grew exponentially, more houses were built in close proximity to each other without proper sewers or clean water supply. The public health issues that came up led to the action of various health reformists who championed the enactment of changes in public health, whose benefits are still enjoyed to date. This article highlights the contributions of Edwin Chadwick, Florence Nightingale, and John Snow as the proprietors of public health reforms and sanitary practices. The article also outlines the prevalent public health issues in this period.

The Victorian era was characterized by a fast growth of the urban population, largely due to the industrial revolution and railway boom, which created a high demand for constant labor. It was difficult to keep up with the growing population and with time, sanitation levels deteriorated partly due to the inability to dispose of sewage properly and partly due to the lack of clean water supply for the residents, states Arnold-Forster (2020). Water sources also were severely contaminated by the sewage. Living in close quarters also meant that it was easier to spread infections from one individual to another. Evidently, poor living conditions correlated with poor sanitation, and a social reformer called Edwin Chadwick was appointed to be in the Poor Law Commission to investigate the sanitary states and formulate recommendations for improving such.

Edwin Chadwick is considered to be one of the greatest reformers of public health during the Victorian era since he deduced a link between poor living conditions and diseases. As stated by Small (2020), Chadwick argued that impoverished laborers could not work properly due to ailments from poor sanitation, especially since the cholera epidemic killed many people. He made this claim to persuade government intervention and recommended the government provide clean water and improve drainage systems. Thus, the major achievement of Chadwick as a Sanitation Commissioner was his idea that the laborers could not attain their full potential in expanding the industries because of their poverty and poor health, thus it would be important to improve their living standards for the benefit of the nation.

Due to the deteriorating sanitary conditions and the emergent public health issues in the Victorian era, there occurred an outbreak of cholera in 1854 that devastated the population due to poor hygienic conditions. The disease also spread quickly because people were staying close to each other, thus a lot of contacts. A physician named John Snow undertook a systematic study of the origin and spread of cholera, helping him be later known as the father of epidemiology (Vineis, 2018). It was initially believed that cholera spread through inhalation of miasma or contaminated air, but Snow’s examination of patients pointed to symptoms related to gastrointestinal infection. He argued that the disease was thus not spread by contaminated air, but rather through consuming contaminated water and food. Otherwise, patients would have manifested pulmonary symptoms.

John Snow’s contribution to epidemiology was developing a systematic way of tracking down the origin of an epidemic and mapping out its spread by tracing the patients’ infection history. His pioneering investigation of the source of the cholera outbreak pointed to water as the key source of the epidemic, and he demonstrated this by removing the Broad Street pump handle to stop people from drawing water. The prevalence of cholera in the days that followed dropped significantly, confirming his theory. His pioneering demonstration led to reforms in public health in that the government developed better sewage drainage systems and also focused on water purification in major cities and towns, and this contributed to the reduction in the effects of the scourge in the following decades.

Another major contributor to the reformation of public health was Florence Nightingale, who pioneered modern nursing, helping elevate it from an unprofessional practice to a highly-skilled and recognized medical occupation. The effects of her contributions were majorly felt during the Crimean War, where she was stationed in Scutari to nurse wounded and ill soldiers (Pattison, Deaton, McCabe, et al., 2022). During her time, most hospitals operated in unsanitary conditions, and the lack of antiseptics caused a lot of cases of reinfection in the hospitals. Also, the hospitals were often overcrowded, patients used unwashed beddings and ate indecent food. Nightingale made it her obligation to provide sanitary conditions by cleaning the hospitals, washing patients’ beddings, and providing proper food for the patients. This led to a drastic decline in soldiers’ mortality, as most of them were initially dying due to infections. The actions of Nightingale have since been adopted as the standard practice of nursing. She championed reforms that made it possible for patients to receive proper treatment in sanitary conditions, also completely eliminating the instances of getting infected by some diseases in the process.

Diseases were the major cause of mortality in the Victorian era, largely due to poor sanitary conditions both at home and in the hospitals, and the laxity to enforce various health policies that would ensure proper handling of infections. Some of the common infections in this period were cholera and typhoid, which were primarily caused by poor sanitation, as well as a general lack of knowledge on the transmission of the diseases (Pattison, Deaton, McCabe, et al., 2022). Edwin Chadwick deduced that poor living conditions translated to poor sanitation, and this led to the prevalence of cholera outbreaks among the poor individuals who also provided the labor force for the industries. To ensure steady economic growth, the issue of sanitation had to be addressed through improving drainage systems and provision of clean water. John Snow attempted to establish the cause of cholera and its epidemiology, and his systematic study of the disease pioneered a new way of tracking epidemics from their epicenter, how they spread, and how they can be contained. Nightingale, in her contribution to public health reforms, made it clear that a clean environment is necessary for the speedy recovery of a patient and to avoid the possibility of reinfection.

In conclusion, public health has made tremendous strides since the Victorian era which lasted from the mid-1800s to the early 1900s. In this period, technological advances were still minute, and applications such as microscopy had not been discovered yet. Thus, the field of medicine was lagging behind and disease containment was hard since there was no consensus on the origin of a disease. For instance, people in the Victorian era believed that cholera was caused by miasma, thus people were not keen on improving their sanitation which would have otherwise effectively helped in reducing the dangers of the epidemic. The mentioned pioneers of public health, Edwin Chadwick, Florence Nightingale, and John Snow, helped bring reforms to the public health sector and changed the outlook of epidemics and other diseases. These applications are still relevant to this day’s public health system.

The American government is making efforts to reform the national healthcare system to ensure that all citizens have access to affordable healthcare. The current system is complicated, with some people relying on private insurance and government programs like Medicare and Medicaid. Although those government-funded programs aim at increasing access to health services, they are limited to vulnerable populations like the elderly, disabled, and low-income households. Despite the government spending more resources on healthcare, the country lags behind as other developed nations that have introduced universal coverage for its people. The government should make arrangements to ensure that all Americans have access to affordable or free healthcare due to the rising healthcare costs which result in advanced levels of uninsured populations (Maruthappu et al. 15). That goal will be achieved by adopting universal healthcare that will offer affordable access to all American citizens. However, the aspect of universal healthcare is a matter that faces various challenges because of the health care crisis. The push for adoption of coverage for all Americans is influenced by the equality variations that exist in the system between the wealthy and the poor households. Acquiring universal insurance for all citizens will result in health and economic benefits for individuals and the whole nation.

Universal healthcare means all people have access to quality healthcare services without discrimination while ensuring that the services do not cause financial challenges, especially on the vulnerable populations (World Health Organization WHO 9). The government is making efforts to achieve a more equitable distribution between the benefits and costs of universal healthcare by evaluating different programs to advance coverage for the uncovered citizens. Every American citizen is entitled to the right to healthcare, and the government should make sure that all individuals can access affordable healthcare (WHO 18). It means that all American citizens should have the opportunity to attain various healthcare services, including prevention, promotion, treatment, and rehabilitation. However, the right to healthcare may remain a distant goal for disadvantaged groups like children and adults living in poor conditions imposed by different factors.universal healthcare

Although the emphasis is on access by offering affordable services, it is also vital to ensure that the services are of good quality. Despite the American government spending a large sum of money on healthcare, many people face challenges in accessing the services. Although most developed nations perceive the issue as an essential element by attaining universal healthcare for its citizens, the US has not yet agreed on a plan that will address the inequalities while providing better alternatives for long-term care and preventive measures (Boudreau, 1). That concept compromises the health of those individuals who cannot afford to pay for the services since the high costs related to healthcare may serve as an obstruction. The American government should have universal coverage to eliminate the variations between the wealthy and the poor people concerning access to health services. The wealthy households can afford all types of healthcare services, while the average citizens lack access to the basic level of preventive services.

Health care is the most important part of living for everyone. We somehow managed to make it expensive and not accessible to everyone. On med city news they did a survey on how many Americans can’t afford health care. The survey states that with 18% of Americans saying in a new survey that they would not be able to afford the care they need. Unfortunately, not only by race, but also by age group, people’s ability to pay for health care varies. When comparing non-white individuals aged 18 to 49 to non-white adults aged 65 and up, non-white adults aged 18 to 49 were more likely to report they couldn’t afford needed care (27 percent) (16 percent ). Similarly, 20% of white persons aged 18 to 49 stated they couldn’t afford care, compared to 8% of white adults aged 65 and up. The division of insurances specifically dental and medical is. Dentistry was not recognized during the establishment of US medical schools. The Commission on Dental Accreditation became an independent license organization in 1974. Dentists were active in 2012, and the profession has a projected 18 percent growth rate through 2024. The reason dental is separate from medical is that the nature of the risk is fundamentally different as is the deferability of the care. Just like how eye care is separate and you don’t go to the hospital it’s a different kind of care and schooling people go to.

