Latest / The Health Care for All Podcast / EP3: Universal Health Care 101 - Defining Universal Health Care
Transcript
- Collin Stackhouse: Welcome back to the Healthcare For All Podcast. I'm Collin Stackhouse. Rebecca: And I'm Dr. Rebecca Schoon. Oregon's on track to become the first state to move to a universal healthcare system, really. So today we are launching something we've been excited about since we started this show, our Universal Healthcare 101 series. Collin Stackhouse: This is the podcast series for anyone who's ever nodded along in a conversation about universal healthcare while thinking internally to themselves, ⁓ ⁓ exactly are we talking about? ⁓ are not alone and this is your episode. Rebecca: So over the course of this series, we're to build your knowledge from the ground up. This topic is legitimately complex and you to understand the real complexity of it, not just a dumbed down version of it. Collin Stackhouse: Today is episode one of the Healthcare 101 series, and we want to start with the most fundamental question of all, what ⁓ is universal healthcare? What does that phrase mean? How different countries around the world answer that question in different ways? ⁓ I know, Rebecca, that you have been very eager teach this episode. Rebecca: That's true, and mostly because I've spent too many nights at dinner tables where I've tortured the people next to me while droning on about this topic. So I'm super excited to share it with an audience who might want to nerd out on a health policy with us. Collin Stackhouse: Okie dokie. So let's start with the definition. What do we mean when we say universal healthcare? Rebecca: ⁓ universal healthcare means just that every person in a given country or region ⁓ access to the health services they need without suffering financial hardship ⁓ That's the World Organization definition. ⁓ And it's those two that are equally important here. Collin Stackhouse: Okay, so break them down for me. Rebecca: Okay, part one, every person automatically has coverage. And most people get this part about universal healthcare. Universal coverage means the system is fundamentally designed around population's needs, not the ability to pay. Collin Stackhouse: Yep, and that already sounds very different from what we have here in the United States. Rebecca: Dramatically different. So ⁓ the United States, to healthcare is largely tied to employment, your age, your income, what state you live in. In a universal system, none of factors determine whether you walk into a doctor's office and get the care you need. So part of the definition is critical as and that's the financial hardship piece. And this is where I think a lot of Americans feel this most acutely. Collin Stackhouse: Totally, because you can technically have insurance, but be underinsured and still go broke getting the healthcare that you need. Rebecca: Exactly. Having an active insurance card in your wallet is not the same as having access to care. ⁓ the US we have millions of people who are technically insured, but they can't afford their deductibles, their copays, their out of pocket maximum. That is universal healthcare, ⁓ even if you'd it coverage. So universal healthcare means financial barrier is removed, ⁓ or at least it's reduced where doesn't prevent people from getting. the care that they need. Collin Stackhouse: That's a pretty common misconception. On social media, I see a ton of people to a state like Massachusetts or Hawaii or Vermont, and they say, they have near universal coverage. That's universal healthcare. I thought they've had it for years now. Rebecca: Exactly. And that is not universal healthcare. And this is a really important distinction. Massachusetts achieved near universal through what's called the individual mandate, where almost everyone is required to buy insurance. So Americans are pretty ⁓ used this concept now because individual mandate was also echoed later in the Affordable Care this Massachusetts plan is actually what the Affordable Act. was based on. So do ⁓ have familiarity with Massachusetts plan. ⁓ But we just explained, having insurance is not the same as being able to benefit from it. So there are people in Massachusetts right now with a valid plan, but who have an deductible say that means they have to spend $8,000 out of pocket before their insurance even kicks in to pay a single dollar towards their healthcare. For a lot of people, that deductible is effectively a barrier between them and getting the care that they need. Collin Stackhouse: Totally, right. So people in Massachusetts and everywhere that are faced with this huge deductible skip their appointments. they feel sick, they're waiting to see if their symptoms just go away on their own. Rebecca: Exactly. to 40 % of adults in the US report that they delay healthcare due to cost concerns. So they skip that appointment, they ration their prescriptions, ⁓ they wait until something minor becomes a crisis, then they go to the emergency room, which is the most expensive point