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Q. The notorious​ Unit 731 members​ from Japan went totally scot-free, I understand​, even though they were probably worse than the Nazis. Do you agree?A. Unit 731 was an Auschwitz equivalent. The perpetrators should all have been tried for war crimes. Particularly evil was Surgeon General Shirō Ishii, commander of the unit.Most of the victims were Chinese and a few Koreans. 30% were Russians. Those that the Soviet forces managed to arrest were tried at the Khabarovsk War Crime Trials in 1949. The rest were secretly given immunity by the U.S. in exchange for the data gathered, to be co-opted into the U.S. biological warfare program, as had happened with Nazi researchers in Operation Paperclip.On 6 May 1947, Douglas MacArthur, as Supreme Commander of the Allied Forces, wrote to Washington that "additional data, possibly some statements from Ishii probably can be obtained by informing Japanese involved that information will be retained in intelligence channels and will not be employed as 'War Crimes' evidence."Victim accounts were then largely ignored or dismissed in the West as communist propaganda.Gen. Ishii lived on the outskirts of Tokyo until his death in 1959. Other "graduates" of Unit 731 include the former governor of Tokyo, the former president of the Japan Medical Association, the former director of the health ministry's preventive health research center, the former chairman and president of Green Cross Corp. and the past heads of a number of Japanese medical schools. The man in charge of vivisections, Yoshisuke Murata, became director of the respected Kyoto Medical School, and later medical director at Kinki University.Perpetrators:Surgeon General Shirō IshiiLt. General Masaji KitanoEpidemic Prevention and Water Purification DepartmentUnmasking Horror -- A special report.; Japan Confronting Gruesome War Atrocity New York Times10 Atrocious Experiments Conducted By Unit 731 - ListverseJapanese World War II veterans recall horrors of Unit 731 (Youtube)Unmasking Horror -- A special report.; Japan Confronting Gruesome War AtrocityMORIOKA, Japan— He is a cheerful old farmer who jokes as he serves rice cakes made by his wife, and then he switches easily to explaining what it is like to cut open a 30-year-old man who is tied naked to a bed and dissect him alive, without anesthetic."The fellow knew that it was over for him, and so he didn't struggle when they led him into the room and tied him down," recalled the 72-year-old farmer, then a medical assistant in a Japanese Army unit in China in World War II. "But when I picked up the scalpel, that's when he began screaming."I cut him open from the chest to the stomach, and he screamed terribly, and his face was all twisted in agony. He made this unimaginable sound, he was screaming so horribly. But then finally he stopped. This was all in a day's work for the surgeons, but it really left an impression on me because it was my first time."Finally the old man, who insisted on anonymity, explained the reason for the vivisection. The Chinese prisoner had been deliberately infected with the plague as part of a research project -- the full horror of which is only now emerging -- to develop plague bombs for use in World War II. After infecting him, the researchers decided to cut him open to see what the disease does to a man's inside. No anesthetic was used, he said, out of concern that it might have an effect on the results.That research program was one of the great secrets of Japan during and after World War II: a vast project to develop weapons of biological warfare, including plague, anthrax, cholera and a dozen other pathogens. Unit 731 of the Japanese Imperial Army conducted research by experimenting on humans and by "field testing" plague bombs by dropping them on Chinese cities to see whether they could start plague outbreaks. They could.A trickle of information about the program has turned into a stream and now a torrent. Half a century after the end of the war, a rush of books, documentaries and exhibitions are unlocking the past and helping arouse interest in Japan in the atrocities committed by some of Japan's most distinguished doctors.Scholars and former members of the unit say that at least 3,000 people -- by some accounts several times as many -- were killed in the medical experiments; none survived.The Unit 731 complex Pingfang, ChinaNo one knows how many died in the "field testing." It is becoming evident that the Japanese officers in charge of the program hoped to use their weapons against the United States. They proposed using balloon bombs to carry disease to America, and they had a plan in the summer of 1945 to use Kamikaze pilots to dump plague-infected fleas on San Diego.The research was kept secret after the end of the war in part because the United States Army granted immunity from war crimes prosecution to the doctors in exchange for their data. Japanese and American documents show that the United States helped cover up the human experimentation. Instead of putting the ringleaders on trial, it gave them stipends.The accounts are wrenching to read even after so much time has passed: a Russian mother and daughter left in a gas chamber, for example, as doctors peered through thick glass and timed their convulsions, watching as the woman sprawled over her child in a futile effort to save her from the gas. The Origins Ban on Weapon Entices MilitaryJapan's biological weapons program was born in the 1930's, in part because Japanese officials were impressed that germ warfare had been banned by the Geneva Protocol of 1925. If it was so awful that it had to be banned under international law, the officers reasoned, it must make a great weapon.The Japanese Army, which then occupied a large chunk of China, evicted the residents of eight villages near Harbin, in Manchuria, to make way for the headquarters of Unit 731. One advantage of China, from the Japanese point of view, was the availability of research subjects on whom germs could be tested. The subjects were called marutas, or logs, and most were Communist sympathizers or ordinary criminals. The majority were Chinese, but many were Russians, expatriates living in China.Takeo Wano, a 71-year-old former medical worker in Unit 731 who now lives here in the northern Japanese city of Morioka, said he once saw a six-foot-high glass jar in which a Western man was pickled in formaldehyde. The man had been cut into two pieces, vertically, and Mr. Wano guesses that he was Russian because there were many Russians then living in the area.Gen. Shiro Ishii, head of Unit 731The Unit 731 headquarters contained many other such jars with specimens. They contained feet, heads, internal organs, all neatly labeled. "I saw samples with labels saying 'American,' 'English' and 'Frenchman,' but most were Chinese, Koreans and Mongolians," said a Unit 731 veteran who insisted on anonymity. "Those labeled as American were just body parts, like hands or feet, and some were sent in by other military units."US POWs shot down in Japan 70 years ago dissected ALIVETerrible fate: Captain Marvin Watkins, top left, and his crew were downed over Japan. Six of them and two others not pictured were dissected alive or subjected to other terrible medical experiments at Kyushu Medical School. Pictured in the back row (l to r) are: Marvin S. Watkins (interrogated and released at the end of war) William R. Fredericks (died in medical experiment), Howard T. Shingledecker, (fate unknown), Charles M. Kearns (died at crash site), Dale E. Plambeck (died in medical experiment) Front row: Robert C. Johnson (died at crash site), Teddy J. Ponczka (died in medical experiment), Robert B. Williams (died in medical experiment), Leon E. Czarnecki (died in medical experiment), Leo C. Oeinck (died at crash site), John C. Colehower (died in medical experiment)The soldiers were flying a B-29 bomber, pictured, when it was shot down over the skies of Japan. Eight of the men on board were taken to the Kyushu Medical School and experimented on. None survived the vivisection.Medical researchers also locked up diseased prisoners with healthy ones, to see how readily various ailments would spread. The doctors locked others inside a pressure chamber to see how much the body can withstand before the eyes pop from their sockets.Victims were often taken to a proving ground called Anda, where they were tied to stakes and bombarded with test weapons to see how effective the new technologies were. Planes sprayed the zone with a plague culture or dropped bombs with plague-infested fleas to see how many people would die.The Japanese armed forces were using poison gas in their battles against Chinese troops, and so some of the prisoners were used in developing more lethal gases. One former member of Unit 731 who insisted on anonymity said he was taken on a "field trip" to the proving ground to watch a poison gas experiment.A group of prisoners were tied to stakes, and then a tank-like contraption that spewed out gas was rolled toward them, he said. But at just that moment, the wind changed and the Japanese observers had to run for their lives without seeing what happened to the victims.The Japanese Army regularly conducted field tests to see whether biological warfare would work outside the laboratory. Planes dropped plague-infected fleas over Ningbo in eastern China and over Changde in north-central China, and plague outbreaks were later reported.Japanese troops also dropped cholera and typhoid cultures in wells and ponds, but the results were often counterproductive. In 1942 germ warfare specialists distributed dysentery, cholera and typhoid in Zhejiang Province in China, but Japanese soldiers became ill and 1,700 died of the diseases, scholars say.Sheldon H. Harris, a historian at California State University in Northridge, estimates that more than 200,000 Chinese were killed in germ warfare field experiments. Professor Harris -- author of a book on Unit 731,”Factories of Death: Japanese Biological Warfare, 1932-45 and the American Cover-Up" (Routledge, 1994) -- also says plague-infected animals were released as the war was ending and caused outbreaks of the plague that killed at least 30,000 people in the Harbin area from 1946 through 1948.The leading scholar of Unit 731 in Japan Tsuneishi Keiichi, is skeptical of such numbers. Professor Tsuneishi, who has led the efforts in Japan to uncover atrocities by Unit 731, says that the attack on Ningbo killed about 100 people and that there is no evidence of huge outbreaks of disease set off by field trials. The Tradeoff Knowledge Gained At Terrible Cost.Many of the human experiments were intended to develop new treatments for medical problems that the Japanese Army faced. Many of the experiments remain secret, but an 18-page report prepared in 1945 -- and kept by a senior Japanese military officer until now -- includes a summary of the unit's research. The report was prepared in English for American intelligence officials, and it shows the extraordinary range of the unit's work.Scholars say that the research was not contrived by mad scientists, and that it was intelligently designed and carried out. The medical findings saved many Japanese lives.For example, Unit 731 proved scientifically that the best treatment for