With that said people should have universal healthcare usually what universal health care is all people have access to the health services they need without financial hardship.The cost of healthcare administration is the most important factor in increasing medical spending in the U.S In the United States, around a third of healthcare expenses are spent on administration; Canada spends a fraction of that is the first reason harvard magazine states. The second component of excessive health-care spending is greed. The list price of insulin in the United States is ten times greater than in Canada. It’s no surprise that pharmaceutical prices in the United States are greater than in Canada, and that star hospitals charge more than community hospitals. When there is nowhere else to go, prices skyrocket. The last part of increased medical spending in the U.S is increased utilization. The United States has the most technologically advanced medical system of any country, and it reflects in spending: the US has four times the number of MRIs as Canada.

In the United States the expenses of healthcare without insurance is detrimental to those in poverty. Not only does it affect the parents but children as well. If the parent can’t get the health treatment it needs. How will the children who will need to grow up healthy and strong? According to science direct their survey indicates that Seventy-seven percent of children in the United States have dental insurance, with public dental insurance accounting for 29 percent so that includes 16.3 million children in the United States, lack dental coverage, which is 2.6 times the number of children without medical coverage.In the connection between insurance coverage, raceethnicity was a significant variable. African-American children were much less likely than white children to have received PDC, regardless of dental insurance typeWhere does the money for universal health care come from? Tax money is the primary source of funding for most universal health care systems. Having tax money go into universal healthcare is much more beneficial to the people instead of the money going to the military. The amount of military spending is enough and the government should focus on other problems on where to spend the tax money.

Other individuals may disagree with universal health care. Some may be afraid that it will cause socialism to arise or communism in politics. They argue that universal healthcare would lower medical concern quality and restrain medical resources. The availability of medical treatment will suffer as a result.This side’s proponents argue that it would bankrupt the regime and be a logistical headache. This side thinks that it’s an individual’s correct and duty to get their own healthcare plan, and that it’s not the government’s part to supply healthcare.

Our life becomes easier with advanced technology, especially in healthcare. Good healthcare not only help us prevent sickness but also gives us access to medicine right away if we, unfortunately, catch a cold or something even more serious. Indeed, without it, we wouldn’t have been able to do anything because we won’t have good health to produce. The United States has been the only industrialized nation that doesn’t guarantee its citizens universal access to healthcare, despite having high taxes per capita. In addition, the United States also spends more per person on healthcare than other nations that offer universal healthcare. In this case, the three people: Dana, Fanny, and Dennis can access healthcare, but that’s only temporary until they out of the dangerous state. After that, a huge debt from the hospital is under their name. Many of us don’t have a good income to cover our health insurance. Therefore, it’s crucial to provide citizens with affordable healthcare. From a Utilitarian perspective, I think it’s morally right for the United States to establish truly universal healthcare. Not only may it increase the GDP of the country, but it may also provide a better life expectancy.

From a utilitarian point of view, universal healthcare would seem able to add a great deal of utility to any society. Improving people’s health would support more productive work and thus improve the economy for all. People would be happier when they feel better. This can help children study more efficiently and the adult can help to develop the economy. As we can see, healthcare, economic, and educational inequities feed each other in a perpetual circle. So, why don’t we improve the most important one so it can help to elevate the rest? In addition, to good health and a good life expectancy. People would be happier when they view taxes as a duty of a citizen because they’re satisfied. Based on the act utilitarianism definition, the right action in a situation action is the one that will produce the greatest overall utility. In this case, universal healthcare would promote more happiness overall. Which is the morally right choice

On the other hand, the cost of a universal healthcare system is much higher than the cost of ensuring all citizens have a fair share of food, shelter, and education. Heavy taxes for people who have better income will help all the citizens to have equal access to healthcare might be one of the solutions. This will put on a burden on the citizens, especially the people who have a better life. Moreover, the healthcare system cannot meet all the demands because the resources are limited. But ensuring people’s health is a task that will not necessarily need healthcare if they have better education about how to have a healthy and balanced diet. As we can see, developed countries always have better health because they all have a good education and know-how to live a healthy life, which is better the developing country. When you have good health, you won’t need healthcare as much, all the resources will be available for the one who truly needs it.

Strive as we might to maintain our health, in the end, to grow sick and frail is an unavoidable part of the human condition. Thus, securing the access to affordable health care should be an important topic for all U.S. citizens. The wealthiest country in the world should not force their citizens to choose between saving their life or losing their home and marriage to medical debt.

Meet Heather Waldron and John Hawley. Until a few years ago, they were a happy and loving family with five children. That was until Waldron had to have an emergency surgery performed in 2017, and the University of Virginia Health System pursed the couple with a lawsuit and a lien on their home to recoup $164,000 in charges. They had to worry about the electricity bill and their children even had to sell their clothes for spending money. Ultimately, this financial ruin contributed to their divorce (Hancock, Lucas, 2019). This family is not alone, and in fact a regular occurrence with our current health care system. This story is one that could have been avoided with a universal health care system, a system offered by the federal government that provides quality medical services to all citizens regardless of their ability to pay.

Thesis Statement

The United States should adopt a Universal Healthcare system because it is an established human right and it lowers health care costs for an economy.

Main Point #1: The US is often known as a champion of human rights around the world.

However, in the United States, there exists a system inherently designed on denying rather than supporting the right to health care. The right to accessible and affordable healthcare is already seen as a universal human right in most of the developed world.

A. Ironically, while the right to healthcare is recognized internationally, its origins began in the United States.

1) As Mary Gerisch from the American Bar states, “Health care was listed in the Second Bill of Rights drafted by Franklin Delano Roosevelt (FDR). Sadly, FDR’s death kept this Second Bill of Rights from being implemented.” (Gerisch, n.d.). His wife, Eleanor Roosevelt continued his work by taking it to the United Nations, where she became the drafting chairperson for the UN’s Universal Declaration of Human Rights (UDHR) in 1948. This reinforces the fact the right to health care has always been an American idea.

2) Mary Gerisch continues to write that the “committee codified our human rights, including, at Article 25, the essential right to health. The United States, together with all other nations of the UN, adopted these international standards.” (Gerisch, n.d.). Since the adoption of the UDHR, all other industrialized countries in the world have gone on to implement universal health care systems. This is not a foreign idea, or as some have claimed, an “immoral socialist idea”, for the idea began right here in the United States.

B. In fact, we can go back farther to the Declaration of Independence and the Constitution.

1) As our Founding Fathers state, all men have “unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness,” (Declaration of Independence, 1776). Without healthcare, we cannot truly preserve life nor can we pursue happiness. As all people will require medical attention at one point or another, the right to life and the pursuit of happiness should be safeguarded by a universal healthcare system.

2) According to the Preamble of the US Constitution, its purpose is to “promote the general welfare” of the people (US Const., Preamble). Healthcare should be considered an urgent priority for the government to ensure that the people’s welfare is well provided for. A lack of healthcare and extreme medical costs are a growing crisis which can be seen in today’s politics.

C. As Stephani Armour states in an article for the Wall Street Journal on September 10, 2019, that the number of Americans without health insurance has reached nearly 28 million (Armour, 2019). This is a crisis, and a crisis ignored cannot be viewed as the government fulfilling its fundamental duty to ensure the welfare of the people is provided for.

3) This is especially the case when you take into consideration the alarming number of medical bankruptcies in the U.S. According to Mark Cussen from Investopedia, he wrote in 2019 that the number one reason for bankruptcy in the U.S. was due to medical expenses, representing 62% of all personal bankruptcies (Cussen, 2019).

4) Mark Cussen goes on to point out that “78% of filers had some form of health insurance”, discrediting the misconception that medical expenses only affect those who are not insured (Cussen, 2019). The right to healthcare is clearly a growing crisis that demands attention from the government in the form of a universal health care system. Providing a universal healthcare system that insures citizens will receive the medical attention required without facing financial ruin falls upon the government to provide the people with wellbeing.

Main Point #2: Contrary to the belief of Universal Healthcare’s opponents, it actually lowers the healthcare costs for an economy.

A. Despite being the only wealthy and developed nation without universal healthcare coverage, according to the Centers for Medicare & Medicaid Services, the United States spent $3.5 trillion in 2017 for healthcare costs. This means more than $10,000 per person and about one-sixth of the country’s economy (Centers for Medicare & Medicaid Services, 2019). We are not saving more by avoiding a Universal health care system. In fact, this far exceeds any other country.

1) According to a cross-national comparison analysis conducted by the Commonwealth Fund that uses data conducted in 2013 from the Organization for Economic Cooperation and Development (OECD), of the 13 high-income countries that were compared (Australia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States), the United States is the highest spender on health care (Squires, 2015).