of entry into system, right? ⁓ So that is not universal healthcare. That's universal coverage with inadequate access. And that difference is huge for patient outcomes, for cost to both individuals and the overall system. So A system where people are delaying care until they're really sick is a much more expensive system. Universal healthcare means people can access care early and access it consistently before small problems become catastrophic ones. Collin Stackhouse: And that is better for a patient's health and it also saves money for the overall system. So insurance coverage is a necessary condition, but it's not sufficient on its own. Rebecca: Yes, coverage gets you to the door. Affordability determines whether you can actually walk through it. when we talk about establishing universal healthcare in Oregon, we are about a system where the financial barrier is gone. That is a much higher bar than Massachusetts set. ⁓ And it's right Collin Stackhouse: So when we talk about Oregon pursuing or trying to move to this universal healthcare system, we're talking about both of those things, covering everyone and making sure that the cost doesn't stop them from actually using the insurance that they have. Rebecca: That's it. That's the North Star. How you get there now, who pays, who delivers the care, how the money moves through the system. That's where universal healthcare systems can diverge. And that's what we'll spend the rest of this episode into. Collin Stackhouse: we get into the different models, we need to understand a distinction which is the financing versus the delivery. Can you talk to me about the differences between those two? Rebecca: Yes, and this is usually when those dinner party guests eyes glaze over. But this is a ⁓ great ⁓ is it's important to understanding why there's not just one of universal healthcare system, countries do it differently, and yet they achieve that same goal of access. ⁓ So let's separate these two questions that often get up together. Question one is who's paying for healthcare? That's Collin Stackhouse: I'm not, my eyes are not glazed. I am engaged. Please tell me. Rebecca: financing. Question two is who is providing the healthcare? The the doctors, the nurses. That's delivery. Collin Stackhouse: And those two things can be different. Rebecca: Absolutely. They're completely different things. here's analogy. You can think about public schools. In the public education is financed by the government through taxes. And the teachers, the principals, the school buildings, those are also operated in the school system. in that case, financing and delivery are both public. think how roads work. Also, publicly financed through taxes, but a lot of the actual construction is done by private contractors. So in this case, you have public financing, but private delivery. Collin Stackhouse: Right, so you could have a universal healthcare system where the government is paying for everything, but the doctor is still working at a private practice. Rebecca: Exactly. And that's actually how most universal healthcare systems work. So government or a public fund handles the but private doctors, private hospitals, private clinics handle the delivery of healthcare. So the doctor still their own practice. ⁓ They just bill a fund or they bill the government instead of the of private companies that we have in the U.S. Collin Stackhouse: Reading people's comments on social media, I can guarantee you that there are many people who are ⁓ and I would say upset about the idea of universal healthcare because they picture a government doctor in a government hospital and mandating their care. Rebecca: Yes, that model does exist. So it's one of the four that we'll talk about, but it's actually the least common among universal healthcare systems. So most universal healthcare countries have private doctors who are just paid by the public system. And that distinction matters a lot for the political conversation we're having in Oregon, because as you one of the biggest fears that people have is that universal healthcare the government's taking over medicine. that's not what we're looking at. The government is just taking over paying the bill, not delivering or controlling how care is delivered. Collin Stackhouse: Okay, so now that we understand versus delivery, and we certainly understand it completely, no further questions. ⁓ talk about the four models that you mentioned earlier. How do different countries actually structure their healthcare systems? Rebecca: Right. So health policy researchers have identified four main models and they're named after the people or context that gave rise to them. So they're the model, the Bismarck model, the national health insurance model and the out of pocket model And I want to be clear upfront, ⁓ these are frameworks, rigid boxes. So most countries might blend elements of more than one, but understanding these four gives us a good starting map. Collin Stackhouse: Okay, so I have my beverage ⁓ spelled differently. Let's go