frostbite was not rubbing the limb, which had been the traditional method, but rather immersion in water a bit warmer than 100 degrees -- but never more than 122 degrees.The cost of this scientific breakthrough was borne by those seized for medical experiments. They were taken outside in freezing weather and left with exposed arms, periodically drenched with water, until a guard decided that frostbite had set in. Testimony from a Japanese officer said this was determined after the "frozen arms, when struck with a short stick, emitted a sound resembling that which a board gives when it is struck."Museum visitors Harbin, Helongjaing ProvinceA booklet just published in Japan after a major exhibition about Unit 731 shows how doctors even experimented on a three-day-old baby, measuring the temperature with a needle stuck inside the infant's middle finger."Usually a hand of a three-day-old infant is clenched into a fist," the booklet says, "but by sticking the needle in, the middle finger could be kept straight to make the experiment easier." The Scope Other Experiments On Humans.The human experimentation did not take place just in Unit 731, nor was it a rogue unit acting on its own. While it is unclear whether Emperor Hirohito knew of the atrocities, his younger brother, Prince Mikasa, toured the Unit 731 headquarters in China and wrote in his memoirs that he was shown films showing how Chinese prisoners were "made to march on the plains of Manchuria for poison gas experiments on humans."In addition, the recollections of Dr. Ken Yuasa, 78, who still practices in a clinic in Tokyo, suggest that human experimentation may have been routine even outside Unit 731. Dr. Yuasa was an army medic in China, but he says he was never in Unit 731 and never had contact with it.Nevertheless, Dr. Yuasa says that when he was still in medical school in Japan, the students heard that ordinary doctors who went to China were allowed to vivisect patients. And sure enough, when Dr. Yuasa arrived in Shanxi Province in north-central China in 1942, he was soon asked to attend a "practice surgery."Two Chinese men were brought in, stripped naked and given general anesthetic. Then Dr. Yuasa and the others began practicing various kinds of surgery: first an appendectomy, then an amputation of an arm and finally a tracheotomy. After 90 minutes, they were finished, so they killed the patient with an injection.When Dr. Yuasa was put in charge of a clinic, he said, he periodically asked the police for a Communist to dissect, and they sent one over. The vivisection was all for practice rather than for research, and Dr. Yuasa says they were routine among Japanese doctors working in China in the war.In addition, Dr. Yuasa -- who is now deeply apologetic about what he did -- said he cultivated typhoid germs in test tubes and passed them on, as he had been instructed to do, to another army unit. Someone from that unit, which also had no connection with Unit 731, later told him that the troops would use the test tubes to infect the wells of villages in Communist-held territory. The Plans Taking the War To U.S. Homeland.In 1944, when Japan was nearing defeat, Tokyo's military planners seized on a remarkable way to hit back at the American heartland: they launched huge balloons that rode the prevailing winds to the continental United States. Although the American Government censored reports at the time, some 200 balloons landed in Western states, and bombs carried by the balloons killed a woman in Montana and six people in Oregon.Half a century later, there is evidence that it could have been far worse; some Japanese generals proposed loading the balloons with weapons of biological warfare, to create epidemics of plague or anthrax in the United States. Other army units wanted to send cattle-plague virus to wipe out the American livestock industry or grain smut to wipe out the crops.There was a fierce debate in Tokyo, and a document discovered recently suggests that at a crucial meeting in late July 1944 it was Hideki Tojo -- whom the United States later hanged for war crimes -- who rejected the proposal to use germ warfare against the United States.At the time of the meeting, Tojo had just been ousted as Prime Minister and chief of the General Staff, but he retained enough authority to veto the proposal. He knew by then that Japan was likely to lose the war, and he feared that biological assaults on the United States would invite retaliation with germ or chemical weapons being developed by America.Yet the Japanese Army was apparently willing to use biological weapons against the Allies in some circumstances. When the United States prepared to attack the Pacific island of Saipan in the late spring of 1944, a submarine was sent from Japan to carry biological weapons -- it is unclear what kind -- to the defenders.The submarine was sunk, Professor Tsuneishi says, and the Japanese troops had to rely on conventional weapons alone.As the end of the war approached in 1945, Unit 731 embarked on its wildest scheme of all. Codename Cherry Blossoms at Night, the plan was to use Kamikaze pilots to infest California with the plague.Toshimi Mizobuchi, who was an instructor for new recruits in Unit 731, said the idea was to use 20 of the 500 new troops who arrived in Harbin in July 1945. A submarine was to take a few of them to the seas off Southern California, and then they were to fly in a plane carried on board the submarine and contaminate San Diego with plague-infected fleas. The target date was to be Sept. 22, 1945.Ishio Obata, 73, who now lives in Ehime prefecture, acknowledged that he had been a chief of the Cherry Blossoms at Night attack force against San Diego, but he declined to discuss details. "It is such a terrible memory that I don't want to recall it," he said.Tadao Ishimaru, also 73, said he had learned only after returning to Japan that he had been a candidate for the strike force against San Diego. "I don't want to think about Unit 731," he said in a brief telephone interview. "Fifty years have passed since the war. Please let me remain silent."It is unclear whether Cherry Blossoms at Night ever had a chance of being carried out. Japan did indeed have at least five submarines that carried two or three planes each, their wings folded against the fuselage like a bird.But a Japanese Navy specialist said the navy would have never allowed its finest equipment to be used for an army plan like Cherry Blossoms at Night, partly because the highest priority in the summer of 1945 was to defend the main Japanese islands, not to launch attacks on the United States mainland.If the Cherry Blossoms at Night plan was ever serious, it became irrelevant as Japan prepared to surrender in early August 1945. In the last days of the war, beginning on Aug. 9, Unit 731 used dynamite to try to destroy all evidence of its germ warfare program, scholars say. The Aftermath No Punishment, Little Remorse.Partly because the Americans helped cover up the biological warfare program in exchange for its data, Gen. Shiro Ishii, the head of Unit 731, was allowed to live peacefully until his death from throat cancer in 1959. Those around him in Unit 731 saw their careers flourish in the postwar period, rising to positions that included Governor of Tokyo, president of the Japan Medical Association and head of the Japanese Olympic Committee.By conventional standards, few people were more cruel than the farmer who as a Unit 731 medic carved up a Chinese prisoner without anesthetic, and who also acknowledged that he had helped poison rivers and wells. Yet his main intention in agreeing to an interview seemed to be to explain that Unit 731 was not really so brutal after all.Asked why he had not anesthetized the prisoner before dissecting him, the farmer explained: "Vivisection should be done under normal circumstances. If we'd used anesthesia, that might have affected the body organs and blood vessels that we were examining. So we couldn't have used anesthetic."When the topic of children came up, the farmer offered another justification: "Of course there were experiments on children. But probably their fathers were spies.""There's a possibility this could happen again," the old man said, smiling genially. "Because in a war, you have to win."Rape of Nanking10 Atrocious Experiments Conducted By Unit 731 - ListverseTHATCHER BOYDThe events of World War II may show humanity at its lowest point. Clashing political ideologies and the ensuing worldwide combat produced a nearly unprecedented level of bloodshed and destruction.Although The Holocaust showed the extreme nature of the war and the horrifying extent to which a nation could be driven, Japan’s Unit 731 facilities, an Auschwitz equivalent, held their own horrors in human experimentation. These are just some of the experiments that were performed during the unit’s existence from 1936 to 1945.10. DismembermentPhoto credit: maywespeak.comLike experiments at Auschwitz and other Nazi concentration camps, Unit 731 doctors and researchers studied the potential survival of soldiers on the battlefield. But instead of using Japanese soldiers for these experiments, Unit 731 used Allied POWs as well as Chinese and Russian civilians.One such war-influenced experiment was in various dismemberments, particularly limb amputations, to study the effects of blood loss. Other forms of dismemberment were purely experimental and not combat-related. For example, some amputated limbs were reattached to other sides of the body. Other times, limbs were frozen and amputated until only the victim’s head and torso remained.Often, this was done without anesthetic for fear of negatively affecting the experiments. Test subjects were degradingly called marutas (“logs”), a reference to the phrase, “How many logs fell?”9. Nanking AtrocitiesPhoto credit: TimeUnit 731 was one of the two most infamous, large-scale war crimes committed by Japan during the Second Sino-Japanese War. The second war crime was the Nanjing Massacre.Besides the atrocities committed, the correlation between the two war crimes was that many POWs and civilians captured during the campaign were used in the Unit 731 experiments. By and large, the anti-Chinese sentiment was still in place between the two events. As soon as Japanese soldiers entered China’s capital in December 1937, the city was host to mass murder and rape.After the orders to eliminate all captives eventually arrived, no one was spared. The atrocities included beatings, drownings, decapitations, mass theft, forced incestuous rape, live burials, addictive drug distribution, and numerous unrecorded crimes.There was even a contest between two Japanese officers to see who would kill 100 people with a sword first. Unlike many of the participants in Unit 731, however, these officers were tried and executed.8. VivisectionPhoto credit: unit731.orgOne of the most common and brutal experiments performed was vivisection. This was done on live subjects without anesthesia as it was believed that the symptoms of decay after death would skew results.One purpose of these vivisections was to practice surgery. In fact, multiple different surgeries were often performed on a subject. Once the victim was of no more use, he was killed and dissected before being burned or placed in a large burial pit.Other