2) David Squires from the Commonwealth Fund writes that according to data collected from the OECD, the “U.S. spent 17.1 percent of its gross domestic product (GDP) on health care in 2013.” (Squires, 2015) and that this was close to 50% more than the next highest spender. This number has continued to rise, as we see an increase healthcare costs.

3) As you can see in this diagram, despite being the only country listed that doesn’t support universal health care, the US pays far more.

B) In fact, multiple studies being conducted by teams of economists from opposing political backgrounds are quickly displaying that a single-payer universal healthcare system could in fact save the nation trillions of dollars over decades.

1) An establish economic research paper conducted by a team of economists with the Political Economy Research Institute (Peri) at the University of Amherst, Bernie Sander’s “Medicare for All” plan could save $2.93 trillion over a decade (Pollin, Heintz, Arno, Wicks-Lim, Ash, 2018). Economists have made it clear that although universal healthcare would require a large initial investment, it would save the economy long-term when compared to our current system.

2) In fact, a study was funded by the Koch brothers by Charles Blahous from the conservative think-tank, Mercatus Center at George Mason University, with the purpose of discrediting a single-payer universal healthcare system in the US. However, even this paper had the unintentional result of pointing out that a single payer universal healthcare system could save Americans more than $2 trillion over a decade (Blahous, 2018).

3) Despite these studies coming from opposing political ideologies and intent, the consensus is clear that a national single-payer healthcare system would in fact save money long-term while increasing coverage.

Conclusion

In conclusion, it is time for the United States to join the rest of the developed world and adopt a universal healthcare system as it is both a human right and lowers the healthcare costs for an economy. It is a rare instance where the people can listen to both their hearts and minds when making a decision. Both morality and logic assert that universal health care is not only a viable option but should be considered a fundamental right in the US.

As was established by the Elanor Roosevelt lead committee of United Nations in 1948, healthcare is a human right, an idea that began in the United States. It is time we take back this idea, for the governments job is to “promote the general welfare” of which healthcare is essential.

The healthcare costs in the United States are the highest in the world with some of the lowest coverage, it is time we put aside political disagreements and listen to the numbers.

As you listen to this speech, everyday more Americans go without coverage, are driven into poverty, and are forced to do things inconceivable in other developed nations, such as ending long-term happy marriages to avoid medical costs.

A hospital visit, the birth of a child, or an unfortunate diagnosis are experiences that every American will encounter at one point or another. Financial ruin or lack of coverage should be the last thing in their hearts or minds.

It is imperative that we push for a universal healthcare system as one day it will affect us all.

Full references

1. Jay Hancock, Elizabeth Lucas. (2019). The Washington Post. ‘UV has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes. Retrieved from https://www.washingtonpost.com/health/uva-has-ruined-us-health-system-sues-thousands-of-patients-seizing-paychecks-and-putting-liens-on-homes/2019/09/09/5eb23306-c807-11e9-be05-f76ac4ec618c_story.html.
2. Mary Gerisch. (n.d.). American Bar Association. Health Care As a Human Right. Retrieved from https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/health-care-as-a-human-right/
3. National Archives. (1776). The Declaration of Independence. Retrieved from https://www.archives.gov/founding-docs/declaration-transcript
4. National Constitution Center. (1788). Preamble: We the People. Retrieved from https://constitutioncenter.org/interactive-constitution/preamble
5. Stephanie Armour. (2019). The Wall Street Journal. Number of Uninsured Americans Rises for First Time in Decade. Retrieved from https://www.wsj.com/articles/number-of-americans-without-insurance-shows-first-increase-since2008-11568128381
6. Mark P. Cussen. (2019). Investopedia. Top 5 Reasons Why People Go Bankrupt. Retrieved from https://www.investopedia.com/financial-edge/0310/top-5-reasons-people-go-bankrupt.aspx
7. Centers for Medicare & Medicaid Services. (2019). NHE Fact Sheet. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html.
8. David Squires. (2015). The Commonwealth Fund. U.S. Health Care from a Global Perspective. Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective.
9. Robert Pollin, James Heintz, Peter Arno, Jeannette Wicks-Lim, Michael Ash. (2018). Political Economy Research Institute. Economic Analysis of Medicare for All. Retrieved from https://www.peri.umass.edu/publication/item/1127-economic-analysis-of-medicare-for-all.
10. Charles Blahous. (2018). Marcatus Working Paper, Mercatus Center at George Mason University. The Costs of a National Single-Payer Healthcare System. Retrieved from https://www.mercatus.org/system/files/blahous-costs-medicare-mercatus-working-paper-v1_1.pdf.

The United States is no doubt one of the best developed countries in the world. At the forefront of technology and scientific development, the country boasts of its high standards of living. However, a look at healthcare, which is the basic pillar of a nation, presents a dismal picture. The growing number of uninsured people is enough reason to believe that the crisis is not looming large but it is already here. While many countries have free healthcare, the government in the United States does not offer the medical services free for their citizens. The government of the United States of America should provide universal healthcare services to its citizens because healthcare is a basic human right, regardless of age, sex, race, religion, and socio-economic status.

Universal healthcare will better facilitate and encourage sustainable, preventive health practices and be more advantageous for the long-term public health and economy of the United States. According to Rick Kahler, President of Kahler Financial Group, “the average of Americans spend more than $10,348 a year on healthcare in the United States, and the cost is the highest in the world” (Kahler). This issue is increasing the burden on citizens because not everyone is able to bear the costly health care bills. Ensuring that all people in the United States have affordable health care coverage that provides a defined set of essential health benefits is necessary in order to move toward a healthier and more productive society. Additionally, our healthcare system must begin to account for and address social determinants that have a profound impact on individual and population health outcomes and costs, such as socioeconomic status, housing and occupational conditions, food security, and the environment. According to the Center for Evaluative Clinical Sciences at Dartmouth, studies show “U.S. states that rely more on primary care have lower Medicare spending (inpatient reimbursements and Part B payments); lower resource inputs, lower utilization rates and better quality of care” (AAFP). Fundamental change is required to shift the direction of the U.S. health system toward one that covers all people and emphasizes comprehensive and coordinated primary care.

Different regions in the U.S. are defined by distinct cultural identities, citizens have unique religious and political values, and the populace spans the socio–economic spectrum. Moreover, heterogenous climates and population densities confer different health needs and challenges across the U.S. Thus, critics of universal healthcare in the U.S. argue that implementation would not be as feasible organizationally or financially as other developed nations. According to Thorpe K.E, “In terms of the national economic toll, cost estimations of this proposal range from USD 32 to 44 trillion across 10 years, while deficit estimates range from USD 1.1 to 2.1 trillion per year” (Thorpe). Beyond individual and federal costs, other common arguments against universal healthcare include the potential for general system inefficiency, including lengthy wait-times for patients and a hampering of medical entrepreneurship and innovation. However, perhaps the most striking advantage of a universal healthcare system in the U.S. is the potential to address the epidemic level of non- communicable chronic diseases such as cardiovascular diseases, type II diabetes, and obesity, all of which strain the national economy. Accessible, affordable healthcare may enable earlier intervention to prevent or limit risk associated with non-communicable chronic diseases, improve the overall public health of the U.S., and decrease the economic strain associated with an unhealthy low- socioeconomic status.

When the population gets healthcare for free, it leads to a decrease in the number of sick people. Hence, being health care free can create numerous healthy people. If people can acquire treatment for free without worrying about the payment, it will help them to find treatment quickly and prevent the transmissible diseases. “People who get health care easily will be healthier, have more productive lives, and they may contribute positively to the community” (Mozaffarian, Rogoff, Ludwig). In other words, free healthcare for people helps to avoid common ailments. Furthermore, it helps them to live longer and achieve a healthy life with more productivity. With this solution, people will not be afraid of affording healthcare with common diseases. Moreover, the government should create equality between people. All inhabitants have the right to receive health care because all of the citizens play an essential role in society. Despite social status, poor people could obtain the same kind of health care that will be provided to wealthy people. This way will provide primary services for all people without any discrimination between them. Some studies show that poor people are “more likely to experience difficulties to access medical services.“

It is an obvious fact that healthcare systems in different countries differ. For this comparative essay, I chose the country of Japan, with the intention of comparing its healthcare system with ours, America.

Access

Japan has a universal, public statutory health insurance system (SHIS) that provides coverage regulated by the government. It is mandatory for all citizens of all ages and anyone who will be living in Japan for more than 90 days to enroll in a SHIS plan. 98.3% of the population is enrolled in SHIS, and the remaining 1.7% of Japanese citizens are low-income and are enrolled in a public social assistance program. The SHIS plan a person enrolls in is based on age, employment status, and/or residency. There is also private health insurance, but it is only supplemental or complementary to public health insurance. In the SHIS, the Japanese government sets the fee schedule and enforces regulations. Costs are simple and clearly laid out. Most citizens pay a 30% coinsurance for services. There is a reduced coinsurance of 20% for children aged 6 and younger and adults aged 70 to 74 with lower incomes and only 10% coinsurance for those aged 75 and older with lower incomes. There are no deductibles in SHIS, and copayments for children’s health care are often subsidized by the government. This simplistic fee schedule cannot be said of the United States, there is a vast array of fees and charges depending on what health coverage an individual has.