through the Beveridge model. B-E-V-E-R-I-D-G-E. Rebecca: So the Beveridge model is named after William Beveridge, a British economist who designed the United Kingdom's National Health Service after World War II And I love to share that fact because a lot of people think that a country or state needs to have a really strong, robust economy and have a huge surplus of money in order to afford universal healthcare. But actually, the UK's post-World War II economy was in absolute ruins. NHS was developed really as a ⁓ gift to the British people for that they endured during the war. Collin Stackhouse: That is interesting, I did not know that and I'm ready for a similar gift here in the US. Rebecca: Exactly. So in this Beveridge model, the government finances and healthcare. So hospitals are government owned the Beveridge model. ⁓ Most doctors are employees. Care paid for through And for the most part, there's bill at the point of service. There's no copay You get sick, you go to the doctor, you go home. No invoice. ⁓ The most you have to pay might your parking fee. Collin Stackhouse: That's the one that most people picture when they think about socialized medicine. Rebecca: Yes, so this term socialized medicine is thrown around a lot conversations about universal healthcare. But really, is the only model where that term is accurate. So the United Kingdom's National Health Service ⁓ is the most famous ⁓ Spain, Scandinavian countries, ⁓ use of But this is actually the minority model ⁓ among universal health systems, both financing ⁓ and are run by the Collin Stackhouse: Model number two is Bismarck, B-I-S-M-A-R-C-K. That's a pretty ⁓ unusual name to show up in healthcare conversation. What's story? Rebecca: So von Bismarck was the chancellor of Germany in the ⁓ 1880s, he was a staunch nationalist, meaning, you know, pretty extreme political conservative. ⁓ But actually created the world's first ⁓ universal system in 1883. And he really it as a political maneuver. he created universal healthcare ⁓ to try to undermine the movement in Germany the time. by showing workers that the government cared about them, that they didn't have to move towards socialism to get their needs taken care of. Collin Stackhouse: That is I did not know that. And it's fascinating that the universal healthcare system was started by a right-wing person to socialism in check and to show that their country cared for its workers. If you mention universal healthcare in the United States now, you are absolutely accused of being a and a socialist right off the bat. Rebecca: Yes, one of those things that make you want to laugh and cry at the same time. So ⁓ we are. ⁓ Collin Stackhouse: Okay, so yeah, no more tears. ⁓ So what, in a Bismarck system, what is the difference? What does it look Rebecca: a system, both employers ⁓ employees pay these insurance funds. They're actually called sickness funds and they pay these payroll contributions. They're often multiple funds or insurers and these are private but they're regulated. They're nonprofit. They have to cover everybody. They cannot make a profit on basic care. They cannot deny coverage. And importantly, doctors and hospitals are largely private in this system too. Collin Stackhouse: Fascinating. So it kind of looks like what we have here in the United States, but it is regulated in such a way that it actually functions. Is that right? Rebecca: That's a that's a very good, characterization. ⁓ the big difference is that these funds are non-profit. So that's one difference ⁓ and heavily, regulated so that they can't engage in all the problematic practices that private insurance in the US regularly does. So Germany, France, ⁓ Switzerland, they all variations of the Bismarck model. ⁓ There are private there are private doctors, but the insurers operate much more like public utilities ⁓ for-profit business. Their entire purpose is to cover people, ⁓ to generate profit for shareholders. Collin Stackhouse: All right, so model number three is national health insurance. This is the one that we keep hearing about and keep talking about in relation to Oregon. Rebecca: Yes, ⁓ National Health Insurance Model, is often where advocates land when they say universal healthcare in American context. ⁓ So here's how it works. There's one public insurance fund, funded through that covers everybody. ⁓ But the and hospitals, remain mostly They just bill this one public fund instead of this Frankenstein patchwork of private insurers that we have now. Collin Stackhouse: Canada, right? Rebecca: Exactly. Canada but also Taiwan, South Korea, a lot of other countries. ⁓ So in Canada, Canadian is covered by their provincial health insurance plan. A in Canada is the equivalent to a state in the US. They go to their private doctor. There are no networks to navigate. ⁓ And then ⁓ those clinicians bill government fund. The doctor gets paid in a really streamlined system. Taiwan also implemented a version of this in 1995. And they went from covering 57 % of their population to 99 % in