times, vivisections were performed to see the internal effects of diseases. Vivisections were also part of crude experiments, like the removal of the stomach and the attachment of the esophagus to the intestines. Images of and testimonies about these surgeries are available online. But view them with discretion as they are extremely graphic.7. Lethal InjectionsInitially, many of Unit 731’s disease experiments were performed as preventative measures. The Japanese had found that 89 percent of battlefield deaths from the First Sino-Japanese War were from diseases. But these experiments into preventative medicines and vaccines evolved into offensive use as the war progressed.Unit 731 was split into eight divisions. The first focused on experimenting with bacteriological diseases, including the bubonic plague, cholera, anthrax, typhoid, and tuberculosis. These bacteria were injected into subjects regularly, and the resulting infections were studied. The outcomes became increasingly deadly because many people lived in communal cells.The Japanese also studied the effects of injecting humans with animal blood, air bubbles that caused embolisms, and seawater. These seawater injections were similar to the seawater ingestion experiments at Auschwitz.6. Venereal DiseasesPhoto credit: CDC/Robert SumpterChildren were not exempt from the unit’s atrocities as vertical transmission from mother to fetus was studied. This included diseases like syphilis. The researchers studied how syphilis would affect the resulting baby’s health and how it would harm the mother’s reproductive system. Although we don’t know the number of children born in captivity, it is known that none had survived when the unit dissolved in 1945.While diseases like tuberculosis and smallpox could be injected, syphilis and gonorrhea required a different method of infection. This was done using a male and a female, one of whom was infected. The couple was forced to have sexual intercourse under threat of being shot. The infected bodies were later vivisected to see the internal results.5. FrostbiteOne of the more horrifying series of experiments revolved around extreme temperatures. While extreme heat was also used on test subjects, extreme cold was used more often as it was suited to certain facility climates in Japan.After the test subjects were taken outside in the cold, water was intermittently poured on their arms until frostbite set into the affected areas. Other times, limbs were frozen and subsequently thawed to study gangrene.One might wonder how the researchers could tell that the arms were frostbitten. According to one officer’s testimony, frostbite had occurred if the “frozen arms, when struck with a short stick, emitted a sound resembling that which a board gives when struck.”However, these experiments did yield scientific findings. The unit determined that rubbing a frostbitten area was not the most effective treatment. Instead, it was better to treat frostbite by immersing the affected area in water warmer than 37.8 degrees Celsius (100 °F) but cooler than 50 degrees Celsius (122 °F). A scene depicting this experiment is featured in the 1988 filmMen Behind the Sun with some artistic license.4. Sexual assaultThe rape and sexual assault of women occurred with tragic frequency in Unit 731. Like the mass rapes and sex slavery exhibited during the Nanjing Massacre (aka “The Rape of Nanjin”), sex crimes committed by Japanese soldiers and researchers were rampant. Although these unlawful acts were committed for pleasure, they were sometimes justified by the researchers as experiments about venereal diseases.However, one guard’s account of a researcher shows the disturbing and casual nature of these crimes. According to the guard, the researcher “told me that one day he had a human experiment scheduled, but there was still time to kill. So he and another member took the keys to the cells and opened one that housed a Chinese woman. One of the unit members raped her.”3. Special Chamber ExperimentsPhoto credit: firsttoknow.comAlthough Unit 731 did plenty of testing in the field, the 6-square-kilometer (2.3 mi) facility was host to numerous buildings for specific experiments. Many of these buildings were used to raise fleas and culture pathogens, but some were specially built for testing.A centrifuge was built to examine how much force it would take to cause death. High-pressure chambers pushed victims’ eyes out of their heads. Forced abortions and sterilizations were conducted, and subjects were treated to lethal doses of X-rays.In an experiment to observe the innate bond between mother and offspring, a Russian mother and her child were monitored in a glass chamber while poisonous gas was pumped in. The mother covered her child in an attempt to save her, but both ultimately succumbed.2. Weapons TestingPhoto credit: china-underground.com, escapeartistes.comIn Unit 731, human subjects were also used in weapons testing at many facilities. The victims were typically taken to an experimental field like Anda and tied to wooden posts for testing. Then the victims had plague-spreading bombs dropped on them en masse, were used for target practice, had grenades lobbed at them, or were burned with flamethrowers.This was very similar to the Imperial Japanese Army’s protocol to use captured Chinese soldiers for bayonet practice. It’s an example of unnecessary cruelty. (baby above)Biological warfarePhoto credit: firsttoknow.comWorld War I brought technological advances in warfare, particularly biological warfare. Inspired by the success produced by these bioweapons (particularly the chlorine gas used during the Second Battle of Ypres), General Shiro Ishii experimented extensively in this area.In addition to dropping bombs filled with diseases like anthrax, cholera, typhoid, and bubonic plague on prisoners, Ishii designed a special porcelain-shelled bomb that allowed infected fleas to disperse and infect a wider area. Again, subjects were often tied to stakes and bombed. Scientists in protective suits examined the bodies afterward.Other times—such as on October 4 and 29, 1940—low-flying airplanes sprayed plague bacteria in the Chechiang province in China, killing 21 and 99 people, respectively. However, estimates for the total number of Chinese killed in this manner vary from 200,000–580,000 people.The Japanese regarded the Chinese as inferior. As a result, the Chinese were considered viable test subjects for these attacks. We can only speculate as to what the unit would have done on a larger scale with these biological weapons.Thatcher Boyd is a writer, actor, film lover, and drinker of a LOT of black coffee. You can reach him here to collaborate, communicate, or just shoot the breeze.Unit 731 General FactsUnit 731 - WikipediaUnit 731: OverviewPure Evil: Wartime Japanese Doctor Had No Regard for Human SufferingUnit 731 and the Japanese Imperial Army's Biological Warfare ProgramJapan revisits its darkest moments where American POWs became human experimentsJapanese World War II veterans recall horrors of Unit 731Published on Aug 14, 2014Former members of Unit 731, a Japanese military unit that conducted illegal human experiments during World War II, can be seen discussing the atrocities they committed in a video that was recently released. Coming just before the 69th anniversary of Japan's surrender on Aug. 15, the video has shed new light on the unit's past activities in northeast China's city of Harbin. They are telling history to a Chinese man who has been researching the unit for 16 years.South Korean Foreign Ministry spokesman Cho Tai Young on May 16, 2013, criticized Japanese Prime Minister Shinzo Abe for posing for a photo in the cockpit of a plane with the number 731 written on its body, during his visit to an Air Self-Defense Force base in Higashimatsushima, Miyagi Prefecture as the figure reminds South Koreans of Unit 731, a former Japanese military unit believed to have conducted human experiments. (Photo: AAP).

My knowledge is first hand in the US, UK and France only.I. Organization of Medical EducationThe major difference starts with degree level: American medical degrees are Graduate or 2nd degree programs; European medical degrees are Undergraduate or 1st degree programs.Europeans can enter medical school earlier than N. Americans and graduate younger by an average of 3 or 4 years. This is a function of the academic curriculum and configuration of “streaming” that takes place earlier in Europe where the intellectual demands are more focused and competitive from a younger age.European earlier “streaming” in secondary school - early specialization and 2 year pre-University programs. From age 13 in many European nations, students choose a general stream (science, mathematics, humanities). The end of compulsory secondary education occurs after 4 or 5 years. At that point, those academically inclined (perhaps 25%-35%) pursue “Upper Level” education, usually administered in the same physical school; the other 65–75% would either start work, head to a vocational school or other training or apprentice program. These “pre University” grades/forms last at least 2 years in only 3 subjects. The academic curriculum approaches University level; the brightest finish by age 18 but many repeat until their grades are sufficient to age 19 or 20. There used to be intervening compulsory military service for some European males, or, internships/apprenticeship prior to University application - but that keeps changing.The result is that entry to medical school, on the surface, can be without a formal first university degree. I entered medical school at age 18, skipping Y1 of 5 years of medical school since I had studied biology and physics. In effect, I graduated at age 23 but with the UK medical degree of MBChB for “Bachelor of Medicine/Surgery” or MBBS in other Commonwealth systems. Yet, in terms of medical school training, it was equivalent to that of American students who first had to do a 4 year Bachelor’s program. In other words, medical graduates can be as young as 23 in Europe but often at least 26 in the US. After that, the specialization clinical programs are a function of available “posts” in public systems like in the UK; that means that very experienced European specialists may be at a rank below what their skill merits if the posts above are not vacated.However, specialist training in the US is often faster. At the end of the day, the average age of a fully accredited “specialist” would be similar on both sides of the Atlantic but with vastly different financial and work/life situations. The earlier entry into medical school in Europe is balanced with a longer trajectory to becoming a fully-fledged “specialist”. European Post graduate specialization is usually much longer than in N. America, sometimes double the time needed.European medical schools and health care systems are subsidized, with the implication that there may be a limited number of “posts” or slots for senior positions, so a UK doctor may take 8 years to move from House Physician/Surgeon to Consultant Surgeon, whereasan American doctor may do so in 4 to 6 years to be an “Attending Physician/Surgeon” or Board Certified Specialist.II. Financial Aspects and Configuration of Medical ProvisionFinancial Circumstances Dominates US Medical