The United States does not have a universal healthcare system. Health care coverage in the United States is a mixture of public and private, as well as for-profit and nonprofit insurers. Options include fee-for-service (FFS), preferred provider organization (PPO), point of service (POS), health maintenance organization (HMO), Medicare, Medicaid, and coverage from the Veterans Health Administration. A majority of US citizens have private insurance that is often provided through their employer, or they may buy it on their own. 12.5% of US adults are uninsured, and countless more are underinsured. Lack of health insurance is perhaps the greatest barrier to accessing health care services and has a tremendous negative effect on an individual’s overall health status.

The only thing close to a universal healthcare system in the United States is the Patient Protection and Affordable Care Act (PPACA), which was signed into law in 2010. Its goal was to expand health insurance coverage to Americans that were uninsured while controlling costs and improving the quality of healthcare. Since its beginning, it has been under scrutiny, and many parts have been amended, including removing the penalty fee for those that did not have health insurance. With the implementation of the PPACA, different plan options became available for people to obtain insurance, but private insurance is the primary health coverage for two-thirds of Americans (67%). Over half of all private insurance is through employers. Most employer plans cover their employees and give various options on the level of coverage and also the option to insure their family. Rarely an employer pays the entire premium. Most of the time the cost is shared between the employer and employee. Only 11% of private health insurance is purchased by individuals from for-profit and nonprofit carriers.

In America, retirees/seniors qualify for Medicare. It is a complex fee-for-service program consisting of parts, A-D. Part A provides hospital insurance and Part B medical insurance. Members can choose to get their coverage just through traditional Medicare, or they can choose to enroll in Part C which is a private health maintenance organization (HMO) called Medicare Advantage. Part D is also optional and is for prescription drug coverage. Medicare is financed through a combination of general federal taxes, a mandatory payroll tax that pays for Part A, and individual premiums.

The unemployed may qualify for Medicaid if their income is low. It is a jointly sponsored state and federal program that pays for medical services for persons who are elderly, poor, blind, or disabled, and for certain families with dependent children who meet specified income guidelines. Medicaid is obtained through the state of residency. The state then received federal matching for providing the health coverage.

Veterans can receive healthcare coverage from the Veterans Health Administration. It is America’s largest integrated healthcare system serving 9 million enrolled Veterans each year. Having other health insurance coverage like Medicare, Medicaid, or private insurance doesn’t affect getting VA healthcare benefits. Each veteran’s medical benefits package is unique. Covered benefits depend on the ‘priority group’ and the advice of the VA primary provider. Retiring veterans may also be eligible for TRICARE. It is a Medicare-wraparound coverage for those that have Medicare Part A and B.

There are two US government-run programs available to children from low-income households. Depending on income level, they may qualify for Medicaid or the Children’s Health Insurance Program (CHIP). CHIP is a state-administered public program created in 1997 for children in low-income families that earn too much to qualify for Medicaid but are unlikely to be able to afford private insurance. CHIP is funded through matching grants from the federal government to the states, and most states charge a low premium and have small copays, if any. Because it is state-administered, exactly how it works varies by state. For example, it is considered an extension of Medicaid in some states, while in others it is a separate program. Currently, 9.6 million children are covered by this program.

Coverage of Medications

In Japan, the coverage for medication for children, the unemployed, and the retired remain under the same rules as the coinsurance percentages. Clinics can dispense medication directly to the patients or they can go to the pharmacy. According to the Commonwealth Fund, the use of pharmacies has been growing. Price revisions for medications are also revised every 2 years. Usually, prices are lowered for new drugs that are selling more than expected, and for brand-name drugs when their generic counterparts become available. Prices of generic drugs have gradually decreased. Also, if a physician prescribes more than 6 drugs regularly to a patient, he receives a reduced fee as a way to improve clinical decision-making.

In the US, the coverage for medication for children, the unemployed, the and retired depends on the coverage they have. Retired individuals with Medicare have the option to purchase private prescription drug coverage under Medicare Part D. Part D covers most outpatient drugs, like those that you would get a prescription for and pick up at the pharmacy. Medicare Part B only covers very limited outpatient prescription drug benefits, like injections that need to be given by a medical professional. For Medicare Part D, copays and coinsurance vary by drug plan: $0–$5 for preferred generics, up to 50% for non-preferred drugs. For the unemployed that qualify for Medicaid, outpatient prescription drugs are an optional benefit under federal law, however, currently, all states provide drug coverage. For children with private health insurance, the copay for prescriptions depends on that specific insurance coverage. For low-income children, the copay for medications is reduced if part of CHIP or possibly free if on Medicaid. Vaccines are often free to uninsured and underinsured children.

Referral to See a Specialist

In Japan, there is no ‘gatekeeper’. Children, the unemployed, and the retired do not need to get a referral to go see a specialist. The term ‘general practice’ in Japan is recent, but historically, there has been no distinction between primary care and specialty care. The fee schedule remains the same for all providers. Patients can see a specialist without a referral and most of the time on a walk-in basis.

A ‘gatekeeper’ is very common for healthcare coverage in the United States. American children, the unemployed, and the retired are often limited to specialty services if it is not deemed necessary or they cannot afford the excessive fees. PPO plans often can schedule an appointment with a specialist without permission from their primary care provider, but those with an HMO or government-sponsored plan do not have that option. Outpatient specialists are free to choose which form of insurance they will accept, or whether they will accept it at all. For example, not all specialists accept publicly insured patients, because of the relatively lower reimbursement rates set by Medicaid and Medicare. Access to specialists for beneficiaries of these programs—not to mention for people without any insurance—can therefore be particularly limited.

Coverage for Preexisting Conditions

In Japan, no one can be excluded from any coverage based on a preexisting condition. This also became true in the United States. Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a ‘pre-existing condition’, that is, a health problem you had before the date that new health coverage starts.

Finance Implications for Healthcare Delivery

In Japan, people benefit from the universal healthcare delivery system. All fees are determined by the government and therefore controlled. Even though most hospitals and medical offices are privately run, they are limited on what they can charge based on government regulations. This allows individuals to seek medical treatment and preventative services more often, thus leading to better health. Not only is health benefited but a person benefits financially as well. Unlike Americans, the Japanese do not need to worry that paying for healthcare will lead to financial ruin. A hospital stay is in the hundreds, whereas in the United States, it is in the thousand and can leave a person bankrupt. Americans often go without medical treatment simply based on the fact that they cannot afford it. Especially if they do not have health insurance, like in the circumstance of losing a job. In Japan, if a person loses their job their health coverage just switches from the employer to a community plan.

The negative financial implications of Japan’s healthcare structure fall on the providers. 50% of hospitals are in financial deficit. This is the opposite in America, where hospitals and doctors make a profit at the expense of the people. In America private practices can, and often do, refuse services to those with government-sponsored insurance like Medicaid. This is mostly due to the low reimbursement and the length of time to receive payment. This is not allowed in Japan. There are also disincentives for providers prescribing certain medications or services because the price is then lowered upon the next government review of fees. Again, this benefits the consumer, not the provider.

In America, both public and private insurers determine their benefit packages and cost-sharing structures as long as it is within federal and state regulations. Private insurers in America are for-profit, while Japan’s statutory health insurance system (SHIS) is a not-for-profit system. Insurers in Japan are not out to make a profit. Anything money not used is carried over to the next year, which could lead to premiums being reduced.

Conclusion

In summary, the comparative analysis covered in this essay has shown that the healthcare systems of Japan and America, although they share some common features, are nevertheless different. As for me, I would prefer the Japanese system, for its accessibility, simplicity, and orientation for the benefit of its population.

An Overview of Health Care Financing in Taiwan

Taiwan is a small island in the eastern part of Asia (midway between the Japan and the Philippines) that is constantly under political debate and diplomatic isolation. Taiwan has been independent since the 1950s, yet China has claimed sovereignty over Taiwan and insists nations cannot have official relations with both countries (Adams, 2010). Taiwan is not formally recognized by the United Nations (UN) and World Health Organization (WHO) which has brought concerns to whether it can survive as an independent-sovereign nation-state (Lu, 2014). Its political status remains a controversial topic both domestically and internationally. Despite these challenges, Taiwan is considered to have achieved an economic miracle with its rapid transition from an agricultural-based to an industrial-based economy. Yet, together with economic development, Taiwan is witnessing an unusually rapid demographic transition. It has a total population of 23.3 million, making it the 17th most densely populated country in the world (Statista, 2008). Taiwanese people are living longer but not healthier and fewer children are being born. The infant mortality rate is at 4.3 deaths/1000 live births and the birth rate in Taiwan is currently below the rate needed to sustain population growth as the current growth is caused by longevity (WPR, 2019). Life expectancy in Taiwan has increased to levels seen in OECD countries, with women living on average to 83.4 years old and men to 76.8 years old (WPR, 2019). It is estimated that people aged 65 and over will account for 24.1 percent of the population by 2030 (WPR, 2019). The leading causes of deaths in Taiwan are non-communicable diseases (accounting for around 80% of deaths), majority caused by cancer, cardio- and cerebral-vascular disease with other dominant health problems that include stroke, diabetes mellitus and accidents (WPR, 2019).