just a single year. We're going to do a whole episode on Taiwan later on because their health system is often ranked number one in the entire world. So we have a lot that we could learn from them. Collin Stackhouse: I think they've been ranked number one for of the last seven years or something close to it. And is essentially what Health Care For All Oregon is advocating for our state's transition. Rebecca: Yes. So one public entity covers all Oregonians and that pays all providers. We mentioned on other episodes Universal Health Plan Board, this governance board is designing what that could look for Oregon. ⁓ The appeal a policy standpoint is efficiency. So instead of thousands of different insurance plans, all with different rules, networks, forms and billing codes. You have one system. Providers spend so much less time on administrative overhead that administrative savings is a part of how single payer systems save money. Collin Stackhouse: So the fourth model is called out of pocket. I'm guessing that this is the one we want to move away from. Rebecca: Exactly. The out-of-pocket model basically what exists in the absence of a universal system. So people pay for their health care directly based on what they can afford. So the dominant model in most low income countries that haven't yet built the infrastructure universal healthcare. But here's the sad The U.S., the wealthiest country in the history of the world, ⁓ still has, as we enormous out-of-pocket exposure. baked right into the system. So deductibles, copays, out of network bills, surprise billing. These are all mechanisms that shift costs directly to the patient right when they are most vulnerable. Collin Stackhouse: Okay, so help me the plane. You have covered a lot of ground today, Rebecca. ⁓ If somebody was listening while they doing the dishes and then they zoned out for a minute, somehow in this incredibly exciting ⁓ information about the four kinds of systems, then they tune back in for these last few minutes, what do you want them to know? What do want them to walk away getting? Rebecca: I would say things. Number one, ⁓ universal healthcare means is covered and no one faces financial ruin getting the care they need. ⁓ It's a definition more outcomes than any particular structure or type of system. ⁓ Number two, there are four models of health systems. The Beveridge model, national health insurance, and out of pocket. ⁓ And most universal healthcare systems blend elements of more than The third most important thing would be any healthcare system is a question of and delivery. So who pays and who provides care? And that can be completely different entities. ⁓ So most universal healthcare systems have private doctors ⁓ are paid by a public fund. Collin Stackhouse: So for us Oregonians specifically, why does this matter right now? Rebecca: the conversation that Oregon is about to have in the legislature, in your living rooms, in town halls, it's going to be full of ⁓ claims and counterclaims. And we know the opposition is going be full on in their efforts to try to confuse people. ⁓ That's the only ammunition they have. ⁓ Notice know the opposition is going to try to confuse people. That's the only ammunition they have. Notice they never try to defend the current system. they try to sow fear, uncertainty. And now, hopefully you have enough foundation to those claims. ⁓ That's what this Universal Healthcare 101 series is designed do. they never try to defend the current system. they try to sow confusion, fear, uncertainty. about what this change would mean. ⁓ people are gonna talk about government takeovers, socialized medicine, rationed care. And hopefully you all have enough foundation to evaluate those claims. ⁓ That's what this Universal Healthcare series is designed to do. ⁓ We're trying to make sure that you have the tools to assess all these issues clearly. Collin Stackhouse: One thing that I want people to take away from this 101 session is that our system is the most expensive on the planet and universal healthcare saves lives and saves money everywhere else. There's no reason why the United States and Oregon is going to be any different. It will save lives and will save money. That's what we're working for. Coming up in the next 101 series, we're going to do a deep dive on two terms you've been probably hearing a lot, which is single payer versus multi-payer. And we'll also break down what people mean when they talk about the public option. These are terms that are gonna be at the center of Oregon's policy debate, and we wanna make sure that you can navigate them with total confidence. And that's coming up soon. Rebecca: And in the meantime, if have questions, if there are things you've heard, ⁓ myths you want us to tackle, please go to HCAO.org ⁓ and them in. ⁓ We'll doing a social media campaign prompting you for questions. ⁓ We're going to read all of them. And our is to answer them on here. Collin Stackhouse: Thank you for being here. Everybody in, nobody out. We'll see you next time.