EducationPublic EU medical schools may be virtually “free” (a few thousand euros per year) to as much as GBP 20–40k in Britain for non-EU (soon non-UK) students.While the American doctor is paid perhaps 3–5 times more than a British doctor (gross), he/she starts out with perhaps $500k or more of debt (Bachelor 4 years, plus MD 4 years); in the private sector, he/she would also have much higher administration costs, malpractice insurance and also have 4 weeks fewer vacation than most European doctors.Administrative complexity and lack of coherent, consistent payor systems dominate US health care provision.Lack of Streamlined Payor systems inflate medical costs with the jumble of hundreds of private insurance payor systems in the US. In terms of an IT metaphor, EU health system can be as tied-down as Apple’s closed “universe” whereas there is more of an umbrella of overlapping US systems akin to Linux, Unix and other operating systems coexisting.Depending upon the EU nation, there may be a single or streamlined payor system; so, a solo practice would still be feasible if not highly lucrative.A US PCP (family doctor) would find it almost impossible to be in a solo practice as the hundreds of reference and claims processing variants from medical insurance would easily overwhelm a sole practitioner; so most PCPs are in group practices or employees of “Health Provider” companies. Apart from Medicare (a public health insurance policy at a Federal level), a typical medical clinic has more administrative staff than healthcare staff to deal with the hundreds of every changing variants of individual policies from dozens of insurance firms.Some US doctors have been so frustrated by the non-medical interference and tardiness of having every medical procedure and prescription influenced by private medical insurers that they refuse all insurance - save for Medicare (out of altruism). They either charge a cash fee or form cooperative groups that propose their own “plans”.III. The Pathway to becoming a fully independent specialist.The Admissions criteria vary from “grades only”, a mix of grades and CV and stratified systems (one part grades only, one part a mix and one part other criterion).France is unique in that anyone with an advanced high school diploma can enter 1st year, but, by design, only 10% of top grading get into the Y2 (numerus clausus by competition).Germany has stratified admissions, 20% based exclusive on grades, 60% on a mix of grades & CV and 20% influence by seniority.US schools vary by State and sector (public or State versus private). However, in the most selective programs (Harvard, Stanford, Yale, Dartmouth, Penn etc.), fewer than 5% of applicants gain entry, so academic scores may be all that differentiate candidates who all have a decent candidacy.In the UK, it used to be mainly purely on academic scores from the “Advanced Level General Certificate of Education” exams administered by London or Cambridge Universities (GCE “A”-Levels) in only three subjects for 2 years following obligatory education (GCE “O”-Levels).For over a decade, the number of medical training slots in the UK has been below a replacement rate, with vacancies filled by a combination of EU doctors and immigrants from Commonwealth nations (the Indian subcontinent, S. Africa mainly). In 2019, 1 in 8 healthcare professionals in the UK were foreign born and trained.With the closing off, unless GB negotiates otherwise, of access to the medical manpower from the EU, Britain would either have to expand a) medical schools or b) access to medical immigration; probably a mixture of the two. Maybe the expected influx of some 1 million Hong Kong people would include doctors to replace EU trained doctors who choose to leave the UK after 2020Curricula in the US tend to be 4 years, followed by clinical training in hospital (“residency”) or in the field (for PCPs). In the EU, the curricula tends to be 5 years, sometimes reduced to 4. The net result is that the age of first medical degree can be as young as 23 in the EU compared to 26 in the US; however, the actual ages tend to be older in the EU than 23 since many students either undergo voluntary preparatory education of 1–2 years, or have to make several attempts, or, male students have 1 year of compulsory military service.Assessment and Attrition during Medical Training. Assessments are a mix of group work, examinations, interviews and clinical evaluation. In general, once one gains admission into medical school, the students advance in a cohort with the vast majority graduating; only in France is there a tweak in that only 10% of those who enter 1st year get into 2nd year (the rest being also a cohort). As such, while grades were key to admission, they are not after admission. In my case, out of some 150 medical students, only two failed to graduate; one committed suicide in his last year and another suffered from endogenous depression.Academic or grades tend to be tougher in the EU simply as there are proportionately far more applicants than school training slots. In general, only the top 10% of academic or entry examination performers get accepted; even fewer for the top schools. There is the French exception, on paper, since there is no minimum grade requirement for 1st year medical school, BUT continuation to Y2 is subject to numerus clausus in that only the top 10% get into Y2; in effect, the French simply funnel students in but make the academic cut after 1 year - It’s extremely stressful. If you happen to be in a year with particularly bright performers, your passing “grade” would be higher than in a year with a less bright cohort!Traditional Grade 85/100 (left) versus Numerus Clausus to select only top 15%.IV. American Considerations in Attending EU Medical SchoolsEnglish language programs are also sometimes offered in Pre-Clinical education (theoretical) in several non-Anglophone nations (CZ, BG, HU, IT, LT) countries, but fluency of local language is expected at the time of clinical training.Outside of GB, IRL and Malta, instruction in English is a “niche” private sector offering - not a mainstream one. Although everyone learns to read, and perhaps write, English, that still means that verbal communication with patients and other personnel would NOT be in English outside of places where there is greater English literacy than in the US or UK! (NL, principally). Unlike the US, Europeans go to a private medical school when one’s grades are insufficient to get into the tougher public or State schools i.e. Those who pay tend be the less academically-performing candidates - almost the opposite to the US phenomenon where the private for-fee medical schools occupy the top ranks of medical research, clinical specialization, and reputation.Hungary offers an English-language medical program (although, it would be difficult to do clinical training in Hungary in English).Italy has a private school offering theoretical (pre-clinical) training in English; however, clinical training would be very difficult if one is not fluent in Italian.This is the case, outside Europe, with UAG (Guadalajara, Mexico) where preclinical instruction is given in English but clinical training would be with Hispanophone patients and staff.Private and public (at State level) medical schools in the US coexist; the key difference is that private schools tend to be more expensive. In the EU, most medical schools are public (national) but a few private universities exist, catering to foreign students in English, sometimes with clinical training arranged with hospitals in another language/country.In the US, the top tier tends to be dominated by private schools, although some State schools are also in the top 10–20.In Europe, there are no private schools, that usually are for foreign students, that are long-established or centers of excellence.Tuition and CostsUS tuition is generally much more costly than in the EU, especially with less financial aid available, and higher living costs.Financial aid, scholarships and loans are more available to American residents than to international students.US schools charge the same tuition regardless of the nationality of the studentState universities offer lower fees for in-State residents, the range of tuition is from $10–40k per year.Private schools, the range is from $35k-93k, with a median of $58kIn the US, some of the most prestigious private schools have large endowments that often mean that anyone who is admitted can have tuition subsidized by the school relative to their ability to pay.The cost of living must also be factored into account as it can vary from $15k-45k per year depending upon location and lifestyle.EU tuition varies from country to country but overall costs are usually much lower than in the US.Public schools are highly subsidized with some in Germany charging under €1k per annum. However, the average seems to be around €9000 per annum for nationals or EU citizens; depending upon the school:International students are charged much higher tuition; with the most expensive in the UK rising to around £35–45k per annum. This is also similar to the few private schools catering to international students. However, due to the insufficiency of numbers medical training posts, that means that the NHS has relied upon foreign MDs, principally from the EU (until January 2021’s Brexit), and from Commonwealth nations like S.Africa, or the Indic nations.Overall costs can be lower than in the US since urban transport is usually denser and subsidized: However, locations like Paris, London, Dublin, Geneva, Zurich and Scandinavia tend to have much higher accommodation costs - similar to Boston, NYC or SFO.V. Beyond Medical School - Differences in Medical Demographics, Admissions Criteria.Economic FrameworkIn Europe, most medical schools are state-funded, public institutions that are highly-subsidized. Medical graduates’ debt would largely be for living costs incurred.In the US, the most prestigious schools are private and have sky-high tuition ($35–93k per year in private schools; $10–40k in State or public schools). In addition, unless one is in a dense urban setting or content to live on campus, additional living costs may include a car (at least $7k per annum in the US).The American graduate may often end up with student debt accumulated for the 8 or 9 years of Bachelor and medical degrees. A Federal loan program is often available but it can mean $300k-$1 million of nearly a decade of no income apart from any part time job. This motivates American graduates to gravitate to the most lucrative specialties, rather than to the most needed ones, and, also, to the most remunerative regions and employers. The expansion of Obamacare to an additional 21 million Americans has placed enormous strains on the inadequate population of Primary Care Physicians (= GPs or FPs) who act as gatekeepers to specialist care.Instead of exploiting the education and experience of immigrant doctors into the US, the AMA and most State Medical Boards have pursued a professional protectionist accreditation system. Especially non-Anglophones would basically have to spend a year or more studying English and medical school coursework that they had not studied for a decade; THEN, Board accreditation would mean a chase for the “leftover” residency slots, often