Following the WHO’s global call to achieve universal health coverage by 2030, Taiwan underwent a large transformation in their health system in March 1995 when they adopted a nationwide health insurance (NHI) system (Lu, 2019). It was previously known as the Bureau of National Health Insurance and merged three existing health insurance programs: government employee insurance, labour insurance and farmers’ health insurance which had only covered 59% of the population at the time (NHIA, 2016). The NHI is a state-run national health insurance agency based on a single-payer model with a global budget that now covers 99.99% of the total population (NHIA, 2016). Through political evolution and reform, Taiwan has strengthened their health care system to serve as a learning model for other countries.

The overall intention of the NHI was to provide health security to all citizens and provide equal access to healthcare, including groups outside the working population. The NHI system is a social insurance program that is organized by the government under the jurisdiction of the Ministry of Health and Welfare (MoHW). The principle goals of the NHI are to provide equal access to health care for all citizens, control total health spending within a reasonable level and promote efficient use of health care resources.

In Figure 1, the organizational structure of the system demonstrates the role of each institutional actors towards achieving the principle goals and smooth running of the NHI. The NHI Administration (NHIA) is the administrative agency that wields a monopolistic power as the single buyer of and payer for health care services including drugs and health care providers (Wu, Majeed & Kuo, 2010). Their responsibilities include managing health insurance affairs, medical quality, research and development, manpower training and information on the health system. The ministry’s NHI committee helps plan and monitor NHI-related tasks, and its NHI Dispute Mediation Committee deals with NHI related disputes (NHIA, 2016). A separate group of specialized groups and offices in six regional divisions across Taiwan handle insurance enrollments, premium collections, utilization review and reimbursements, and the management of contracted medical institutions with twenty-one liaison offices to serve the public (NHIA, 2016). Figure 1: Organization Structure of the Ministry of Health and Welfare (NHIA, 2016)

Health Expenditure

When the NHI was first initiated, there was a push to ensure that the % of gross domestic product (GDP) spent on national health expenditures (NHE) would not create a burden to the overall economy of Taiwan (Cheng, 2003). Before the NHI, Taiwan’s NHE as % of GDP of 4.31 in 1991 with a population of 20.5 million and now in 2017, total health spending in Taiwan was 6.44 % of GDP with a population of 23.5 million (DoS, 2019). Its nominal GDP in millions NT$ has increased by 71.3% (DoS, 2019). Public health expenditure as of % of current health expenditures (CHE) accounts for 63.5% with out-of-pocket payments as % of CHE are 35.52% (DoS, 2019). The compulsory contributory health insurance schemes as of % of public CHE was around 69.9% before the integration of NHI which rose to 89.9% in 2017 (DoS, 2019). Figure 2 shows the breakdown of health expenditures where the NHIA is 53.69% of the total government budget and out-of-pocket expenditures takes 33.63% of the private sector (DoS, 2019). These out-of-pocket costs include household expenditure on medical equipment and instruments, household expenditure on medical (including outpatient and inpatient care, dental prosthesis & orthopedics, sanatorium, nursing homes, childbirth recovery center, traditional medical treatments, etc., and household expenditure on health care appliances (Adams, 2010). The NHI system operates under financial self-sufficiency and pay-as-you-go principles. In the beginning, it adopted the fee-for-service approach as the primary payment system, taking previous standard payment rates from the government/employee schemes as a basis. [image: ]However; this led to an uncontrolled increase in medical expenses, affecting the quality of care. Until 2011, Taiwan was running a deficit until they implemented the 2nd Generation NHI which included reforms to stabilize the NHI finances which is seen in Figure 4. Taiwan’s NHI seems to be a striking example of a huge expansion in coverage, but with little corresponding increase in health care expenditure per person. The health care financing model is progressive and has pushed its rank to 9th place in the Bloomberg Health Care Efficiency Index (2018), making it one of the best in the world (Miller & Lu, 2018). Interestingly, Taiwan’s health care costs far less than highly developed countries in Europe and North America (Switzerland and Canada spent 11.6% and 10.4% of GDP per capita on health expenditures in 2016) (Statista, 2008). Although Taiwan’s unemployment rate is at 3.7% and out-of-pocket spending is increasing, its health finance system prevents catastrophic costs to households and public satisfaction remained high at 85.8 percent in 2017 as seen in Figure 3 (CEIC Data, 2008; Statista, 2008: NHIA, 2016). Figure 3: Trends of NHI Satisfaction Rate (DoS, 2019)

Figure 2: Breakdown of % Health Spending (DoS, 2019)

Figure 4: Finance trends after 2nd Generation NHI (NHIA, 2016)

Financial Flow

The financial flow in the Taiwan’s health system for NHE is divided into three groups: financial resources, financial allocation and financial agents. The financial resources involve where the money comes from: the government sector, enterprise and private non-profit organization and households (who comprise of over half) (NHIA, 2016). Financial allocation looks at where the money is being spent: general administration (2.15%), public health (4.37%), personal health care (88.17%) and capital formation (5.31%) (DoS, 2019). Personal health care refers to services in the health care basket which will be discussed later. The financial agents are those who are the liaisons to deliver the health services which include the public sector (central government, county/city government, public medical institutions and the NHIA) and the private sector (out-of-pocket, enterprise and private non-profit organization, and private administrative fee of health insurance) (NHIA, 2016).

Specifically looking at the revenue collection for the NHI, it is financed by taxes, premiums and a very small copay and coinsurance components (NHIA, 2016). Every citizen and resident are covered and required to pay a monthly premium except those from low-income and disadvantaged populations (NHIA, 2016). Majority of the revenue is from the payroll-based premiums which are contributed by salaried workers and their employers, non-salaried workers and unemployed persons, and subsidies from veterans, individuals from low-income household, prisons, and disadvantaged groups (DoS, 2019). The agency involved to review the premium rates and the scope of insurance is the NHI Committee, comprised of the insured, medical service providers, employers, experts, impartial public figures and representatives from relevant agencies (NHIA, 2016). Their responsibilities include negotiating, determining and allocating total annual medical payment expenses to balance the system’s operations which led to the classification system (NHIA, 2016). The NHI enrollees are categorized into six different classification for the insured and their insured units (see Figure 5). Figure 5: Calculating Premiums (NHIA, 2016)

Regarding health providers for cost control, the Bureau of the NHI (BNHI) first imposed global budgets sequentially on primary care, hospital care, and renal dialysis (Lu, 2014). It continues to update and has added diagnosis-related group (DRG) payment systems based on Taiwan’s inpatient care (NHIA, 2016). It is now a full-scaled global budget payment system which has lowered the growth rate of medical expenses to 5% and a medical quality assurance program with medical groups was implemented to oversee quality control (PWC Taiwan, 2018). The NHIA has also determined clinical services guidelines for treatment and drafted standards for professional review, case histories, and much more to improve medical quality (NHIA, 2016). The NHIA is consistently revising new treatment items reflecting technological process and real clinical needs with also strategic funding in areas such as nursing staff. To incentivize medical service providers, the BNHI introduced capitation and pay-for-performance for the treatment of breast cancer, cervical cancer, diabetes, tuberculosis and asthma (Lu, 2014). This list continues to grow based on population data with the goal to encourage medical service providers to focus on holistic care and prevention methods.

Coverage of the Statutory Financing system

The NHI is designed to ensure that everyone had equal rights to health care, including groups out of the working population. The statutory financing system covers not only persons who are citizens of the Republic of China [ROC] (Taiwan) but also new immigrant residents, foreign white-collar workers, overseas Chinese and foreign students, and military personnel who have lived in Taiwan for over six months (NHIA, 2016). Taiwan pushed the vision of equal access to treatment and right to medical care by also providing health insurance to inmates at correctional facilities and ROC nationals who have lived abroad for an extended period and wish to re-enroll. These changes reflect society’s expectation of fairness and justice for health, providing coverage up to 99.9% of the population and more (NHIA, 2016).