in “rural” and less popular regions.When you have a 40 year old ophthalmologist immigrant in the US, the prospect of two years to pass medical exams and then face the challenge of finding a suitable residency - most of which would be in Family Medicine or Internal Medicine, it means that experienced specialists and surgeons are effectively kept out of competing with US-trained doctors.However, in a bizarre turn of events, the severe shortage of PCPs has led to the creation of ersatz PCPs in the form of “Physician Assistants” (2 year program - no obligatory clinical training; supposedly always under an MD - but often abused) and “Nurse Practitioners” (nurses who pursue a 4 year Masters program) who have more independence than PAs in that they can work independently as PCPs and prescribe all except neuroleptics. So, the person in white coat at the clinic may have 2 to 4 years less medical training than the most junior of freshly minted immigrant doctor!Would you prefer to see a foreign oncologist with 15 years experience, or a “Physician’s Assistant” fresh out of 2 years’ education, or even an “Advanced Nurse Practioner” who has 4 years of training? If language is a problem, take an interpreter. Especially now, with the pandemic, it is such a waste to have perhaps thousands of experienced foreign MDs stuck doing some other work, and instead have pseudo family “doctors” with far less education and clinical exposure. Maybe the FMG should be better educated in spoken English than being obliged to basically re-do final year medical school, and then hospital training.Foreign Medical Education for Americans. Even Americans who attend foreign medical schools are disadvantaged if they try to subsequently integrate into the US medical training systems. Even if they handily pass the USMLE etc., some 50% of them are never “matched” with a residency of their choice and location, and they pursue some other profession. Their only advantage over foreign-born FMGs is that they don’t need a visa to work and stay.Medical Schools in large Anglophone nations. The UK, Ireland, Australia, NZ, India and South Africa. While tuition and language are most attractive, can you believe that academic competition is much higher than for the average US medical school? If you can’t get into Harvard or Columbia or Penn, it is highly unlikely that you would have the academic profile to get into UCL, Cambridge, Edinburgh, Sydney, New Delhi or Cape Town medical schools. Those schools are public and often there are insufficient number of training posts (particularly in Britain that may see 12% of its medical workforce leave after Brexit to return to the EU). On the other hand, although you would be in the same category as all other FMGs when it comes to residency, the pedigree of the UCL, Cambridge, Oxford, Imperial College London, Edinburgh, Melbourne, Sydney, Tropical SoM London may well give you a calling card in the US - particularly if you first arrange a “medical elective” in the city and hospital group of your choice between 3rd-4th or 4th/5th years. I did my medical elective in UCSF Moffitt Hospital and, had I wished to get residency, it was easy to sit and pass the ECFMG and USMLE when I was still in Medical School in the UK; there was also no language barrier with patients (especially as I could converse in Spanish for Hispanophone patients).Anglophone Island Schools- Limited Clinical Program. Americans who choose an “off shore” medical education are viewed as “less academically performing” since they were not accepted into US schools. In some ways, the handicap is not “intelligence” but lack of challenging medical cases. The medical school in the tiny Caribbean islands (Grenada, Sint Marteen, Saba) just don’t have much tertiary medical infrastructure or patients.Non-Anglophone Big city Schools with English Programs - Make sure US Pathway to Residencies after Y4. Any international public school would have competition as intense as top private universities in the US. However, the great advantage would be low cost if you can choose say between Harvard and Karolinska Institute or Heidelberg. Only private medical schools with a reserved quota for international students would be readily accessible. Americans may also attend a medical program in a larger, urban setting with decent tertiary medical infrastructure in English, but they cannot really get adequate clinical training unless they fluently speak the language of locals past 4th year (when clinical training begins). These are not top ranked schools but you don’t have to be “genius level” to make a good GP, PCP. one should have great diligence and a good heart for the well-being of others.The best-known programs include that at the UAG (Guadalajara, Mexico), the 2nd largest Mexican city.In W. Europe, there are two Italian medical schools with formal teaching in English, the excellent (but very competitive and limited to GP training) La Sapienza University (Rome) better known for Art, Archaeology and History; I understand that the University of Navarra (Spain) also has a medical program mostly in English.A slew of Eastern European schools also offer medical pre-clinical training in English. Budapest’s Semmelweis is an old school that offers an English program. However, check if they have any streamlined pathway to USMLE and US residency arrangements if your intention is to work in the US.In Asia, Khalifa Univeristy in Abu Dhabi is private school founded recently but not particularly affordable. In addition, a few dozen Chinese medical schools have opened their doors to non-Chinese students including the oldest Western Medicine school in China, Sun-Yat-Sen in Guangzhou province. Tuition in the PRC would be much more reasonable (some $6k-$10k per year). Again, make sure that you either have a ready pathway to US Residencies or are already fluent in local language and content in remaining.Supply and Demand of MDs. Shortage of GPs in the US, of specialists in the EU.In the US, there is a high desire to specialize, partly as medical graduates have accumulated some 8 years of tuition and living cost debt, that can easily reach $500k. Extreme shortage of PCP/GPs in USA, ever since Obamacare added nearly 20 million more Americans as “Patients”In the EU, there are proportionately fewer slots for specialist training, and even fewer in the public health systems as head specialist, leading to long periods in a junior position. As a result, there are shortages of specialists, notably in ophthalmology and some types of surgery.MD Protectionism - Immigrationin the US. Instead of facilitating the process of foreign medical immigration to the US to meet the enormous shortage of GP/FP/PCPs that medical regulators have taken the short-sighted corner-cutting policy of allowing “Nurse Practitioners” (nurses with a Masters of 4 years) who can act as GPs, including prescribing, and “Physician Assistants” (with only 2 years training but who must work under the supervision of an MD) attempting to fill those roles. It’s misguided. It’s counter-productive since the FMG would be able to fill the extreme shortage of “gatekeeper” PCPs in the US, whereas American MDs are more likely to be in specialist programs.in the EU, there is mutual acceptance of EU degrees but each country may have specific requirement for Board registration; in reality, EU-trained doctors can work anywhere in the EU. After Brexit, Britain’s medical staff shortages will jump, as EU doctors would no longer be free to work in the UK, and vice versa masked its chronic under-funding of medical education since about 12–18% of NHS doctors are foreign-trained, most of whom are EU citizens. However, it may also have caused shortages in parts of Europe with a brain drain from East to West. While northern Europeans tend to speak excellent English, Europeans from other countries may have to either choose non-clinical careers or go to the effort of gaining fluency in English.Discriminatory Admissions Criteria at some Private US schools EU schools place most emphasis on academic grades with a few exceptions. They have strict EU non-discriminatory admissions criteria. However, the lack of national guidelines on admission criteria, especially in private schools has a highly variable influence on non-academic factors.“Affirmative Action” Formalized Pro-Black Discrimination Social engineering “reverse” discrimination of Blacks to encourage “minorities” (=Blacks in US parlance; the term usually does not refer to numerical minorities like Asians, gays, deaf etc.) also plays a variable role in the US where there are even “traditionally Black” universities (Itself a most inegalitarian/racist concept); I had a French friend who did his post-doc at Howard, completely unaware of its predominantly “Black” reputation - He and a Pole were the only two White faces in their section (but both had a great experience, once the others realized they were foreign!)Influence, Money and Fame. US private medical schools are NOT egalitarian and can be unabashedly “discriminatory” in a positive or negative sense. A wealthy donor parent or a prominent personality explain why some Bushes and Trumps gain access to school where they are surrounded by far more academically accomplished students. The fact that DT was able to attend (although he was mostly absent) Penn for an economics Undergrad (i.e. probably NOT Wharton, NOT an MBA, although the faculty may have overlapped), has tarnished Penn’s reputation somewhat.Unofficial “Anti-Asian Discrimination” Some schools have an unspoken bias against Asians (ironically, a numerical “minority” in the US) against a backdrop of a much higher proportion of students of Asian origin than in the general State population.On closer examination, it may be that recent immigrant “Asians” perform better than average as they are often offspring from the most skilled immigrants . This has come about as a result of recent changes in immigration policies from accepting almost anyone from Europe from the late 19th to mid 20th Century (no money, no education, not English speaking) to screen for wealthier, more educated profile of immigrants. So, barring family-sponsored, undocumented and refugee immigrants, latter 20th Century immigrants to the US had to be of higher socio-economic profile that the average American.Since the majority of the world’s population is “Asian”, most qualified immigrants are Asian (Indian, West, Central, Southeast and East Asian) immigrants simply as a result of statistics, 27% of humans are of Indian subcontinental origin and 22% are of East Asian origin, if one adds South-east and Central Asians, the total approaches 60% of humanity.This is supported by examining the immigrant background of prominent “minority” Americans.Leading “Black” politicians are offspring of one or more Black immigrant parents who arrived educated: Barak Obama (Kenyan father was PhD), Senator Kamala Harris (Jamaican father was Economics Professor at Stanford, Indian mother was PhD cancer researcher!), Dr. Wayne Frederick, President of Howard University (a real-life Doogie Howser MD, immigrated from Trinidad to enter a joint BS/MD program at age 16 at Howard, completing it by age 22 as MD!).Past Governor Nikki Haley (née Nimrata Randhawa) was born to Indian (Punjabi) immigrants, her father being a PhD Professor in South Carolina. I just wish she would stop with the whitening skin treatments and electronic lighteners.Then, a highly disproportionate number of prominent Hispanics are offspring of Cuban immigrants (Senator Marco Rubio, Senator Robert Menendez, Senator Ted Cruz, Andy Garcia, Gloria Esteban, Eva Mendes, Cameron Diaz); yet, Cuba is a nation of just over 10 million! Cuban Americans are around 500k versus a total of some 55 million Hispanic Americans, mostly of Meso-american origin and based mostly in the southwestern USA. However, unlike most refugee immigrants, it was the better educated, better-to-do Cubans who dominated the immigrant wave from Cuba to the USA as of 1960.