As discussed earlier, the NHI classifies the premiums in six categories as seen in Figure 5. Salaried workers are responsible for 30% of their personal and dependents’ premiums where employees pay approximately 30-60% depending on the occupation (NHIA, 2016). The other 10% is covered by the government (NHIA, 2016). For workers with large families, the employers cover the worker and 0.7 of the dependent, while the worker must pay the premium themselves up to three dependents (NHIA, 2016). Non-salaried workers (self-employer, unemployed, no regular pay) must pay insurance premiums for themselves and their dependents but the amounts are based on different calculation methods which is influenced by their self-reported income (NHIA, 2016). The government also introduced supplementary premiums to include large bonuses, part-time income, professional service income, dividend income, interest income and rental income that was not originally included in the six classification (NHIA, 2016). By expanding the premium base, it was able to ensure persons have a fairer burden and improve NHI’s deficit. To cover low-income and disadvantaged populations, the system receives supplementary funds in the form of premium overdue charges, public welfare lottery earnings distributions and tobacco health and welfare surcharges (NHIA, 2016).

Once insured, persons receive a health insurance card which works with the e-health technology that is found in every health clinic. With the card, the scope of the medical coverage provides medical services at organizations such as hospitals, clinics, pharmacies and medical examination organizations when they get sick, injured, or birth. The NHI currently covers outpatient care, inpatient care, traditional Chinese medicine, dental care, child delivery, physiotherapy, rehabilitation, home health care, chronic mental illness rehabilitation, and many more (Wu et al., 2010). The scope of medical payments include diagnosis, examination, lab tests, consultation, surgery, anesthesia, medication, materials, treatment, nursing, and insurance covered hospital rooms (Wu et al., 2010). This health basket essentially covers all health care services. The public can also freely choose to receive medical care services at any NHI contracted hospital, clinic, pharmacy or medical laboratory (approximately 92.74% of all health organizations are under NHI); even while overseas if they have an unforeseen illness or injury (NHIA, 2016). They simply apply for reimbursement of medical expenses paid overseas within six months after receiving emergency treatment, outpatient treatment, or hospital discharge.

Taiwan’s health system does not include a gatekeeper position but there are patient cost-sharing mechanisms in place. To encourage patients to seek treatment at local clinics, a penalty fee is placed on outpatient visits to hospitals without first receiving a referral from primary care, but it is very low. To constrain growing utilization rate due to moral hazard, the BNHI incorporated co-payment of US2$ for each out-patient visit to clinics, US$5 for each visit to medical center outpatient clinics, and a 10% co-insurance for inpatient services (Chen, Bernell & Mcmullen, 2008). It also capped the total amount that each patient pays for each admission is 6% and for each year, 10% of the average national income per person (Lu, 2014). However; these copayments are waived in cases of major illnesses and injury, child delivery, and those who see care in the mountain and offshore island areas (rural Taiwan). The main purpose of these cost-sharing mechanisms is to encourage the public to first seek care at primary care level hospitals and clinics, and if needed to be referred to the appropriate specialist hospital department for further care. This would help specialized, large hospitals to focus on serious illnesses and medical research while primary-level hospitals and clinics become the frontline of primary care. However; although the burden of health is aimed to be equal for all Taiwanese citizens, research showed that richer families continue to pay more through out-of-pocket or private insurance than poor families to gain greater access to quality health care (Chen et al., 2008). The gap between the rich and poor is widening but there is little research done to understand the situation.

Private Health Insurance

Even with the introduction of NHI, the public still relies on voluntary health insurance which was dominated by American insurance companies in the past (Liu & Chen, 2002). The incentive for private health insurance is used to pay for amenities such as their copayments, hospital room upgrades (public sector has up to three beds in a room), or services not covered by the NHI basket could include elective surgeries (Liu & Chen, 2002). The private health insurance premiums take in consideration of age, gender but are unrelated to the level of health risk such as drinking and smoking. These expenses are considered out-of-pocket and is up to the individual for purchasing. Almost all policies exclude new subscribers over aged 64 and with an increase in range of NHI copayments, private insurance is appealing to help patients with copayments for outpatient care (Liu & Chen, 2002). Private health insurance is available for individuals who have high-incomes (particularly those in Taiwan who own a house as it is quite expensive). Research also showed that individuals with four members or more had a higher percentage of private health insurance purchasing compared to smaller families (Liu & Chen, 2002). There is a small percentage of health care organizations (around 8%) that provide health care services to private health insurance purchasers with debates about better quality of care (NHIA, 2016). Interestingly, the implementation of NHI did not increase or decrease the purchase of private health insurance. The Taiwanese government also encourages the purchase of private insurance against financial crisis with a tax deduction policy because it can assist with the rising health expenditures that the government pays to cover citizens (Liu & Chen, 2002).

Out-of-pocket payments

[image: ]As the NHI is a compulsory enrollment system, it is inevitable that some low-income families and economically disadvantaged groups will not be able to afford these health premiums. To combat this, the NHIA provides a widespread of assistance measures aimed at maintaining a strong safety net and promoting the spirit of mutual assistance. These measures are aimed to those suffering with catastrophic illnesses such as cancer, kidney diseases requiring dialysis, hemophilia, mental illness and economically-disadvantaged citizens (NHIA, 2016). There are also measures in place for those living in rural areas (such as mountains and offshore islands), and patients suffering from rare or critical illnesses. In 2016, approximately 26.1 billion ($NT) in premium subsidies was provided to approximately 3.01 million individuals (DoS, 2019). A breakdown of the financial assistance provide to the disadvantaged population can be seen in Figure 6. Figure 6: Financial Assistance provided by the NHIA (DoS, 2019)

The NHIA provides interest-free loans to people facing economic hardship to pay for their NHI premiums and unpaid out-of-pocket expenses to safeguard their right to care. In 2016, 2,339 loans were taken out which amounted to 170 million ($NT) (DoS, 2019). For those who did not qualify for relief loans and could not pay for overdue premiums, they were given permission to repay the fees in installments (around 91 000 cases were approved in 2016) (DoS, 2019). Persons can also seek assistance from public interest groups, companies, and personal charities to cover their premiums (8,489 cases were successful covered in 2016) (DoS, 2019). The NHI had a strong principle of providing equal access to medical care and treatment is always covered regardless if premiums were unpaid or not, if citizens have their insurance card. Although; if the insurance card is lost/stolen at the time of treatment, persons must pay out-of-pocket and have the right to request for reimbursement within six months. This move embodied the government’s goal of protecting the weakest in society and prevent catastrophic household costs. As mentioned earlier, the system receives supplementary funds in the form of premium overdue charges, public welfare lottery earnings distributions and tobacco health and welfare surcharges. The program is called “Program to Ease the Medical Care Burden of disadvantaged Persons” where the NHIA actively selects and notifies people eligible for this program to help pay for their overdue health insurance premiums (DoS, 2019). In mid-year of 2017, the cumulative subsidies totaled to 3.66 billion ($NT) and benefited 213, 137 persons (DoS, 2019). Patients who qualify for NHIA subsidies also do not have to pay the co-pay rates or it is much lower to lower out-of-pocket costs (NHIA, 2016). The NHIA also uses special funds to pay for drugs designate by the MoHW to treat rare diseases and ease the economic burden of care for these patients (NHIA, 2016).

To encourage medical providers to work with people with disabilities, dental services are offered a higher reimbursement rate to encourage dentists to provide dental care to those who are medically vulnerable (DoS, 2019). With people who have catastrophic illnesses such as end-stage renal life, chronic mental illness, etc., they are given a different insurance card to exempt any out-of-pocket costs. In 2016, the NHI medical expenditures covered approximately 181 billion ($NT) which a high percentage was focused on purchase of drugs (DoS, 2019). Additionally, out-of-pocket spending was increasing due to the prevalence of multiple chronic diseases and to prevent redundant treatment plans, medications and examinations, the NHIA created the Hospital Integrated Care Program where participants have lower copayments, registration fees, reduced wait times and increased care safety and quality (NHIA, 2016). This prevents multiple visits with doctors and tailor patient-centered care with less costs and wastage to the health system.

Evaluation & Conclusion

Since the introduction of the NHI, the NHIA has achieved its goal of easing the public’s medical care burden with the support of the people in Taiwan and the medical community. The NHIA has succeeded in easing the NHI premium burdens, reducing administrative expenditures, shortened waiting time and minimizing the administration cost (which is less than 1% of the GDP for THE per capita) (Miller & Lu, 2018). The NHI system faced many challenges in its integration years with 40% public satisfaction but after introducing new forms, the NHI is considerably strong (Adams, 2010). Its new goals are to focus on making the most of resources and providing continuous, holistic care with introducing the Integrated Home Health Care Program (NHIA, 2016). Taiwan’s major challenges lie within the rising of health care expenditures, overcrowding and heavy staff workloads, rising medical-legal disputes and medical violence (patient to medical staff) (Lu, 2014). However; the NHIA is continuously listening to the citizens and reforming the program that the country believes in as seen in Figure 4 with the 2nd Generation NHI.

Around the world, Taiwan is a leading model for health systems and it has been internationally recognized for its efforts. The NHI is not only progressive but receptive to change. It took a societal approach to consider human rights and the principle of fairness with revisions over the years which is impressive considering its disadvantaged position in the political realm (which includes its status with the WHO and the UN). Most data online can only be found on the NHI database. However; the Taiwanese culture is about being humble, and open. In 2017, the NHIA had over 700 foreign visiting guests from over 54 countries worldwide to learn about the health care financing system (DoS, 2019). Taiwan’s health system is formidable because it has managed to deliver high standards of care while keeping costs down, enabling all citizens to receive a comprehensive health care.

References

1. Adams, J. (2010). Special Report: Health Care in Taiwan. Global Post. Retrieved from: http://homepage.ntu.edu.tw/~ntut019/ecomicro/Health-Taiwan-GlobalPost.pdf
2. CEIC Data. (2008). Taiwan Unemployment Rate. Retrieved from https://www.ceicdata.com/en/indicator/taiwan/unemployment-rate
3. Chen, WY., Bernell, S., & Mcmullen, B.S. (2008). The new co-payment policy under Taiwan’s National Health Insurance: Welfare gain or welfare loss? Expert Review of Pharmacoeconomics & Outcomes Research, 8(2), 141-9. Retrieved from https://doi.org/10.1586/14737167.8.2.141
4. Cheng, TM. (2003). Taiwan’s New National Health Insurance Program: Genesis and Experience so Far. Health Affairs, 22 (3). Retrieved from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.61
5. Department of Statistics (DoS). (2019). National Health Expenditure. Retrieved from https://www.mohw.gov.tw/cp-4271-46083-2.html
6. Statista. (2008). Demographics. Retrieved from https://www.statista.com/statistics/321439/taiwan-population-distribution-by-age-group/
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8. Lu, R.J. (2014). Universal Health Coverage Assessment: Taiwan. Global Network for Health Equity. Retrieved from http://gnhe.org/blog/wp-content/uploads/2015/05/GNHE-UHC-assessment_Taiwan-1.pdf.
9. Miller, LJ. & Lu, W. (2018). These are the economies with the most (and least) efficient health care. Retrieved from https://www.bloomberg.com/news/articles/2018-09-19/u-s-near-bottom-of-health-index-hong-kong-and-singapore-at-top
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14. Breakdown of Taiwan’s Health Spending
15. Ministry of Health and Welfare & it’s subordinate organization (Public) Other Public Sector National Health Insurance Administration (Public) Out-of-pocket (Private) Enterprise and Private non-profit institution (Private) Private Administrative Fee (Private)

The Republic of Sudan is situated in the northeast of Africa and is considered to be a low-middle-income country. It is the third largest African country in terms of geographical coverage after Algeria and the Democratic Republic of the Congo. The nation has a well-established healthcare system with many drawbacks, mostly due to economic and administrative factors followed by prolonged political turmoil and sanctions.

Public health expenditure (percent of GDP) stayed at about 1% and, at best, was closer to 2% in 1995-2013. In 2007-2010, substantial progress was made at a rate of 2.22%, suggesting an improvement in the production of infrastructure dependent on oil (Mahjoub Ebaidalla & Mohammed Elhaj). Sudan is awarded on natural and human capital, but economic and social growth has been below expectations. Similarly, statistics on health funding and spending are inadequate and incomplete. It makes it difficult for decision-makers to prepare, allocate and clearly see the deficient region. The available information has shown that overall government expenditure on health is very low and that the health sector is underfunded. As overall government expenditure increased largely due to oil revenue growth, the total allocation to the health sector also increased in absolute terms until 2011. The National Health Insurance System comprises about 8% of the population, most of whom are government workers (75%), the rest are poor families (6%), families of martyrs (3%) and students (2%). External assistance to the health sector has not been substantial in the last decade, although some foreign organizations have been committed to working with the government to improve and expand health programs, including those funded by the World Bank.

In 1976, Sudan introduced primary health care as the main health care policy and, in its future plans and policies, focus was focused on primary health care. Policies and plans in Sudan are drawn up at three levels that include federal, state and district (also known as locality). The federal government is responsible for the implementation of national health policies, programs, initiatives, overall monitoring and assessment, planning, training and international relations. The state level is concerned with state policies, initiatives, and on the basis of federal requirements for the funding and execution of programs. Districts or localities nearest to residents mainly provide primary health services, promote wellness and facilitate community involvement in the services of their health and the environment. They are also responsible for water and sanitation facilities. This well-established district framework is a key component of the decentralization strategy followed in Sudan, which in effect provides a wider space for local government, administration and enables the control and monitoring efforts of higher authorities to be overcome.

There are some weaknesses in the health system of Sudan which include the following:

• There are no consistent processes for enforcing, tracking and reviewing the process for the policies and plans in the program.
• Poor data consistency, storage and dissemination of information across all aspects of the health system.
• Fragmented health information network.
• Unclear management structures for collaboration and instruction between the federal and state departments of education, the military, police, universities, private sector and civil society.
• Not enough postgraduate training.
• Weak HR works at a decentralized level and low regional distribution with urban segregation.
• No ongoing program of professional development for health care.
• Deterioration of civil services due to out-of-datedness.
• Logistic supply (equipment, disposables, medicines, etc.)
• Out-of-pocket payments.
• Impaired access and use of health services.
• Inequitable distribution of health care facilities.
• Lack of preventive and pro-active health care (primary prevention).
• Inadequate referral network.

There are many opportunities for improvement of health care system in Sudan which include recent international commitments, decentralization leading to better decisions and actions, external financing incentives (WHO), partnerships with foreign institutions and universities, improved efficiency in the economy, initiative for reforming the health system.

Various steps can be considered to improve the current health care system in Sudan. First, the establishment of law enforcement divisions in districts, state health ministries, and federal health ministries would significantly improve compliance with existing policies. In addition, the establishment of a contact channel between all levels of policy making would allow efficient and timely decisions to continue, amend or even put an end to these policies. Secondly, it is recommended not only to track the progress of ongoing initiatives and programs, but also to pay special attention to the evaluation of the outcome. It is also recommended to further promote the use of the health information system, improve data quality and enhance the value of dissemination of results. Third, creating incentives for medical practitioners, delivering appropriate facilities and rising the doctor-to-physicist ratio to reach the norm would potentially reduce the high skilled attrition rate. Finally, it is proposed to upgrade primary health care facilities and create new units to meet existing needs and population growth, as well as to follow a bottom-up approach focused on community empowerment, disease prevention and health promotion.

Sudan’s health care network has a robust array of long-term or short-term action plans and policies. The implementation and management of the fragile health data system is weak. The main external factors undermining the system are the global economic instability that led to reductions in the health budget. Sudan is not a liberal country, and long-standing economic sanctions have also significantly affected the country’s ability to operate a viable, sustainable healthcare system, along with the gradual erosion of the number of healthcare professionals. Sudan needs to further reflect on the strengths it has and explore the tools available to develop basic health indicators.

Public health is about helping individuals stay healthy by protecting them from possible threats to their health, this can be done through promoting medicine and nursing but before individuals get to the state of needing medicine, public health may put in place resources to improve their health and wellbeing and reduce the causes of ill health. This is done through the work put into these three domains which include health protection, health improvement, and healthcare public health. Health protection is related to protecting people’s health, this can be done by looking at the biological and environmental threats posed to individuals for example pollution has a massive impact on the health of individuals as long-term exposure to polluted air can have permanent health effects like asthma and possibly even cancer leading to lives being shortened. Therefore, to help combat the possibility of these conditions occurring for individuals due to high pollution levels, health protection may be put in place to preserve the health of the public. Health improvement aims to improve people’s health by helping and encouraging people to quit taking part in certain behaviors like smoking or helping to improve their living conditions that may be having an impact on their health. For example, if an individual sleeps in a damp and moldy room it can be extremely detrimental to their health as they could inhale mold fragments causing them to experience nasal congestion and wheezing which over time could lead to reduced lung function and chronic health problems like asthma. Healthcare public health works to ensure that health services are the most effective and efficient for individuals as well as equally accessible to ensure everyone who needs healthcare can get access to it.