The answer requires quite a bit of education, information and foresight as every other 1st world country has had a proven Universal health care system for decades that is lower cost with better outcomes than the USA health care system.US Spends More on Health Care Than Other High-Income Nations But Has Lower Life Expectancy, Worse HealthPeople such as myself fight for the ACA because it is the only form of Universal health care available to USA citizens under age 65. All citizens including yourself are winners because of this as the Biggest Cause of Personal Bankruptcies? Medical Bills.You are a winner under this system in the long run because when the tax-exempt health sharing program kicks you out or when the tax-exempt health sharing program you are in becomes bankrupt you will have access to Universal health care.Your tax-exempt health sharing program is not large enough to be financially stable and is likely not available to all citizens especially those with pre existing conditions. we need to take care of all citizens.Universal health care is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship.[3]We need all healthcare model that covers all citizens not just the ones that happen to be fortunate and well off.The ACA (Patient Protection and Affordable Care Act - Wikipedia) is not the optimal solution as the best solution is likely a Single-payer healthcare which is a proven economic model practiced in many 1st world countries. It is probably the best proven method of providing economically efficient Universal health care.Here are the wikipages describing how Universal health care - Wikipedia works in all countries around the world. The ACA is a decent start although it is time to improve it not throw it out going back to the 3rd world stone ages.Even Trump may now realize this inescapable fact as Here’s why Trump is already waffling on Obamacare.Universal health care - WikipediaUniversal health care, sometimes referred to as universal health coverage, universal coverage, or universal care, usually refers to a health care system which provides health care and financial protection to all citizens of a particular country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes.[2]Universal health care is not one-size-fits-all and does not imply coverage for all people for everything. Universal health care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered.[2]It is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship.[3]The health policy framework is of central importance. Thus, in the development of universal health systems, it is appropriate to recognize "healthy public policy" (Health in All Policies) as the overarching policy framework, with public health, primary health care, and community services as the cross-cutting framework for all health and health-related services operating across the spectrum from primary prevention to long term care and end-stage conditions. Although that perspective is both logical and well grounded in the social ecological model, the reality is different in most settings, and there is room for improvement everywhere.[4]History[edit]The first move towards a national health insurance system was launched in Germany in 1883, with the Sickness Insurance Law. Industrial employers were mandated to provide injury and illness insurance for their low-wage workers, and the system was funded and administered by employees and employers through "sick funds", which were drawn from deductions in workers' wages and from employers' contributions. Other countries soon began to follow suit. In the United Kingdom, the National Insurance Act 1911 provided coverage for primary care (but not specialist or hospital care) for wage earners, covering about one third of the population. The Russian Empire established a similar system in 1912, and other industrialized countries began following suit. By the 1930s, similar systems existed in virtually all of Western and Central Europe. Japan introduced an employee health insurance law in 1927, expanding further upon it in 1935 and 1940. Following the Russian Revolution of 1917, the Soviet Union came close to a universal health care system. It established a fully public and centralized health care system in 1920.[5][6]However, it was not a truly universal system at that point, as rural residents were not http://covered.In New Zealand, a universal health care system was created in a series of steps, from 1939 to 1941.[7][8]In Australia, the state of Queensland introduced a free public hospital system in the 1940s.Following World War II, universal health care systems began to be set up around the world. On July 5, 1948, the United Kingdom launched its universal National Health Service. Universal health care was next introduced in the Nordic countries of Sweden (1955),[9]Iceland (1956),[10] Norway (1956),[11] Denmark (1961),[12] and Finland (1964).[13]Universal health insurance was then introduced in Japan (1961), and in Canada through stages, starting with the province of Saskatchewan in 1962, followed by the rest of Canada from 1968 to 1972.[7][14]The Soviet Union extended universal health care to its rural residents in 1969.[7][15]Italy introduced its Servizio Sanitario Nazionale (National Health Service) in 1978. Universal health insurance was implemented in Australia beginning with the Medibank system in 1975, which led to universal coverage under the Medicare system, established in 1984.From the 1970s to the 2000s, Southern and Western European countries began introducing universal coverage, most of them building upon previous health insurance programs to cover the whole population. For example, France built upon its 1928 national health insurance system, with subsequent legislation covering a larger and larger percentage of the population, until the remaining 1% of the population that was uninsured received coverage in 2000.[16][17]In addition, universal health coverage was introduced in some Asian countries, including South Korea (1989), Taiwan (1995), Israel (1995), and Thailand (2001).Following the collapse of the Soviet Union, Russia retained and reformed its universal health care system,[18] as did other former Soviet nations and Eastern bloc countries.Beyond the 1990s, many countries in Latin America, the Caribbean, Africa, and the Asia-Pacific region, including developing countries, took steps to bring their populations under universal health coverage, including China which has the largest universal health care system in the world.[19]A 2012 study examined progress being made by these countries, focusing on nine in particular: Ghana, Rwanda, Nigeria, Mali, Kenya, India, Indonesia, the Philippines, and Vietnam.[20][21]Funding models[edit]Universal health care in most countries has been achieved by a mixed model of funding. General taxation revenue is the primary source of funding, but in many countries it is supplemented by specific levies (which may be charged to the individual and/or an employer) or with the option of private payments (by direct or optional insurance) for services beyond those covered by the public system.Almost all European systems are financed through a mix of public and private contributions.[22]Most universal health care systems are funded primarily by tax revenue (like in Portugal[22] Spain, Denmark, and Sweden). Some nations, such as Germany and France[23] and Japan[24] employ a multipayer system in which health care is funded by private and public contributions. However, much of the non-government funding is by contributions by employers and employees to regulated non-profit sickness funds. Contributions are compulsory and defined according to law.A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency.Universal health care systems are modestly redistributive. The progressivity of health care financing has limited implications for overall income inequality.[25]Compulsory insurance[edit]This is usually enforced via legislation requiring residents to purchase insurance, but sometimes the government provides the insurance. Sometimes, there may be a choice of multiple public and private funds providing a standard service (as in Germany) or sometimes just a single public fund (as in Canada). Healthcare in Switzerland and the US Patient Protection and Affordable Care Act are based on compulsory insurance.[26][27]In some European countries in which private insurance and universal health care coexist, such as Germany, Belgium, and the Netherlands, the problem of adverse selection is overcome by using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus, a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price, and there is no advantage to eliminate people with higher risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but they compete mainly on price and service. In some countries, the basic coverage level is set by the government and cannot be modified.[28]The Republic of Ireland at one time had a "community rating" system by VHI, effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. That resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market, which then made higher profits at VHI's expense. The government later reintroduced community rating by a pooling arrangement and at least one main major insurance company, BUPA, then withdrew from the Irish market.Among the potential solutions posited by economists are single-payer systems as well as other methods of ensuring that health insurance is universal, such as by requiring all citizens to purchase insurance or limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.[29][30]Single payer[edit]Single-payer health care is a system in which the government, rather than private insurers, pays for all health care costs.[31]Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or own and employ healthcare resources and personnel (as was the case in England before of the Health and Social Care Act). "Single-payer" thus describes only the funding mechanism and refers to health care financed by a single public body from a single fund and does not specify the type of delivery or for whom doctors work. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.Tax-based financing[edit]In tax-based financing, individuals contribute to the provision of health services through various taxes. These are typically pooled across the whole population, unless local governments raise and retain tax revenues. Some countries (notably the United Kingdom, Canada, Ireland, Australia, New Zealand, Italy, Spain, Portugal, Greece and the Nordic countries) choose to fund health care directly from taxation alone. Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation, either by directly paying their medical bills or by paying for insurance premiums for those affected.Social health insurance[edit]In social health insurance, contributions from workers, the self-employed, enterprises and government are pooled into a single or multiple funds on a compulsory basis. The funds typically contract with a mix of public and private providers for the provision of a specified benefit package. Preventive and public health care may be provided by these funds or responsibility kept solely by the Ministry of Health. Within social health insurance, a number of functions may be executed by parastatal or non-governmental sickness funds or in a few cases by private health insurance companies.Private insurance[edit]In private health insurance, premiums are paid directly from employers, associations, individuals and families to insurance companies, which pool risks across their membership base. Private insurance includes policies sold by commercial for profit firms, non-profit companies, and community health insurers. Generally, private insurance is voluntary in contrast to social insurance programs, which tend to be compulsory.[32]In some countries with universal coverage, private insurance often excludes many health conditions that are expensive and the state health care system can provide. For example, in the United Kingdom, one of the largest private health care providers is BUPA, which has a long list of general exclusions even in its highest coverage policy,[33] most of which are routinely provided by the National Health Service. In the United States, dialysis treatment for end stage renal failure is generally paid for by government, not by the insurance industry. Those with privatized Medicare (Medicare Advantage) are the exception and must get their dialysis paid through their insurance company, but those with end stage renal failure generally cannot buy Medicare Advantage plans.[34]The Planning Commission of India has also suggested that the country should embrace insurance to achieve universal health coverage.[35] General tax revenue is currently used to meet the essential health requirements of all people.Community-based health insurance[edit]A particular form of private health insurance that has often emerged if financial risk protection mechanisms have only a limited impact is community-based health insurance. Individual members of a specific community pay to a collective health fund, which they can draw from when they need of medical care. Contributions are not risk-related, and there is generally a high level of community involvement in the running of these plans.Implementation and comparisons[edit]Main article: Universal health coverage by countrySee also: Health care system and Health systems by countryHealth spending per capita, in US$ purchasing power parity-adjusted, among various OECD countriesUniversal health care systems vary according to the degree of government involvement in providing care and/or health insurance. In some countries, such as the UK, Spain, Italy, Australia and the Nordic countries, the government has a high degree of involvement in the commissioning or delivery of health care services and access is based on residence rights, not on the purchase of insurance. Others have a much more pluralistic delivery system, based on obligatory health with contributory insurance rates related to salaries or income and usually funded by employers and beneficiaries jointly.Sometimes, the health funds are derived from a mixture of insurance premiums, salary related mandatory contributions by employees and/or employers to regulated sickness funds, and by government taxes. These insurance based systems tend to reimburse private or public medical providers, often at heavily regulated rates, through mutual or publicly owned medical insurers. A few countries, such as the Netherlands and Switzerland, operate via privately owned but heavily regulated private insurers, which are not allowed to make a profit from the mandatory element of insurance but can profit by selling supplemental insurance.Universal health care is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards. Most implement universal health care through legislation, regulation and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis. Usually, some costs are borne by the patient at the time of consumption, but the bulk of costs come from a combination of compulsory insurance and tax revenues. Some programs are paid for entirely out of tax revenues. In others, tax revenues are used either to fund insurance for the very poor or for those needing long-term chronic care.The United Kingdom National Audit Office in 2003 published an international comparison of ten different health care systems in ten developed countries, nine universal systems against one non-universal system (the United States), and their relative costs and key health outcomes.[36]A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004.[37]In some cases, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care.Single-payer healthcareSingle-payer healthcare is a system in which the state, rather than private insurers, pays for all healthcare costs.[1]Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or may own and employ healthcare resources and personnel (as is the case in the United Kingdom).The term "single-payer" thus describes the funding mechanism, referring to healthcare financed by a single public body from a single fund, not the type of delivery or for whom physicians work. The British system is technically not single payer, as it consists of a number of financially and legally autonomous trusts.The actual funding of a "single payer" system comes from all or a portion of the covered population. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.Description[edit]Single-payer health insurance collects all medical fees and then pays for all services, by a single government (or government-related) source.[2]In wealthy nations, that kind of publicly managed insurance is typically extended to all citizens and legal residents. Examples include the United Kingdom's National Health Service, Australia's Medicare, Canada's Medicare, and Taiwan's National Health Insurance.The standard usage of the term "single-payer healthcare" refers to health insurance, as opposed to healthcare delivery, operating as a public service and offered to citizens and legal residents towards providing nearly universal or universal healthcare. The fund can be managed by the government directly or as a publicly owned and regulated agency.[2]Some writers describe publicly administered systems as "single-payer plans". Some writers have described any system of healthcare which intends to cover the entire population, such as voucher plans, as "single-payer plans",[3] but that is uncommon.Countries and regions[edit]Many nations worldwide have single-payer health insurance programs. These programs generally provide some form of universal healthcare, which are implemented in a variety of ways. In some cases doctors are employed, and hospitals run by, the government such as in the United Kingdom[4] or Spain.[5]Alternatively the government may purchase healthcare services from outside organizations, such as the approach taken in Canada.Australia[edit]Healthcare in Australia is provided by both private and government institutions. Medicare is the publicly funded universal health care venture in Australia. It was instituted in 1984 and coexists with a private health system. Medicare is funded partly by a 2% income taxlevy[6](with exceptions for low-income earners), but mostly out of general revenue. An additional levy of 1% is imposed on high-income earners without private health insurance. As well as Medicare, there is a separate Pharmaceutical Benefits Scheme that considerably subsidises a range of prescription medications. The Minister for Health, currently Sussan Ley, administers national health policy, elements of which (such as the operation of hospitals) are overseen by individual states.Canada[edit]See also: Canadian and American health care systems compared and Medicare (Canada)Healthcare in Canada is delivered through a publicly funded healthcare system, which is mostly free at the point of use and has most services provided by private entities.[7]It is guided by the provisions of the Canada Health Act of 1984.[8]The government assures the quality of care through federal standards. The government does not participate in day-to-day care or collect any information about an individual's health, which remains confidential between a person and his or her physician. Canada's provincially based Medicare systems are cost-effective partly because of their administrative simplicity. In each province each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses healthcare to be involved in billing and reclaim. Private insurance represents a minimal part of the overall system.Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes, except in British Columbia, the only province to impose a fixed monthly premium which is waived or reduced for those on low incomes.[9]There are no deductibles on basic health care and co-pays are extremely low or non-existent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). A health card is issued by the Provincial Ministry of Health to each individual who enrolls for the program and everyone receives the same level of care.[10]There is no need for a variety of plans because virtually all essential basic care is covered, including maternity and infertility problems. Depending on the province, dental and vision care may not be covered but are often insured by employers through private companies. In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered. These can be paid out-of-pocket or through private insurers. Health coverage is not affected by loss or change of jobs, as long as premiums are up to date, and there are no lifetime limits or exclusions for pre-existing conditions.Pharmaceutical medications are covered by public funds for the elderly or indigent,[11]or through employment-based private insurance. Drug prices are negotiated with suppliers by the federal government to control costs. Family physicians (often known as general practitioners or GPs in Canada) are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Canadians do wait for some treatments and diagnostic services. Survey data shows that the median wait time to see a special physician is a little over four weeks with 89.5% waiting less than three months. The median wait time for diagnostic services such as MRI and CAT scans[12] is two weeks, with 86.4% waiting less than three months.[13]The median wait time for surgery is four weeks, with 82.2% waiting less than three months.[14]Spain[edit]Building upon less structured foundations, in 1963 the existence of a single-payer healthcare system in Spain was established by the Spanish government.[15]The system was sustained by contributions from workers, and covered them and their dependents.[16]The universality of the system was established later in 1986. At the same time, management of public healthcare was delegated to the different autonomous communities in the country.