Before getting further into public health now, it’s important to talk about the origins and aims of public health policy and how they contributed to the public health systems. World War II started in 1939 and ended in 1945, it had a massive impact on the public within the UK both during and after it ended which then led the government and other major political parties to become aware and concerned about the health of the public. There were serious injuries that had never been seen before and they were due to the bombing raids that happened during the war, people who had also fought in the war sustained these serious injuries. For these injuries, the people who could afford it had private health insurance that would help towards their medical bills but those who couldn’t afford to pay for a doctor or medicine had to go without proper medical help for their injuries. It was reported that approximately 450,700 civilians from the UK and in the military died during World War II. This highlights the many losses that the whole UK has taken, many had lost their families and there also may have been fewer people to fill job opportunities within the UK. This led to the Beveridge Report being published as the government had commissioned Sir William Beveridge to investigate how the country could recover from this war. Beveridge had experience with political affairs and was an expert on the problem of unemployment meaning he could give helpful ideas to help the UK government recover from the recent events. The report was published in 1942 and was welcomed by the public, it stated how the post-war period was a time for radical change and one recommendation given was that the government should find ways to fight disease. During World War II measles was a notifiable disease in both England and Wales, highlighting it as one of the diseases the Beveridge Report said to fight. Measles is a highly infectious viral disease that could lead to serious complications like pneumonia or encephalitis which is the inflammation of the brain. If an individual was to be infected by measles it would damage and suppress their whole immune system making this individual more likely to catch other infectious diseases. This effect can last for as much as 3 years after they’ve recovered from measles, this shows the importance of the government to tackle the disease to help protect the health of the public. Measles is spread through water droplets either by the coughing or sneezing of an infected person. In 1940, there was an epidemic of measles with approximately 400,000 cases that were reported showing how much of a serious illness it was at the time, especially as this epidemic was during WWII showing how it may have been negatively affecting the immune systems of the public along with health conditions that came because of the war. Every year people die because of infectious diseases like pneumonia, meningitis, tuberculosis, and polio which showed evidence that there was a need for healthcare within the UK. Although there had been numerous reports on improving healthcare between the First and Second World Wars nothing had been implemented until 1945. 1945 was the year that the new labour government took on the recommendations of the Beveridge report resulting in the National Health Service Act being passed in 1946 and coming into force in 1948. On July 5th, 1948 the NHS was introduced to ensure that people in the UK would receive free healthcare no matter their income, it was the first health service of its kind in the world. For the NHS to provide free healthcare for everyone it means that it would be completely financed by tax (national insurance), benefiting every person in the country and being available from birth to death. The NHS being introduced meant that for the first time, people could receive diagnosis and treatment of any illness either at their home or hospital, this also included dental and ophthalmic care. The government’s decision to implement a national health service has had a significant impact on the nation’s health as it has improved the health of millions.

Now that healthcare was being prioritized due to the introduction of the NHS in 1948, it showed how the UK government was able to put together the 6 main aims of the public health policy. The UK government had an overriding moral aim to ensure that the health of its citizens was paramount meaning it was put in high importance for all service users. This was especially important for the time during and after the second world war because of how much of an impact it had on the citizens of the United Kingdom both in terms of the number of causalities and the aftermath of the war. Planning national provision of health care and promoting the health of the population was an aim of the public health policy, this started as the NHS began providing a more accessible health service for everyone so this aim could be met. This was done through ensuring fair and equal health services were available for the whole of the UK at a good standard regardless of the public’s social status or geographical location within the UK. To provide these types of services for citizens and meet the needs of the changing demographic, public health policy must be responsive and ready for the future by planning the future needs and care the public may need in certain situations that could occur. The government must gather statistical data and commission reports on the current trends within health to help predict any possible future developments in the health status of the nation so that action can be taken quickly to prevent or combat any health issues that have a chance of occurring in the future. A way in which health can be promoted to the population within the UK is by highlighting factors that can influence health, for example, lifestyle choices including whether you drink or smoke and others such as unemployment and housing, by the government discovering and conducting this kind of information it can help to shape the planning process for health provision. For example, the Better Health campaign was launched in 2020, the job of this campaign is to support individuals with their weight loss journey by providing advice on how they can quit smoking and drink less. This highlights the promoting health aim of public health policy to keep the public fit and healthy. Throughout the years as technology has advanced and more resources like equipment and medicine are now being available, it shows how the public may have high expectations for public health to provide good healthcare. Furthermore, as there are now more resources due to the health trends throughout the year and many medical conditions, the new resources have allowed these medical conditions to become more treatable leading to the life expectancy within the UK increasing. Even though life expectancy has increased over time, there are still significant health problems the people of the UK suffer from, including dementia and mental health issues, this has led public health to public health raising awareness of how these health issues can be overcome, including eating healthy and exercising. Doing these actions will help to improve the health of the public.

During and after the war, it was noted that health officials rationed food, and this was said to have improved the health of the public. By food being rationed it meant that the public had a fixed allowance of food, this may have stopped them from getting more than their body needed therefore improving their health. Many illnesses and conditions were brought on by the war or other reasons such as poverty, this then led the local authorities at the time to introduce the children’s and mental health departments to help support the individuals with these illnesses and conditions. This became known as the ‘social citizenship’ agenda, which allowed the government, for the first time, to become the provider of welfare in terms of the public’s health, happiness, and fortune. This shows how public health identified the needs of the public and provided a way in which these needs could be met, through this agenda. In 1946, the World Health organization identified health as a separate issue in which governments must be involved to benefit the physical, mental, and social well-being of the public. As a way to benefit the wellbeing of the public, films on topics such as fireworks, crossing the road safely, and sexual helped to raise public awareness therefore benefiting the public and their wellbeing as they were being educated. For public health to continue to identify and monitor the needs of the population their understanding and predictions on social change were pivotal for providing treatment and controlling diseases. Ways in which the government adapts to social change is by raising awareness on social topics like illegal drug use through the use of campaigns. The government would also respond to medical evidence on the links between smoking and various types of cancers such as lung cancer, this then allowed them to lead a range of interventions that would monitor what the public had access to, and the advertising of cigarettes would be restricted to preserve the wellbeing of smokers and the public as a whole. Smoking in the workplace within England was then banned on July 1st, 2007.

Another aim of public health policy was to identify and reduce the inequalities between groups and communities within society. Health inequalities between groups and communities include one’s health status, access to care, and the quality of their care. It is important to identify and reduce these because inequalities are unfair and it leads to individuals not being treated equally or being treated according to their needs, this then impacts negatively on their wellbeing something that public health policy is aiming to benefit. For some people within the UK, there are unfair and avoidable inequalities in their healthcare access and experiences which public health policy aims to overcome. This leads to the public health policy aim of protecting individuals, groups, and communities from threats to their health and well-being that arise because of environmental hazards and communicable diseases. Health inequalities may mean that people are unable to receive healthcare because of their social status or where they live, this protection aim then highlights how public health aims to protect the public no matter any other existing factors such as where they live. Environmental hazards are hazards that can cause harm with or without contact such as pollution or tobacco smoke and a communicable disease is an illness that can be transmitted from one person to another. From the 1970s onwards factors like crime rate, housing conditions, and education were observed as affecting the health and wellbeing of individuals. This then led to worldwide and national guidelines being put into practice to monitor these issues and protect society from health threats and hazards. Legislation about toxic waste and standards governing air quality within cities was put in place to keep society safe from environmental hazards like pollution. To protect society from communicable diseases the director of health required local authorities to be directly responsible for the health of their residents by telling their residents to report their illnesses to their GP or local hospital, this then allowed the regional health team to monitor these health illnesses. There was a system put in place where if several cases of an infectious disease was reported, an outbreak management team would investigate monitor its spread through the local area, and then put in place medical resources to prevent any further spread, this would then protect the public from the spread of communicable diseases, reducing the likelihood of the disease infecting more of the public.

National health problems are issues that can affect any sector of society, they may be more prevalent in some sectors rather than others and some regions may find that they are at a higher risk of developing this health problem in comparison to other regions. For example, a health problem like pollution affects everybody but pollution levels may be higher in one area rather than the other. Therefore, from the problem of pollution, individuals who have asthma may be affected more by the higher levels of pollution in comparison to someone who doesn’t suffer from asthma. This is because pollution can make asthma symptoms worse and as a result trigger attacks. Public health policy aims to address specific national health problems to help tackle them which would then improve and benefit the wellbeing of individuals who are impacted by these health problems. One recent guideline that has been published and concerns public health is about raising awareness of the importance of good indoor air quality within homes, this highlights how public health is tackling health problems through the use of guidelines to overcome health issues.

Health screenings are important because they look for diseases before you even have symptoms, this will allow diseases to be found early making them easier to treat. This is very good for conditions like cancer because the condition is found, and more can then be done to combat the cancer before it worsens, negatively impacting the health of the individual. If an individual is found to have a problem after their screening test a further investigation will be recommended to conduct the solution to their health problem. Public health aims to develop programs to screen for early diagnosis, which will put the health of the public first as diseases can be found quicker which will allow treatment for these diseases to also take place quicker which will then help to fight the disease.