[17]While previously this was not the case, in 1997 it was established that public authorities can delegate management of publicly funded healthcare to private companies.[18]Additionally, in parallel to the single-payer healthcare system there are private insurers, which provide coverage for some private doctors and hospitals. Employers will sometimes offer private health insurance as a benefit,[19] with 14.8% of the Spanish population being covered under private health insurance in 2013.[20]In 2000, the Spanish healthcare system was rated by the World Health Organization as the 7th best in the world.Taiwan[edit]Healthcare in Taiwan is administrated by the Department of Health of the Executive Yuan. As with other developed economies, Taiwanese people are well-nourished but face such health problems as chronic obesity and heart disease.[21]In 2002 Taiwan had nearly 1.6 physicians and 5.9 hospital beds per 1,000 population.[21]In 2002, there were a total of 36 hospitals and 2,601 clinics in the country. Per capita health expenditures totaled US$752 in 2000.[21]Health expenditures constituted 5.8 percent of the gross domestic product (GDP) in 2001 (or $951 US in 2009[22]); 64.9 percent of the expenditures were from public funds.[21]Overall life expectancy in 2009 was 78 years.[23]The current healthcare system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health-care funds. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[24]NHI is mainly financed through premiums, which are based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers. Most health providers operate in the private sector and form a competitive market on the health delivery side. However, many healthcare providers took advantage of the system by offering unnecessary services to a larger number of patients and then billing the government. In the face of increasing loss and the need for cost containment, NHI changed the payment system from fee-for-service to a global budget, a kind of prospective payment system, in 2002.United Kingdom[edit]Healthcare in the United Kingdom is a devolved matter, meaning England, Northern Ireland, Scotland and Wales each have their own systems of private and publicly funded healthcare, generally referred to as the National Health Service (NHS). Each country having different policies and priorities has resulted in a variety of differences existing between the systems.[25][26]That said, each country provides public healthcare to all UK permanent residents that is free at the point of use, being paid for from general taxation. In addition, each also has a private sector which is considerably smaller than its public equivalent, with provision of private healthcare acquired by means of private health insurance, funded as part of an employer funded healthcare scheme or paid directly by the customer, though provision can be restricted for those with conditions such as AIDS/HIV.[27]The individual systems are:England: National Health ServiceNorthern Ireland: Health and Social Care in Northern Ireland (HSCNI)Scotland: NHS ScotlandWales: NHS WalesIn England, funding from general taxation is channeled through NHS England, which is responsible for commissioning mainly specialist services and primary care, and Clinical Commissioning Groups (CCGs), which hold 60% of the budget and are responsible for commissioning health services for their local populations.[28]These commissioning bodies do not provide services themselves directly, but procure these from NHS Trusts and Foundation Trusts, as well as private, voluntary and social enterprise sector providers.[29]United States[edit]A number of proposals have been made for a universal single-payer healthcare system in the United States, most recently the United States National Health Care Act, (popularly known as H.R. 676 or "Medicare for All") but none has achieved more than 20% congressional co-sponsorship.Advocates argue that preventive healthcare expenditures can save several hundreds of billions of dollars per year because publicly funded universal healthcare would benefit employers and consumers, that employers would benefit from a bigger pool of potential customers and that employers would likely pay less, would be spared administrative costs, and inequities between employers would be reduced. Advocates also argue that single payer could benefit from a more fluid economy with increasing economic growth, aggregate demand, corporate profit, and quality of life.[30][31][32]Also, for example, cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal.[33][34]Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventive health care,[35] although estimates from the Congressional Budget Office and The New England Journal of Medicine have found that preventive care is more expensive due to increased utilization.[36]Any national system would be paid for in part through taxes replacing insurance premiums, but advocates also believe savings would be realized through preventive care and the elimination of insurance company overhead and hospital billing costs.[37]An analysis of a single-payer bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year.[38]The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.[39]Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, are seen as possible routes to enacting single-payer on the federal level.[40][41]In December 2014, Vermont cancelled its plan for single payer healthcare.[42]National policies and proposals[edit]Medicare in the United States is a single-payer healthcare system, but is restricted to only senior citizens over the age of 65, people under 65 who have specific disabilities, and anyone with End-Stage Renal Disease.[43]Government is increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on individuals' medical care in 2004.[44]However, studies have shown that the publicly administered share of health spending in the U.S. may be closer to 60% as of 2002.[45]According to Princeton University health economist Uwe Reinhardt, U.S. Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) represent "forms of 'social insurance' coupled with a largely private health-care delivery system" rather than forms of "socialized medicine." In contrast, he describes the Veterans Administration healthcare system as a pure form of socialized medicine because it is "owned, operated and financed by government."[46]In a peer-reviewed paper published in the Annals of Internal Medicine, researchers of the RAND Corporation reported that the quality of care received by Veterans Administration patients scored significantly higher overall than did comparable metrics for patients currently using United States Medicare.[47]The United States National Health Care Act, is a perennial piece of legislation introduced in the United States House of Representatives by Representative John Conyers (D-MI) every year since 2002.[48]The act would establish a universal single-payer health care system in the United States, the rough equivalent of Canada's Medicare, the United Kingdom's National Health Service, and Taiwan's Bureau of National Health Insurance, among other examples. Under a single payer system, all medical care would be paid for by the Government of the United States, ending the need for private health insurance and premiums, and probably recasting private insurance companies as providing purely supplemental coverage, to be used when non-essential care is sought. The bill was first introduced in 2002,[48] and has been reintroduced in each Congress since. During the 2009 health care debates over the bill that became the Patient Protection and Affordable Care Act, H.R. 676 was expected to be debated and voted upon by the House in September 2009,[49] but was never debated.[50]The Congressional Budget Office and related government agencies scored the cost of a single payer health care system several times since 1991. The General Accounting Office published a report in 1991 noting that "[I]f the US were to shift to a system of universal coverage and a single payer, as in Canada, the savings in administrative costs [10 percent of health spending] would be more than enough to offset the expense of universal coverage.”[51]The CBO scored the cost in 1991, noting that "the population that is currently uninsured could be covered without dramatically increasing national spending on health" and that "all US residents might be covered by health insurance for roughly the current level of spending or even somewhat less, because of savings in administrative costs and lower payment rates for services used by the privately insured.[52]A CBO report in 1993 stated that "[t]he net cost of achieving universal insurance coverage under this single payer system would be negative" in part because "consumer payments for health would fall by $1,118 per capita, but taxes would have to increase by $1,261 per capita" in order to pay for the plan.[53]A July 1993 scoring also resulted in positive outcomes, with the CBO stating that, "[a]s the program was phased in, the administrative savings from switching to a single-payer system would offset much of the increased demand for health care services. Later, the cap on the growth of the national health budget would hold the rate of growth of spending below the baseline."[54]The CBO also scored Sen. Paul Wellstone's American Health and Security Act of 1993 in December 1993, finding that "by year five (and in subsequent years) the new system would cost less than baseline."[55]A 2014 study published in the journal BMC Medical Services Research by James Kahn, etal, found that the actual administrative burden of health care in the United States was 27.4% of all national health expenditures. The study examined both direct costs charged by insurers for profit, administration and marketing but also the indirect burden placed on health care providers like hospitals, nursing homes and doctors for costs they incurred in working with private health insurers including contract negotiations, financial and clinical record-keeping (variable and idiosyncratic for each payer). Kahn, et al. estimate that the added cost for the private insurer health system in the US was about $471 billion in 2012 compared to a single payer system like Canada's. This represents just over 20% of the total national healthcare expenditure in 2012. Kahn asserts that this excess administrative cost will increase under the Affordable Care Act with its reliance on the provision of health coverage through a multi-payer system.[56]State proposals[edit]Several single-payer state referendums and bills from state legislatures have been proposed, but, with the exception of Vermont,[57] all have failed. In December 2014, Vermont canceled its plan for single payer health care.[42]California[edit]California attempted passage of a single-payer bill as early as 1994,[58]and the first successful passages of legislation through the California State Legislature, SB 840 or "The California Universal Healthcare Act" (authored by Sheila Kuehl), occurred in 2006 and again in 2008.[59]Both times, Governor Arnold Schwarzenegger vetoed the bill.[60]State Senator Mark Leno has reintroduced the bill in each legislative session since.[61]Colorado[edit]Colorado Amendment 69, will have a ballot proposal in November 2016 to vote on a single payer healthcare system funded by a 10% payroll tax split 2:1 between employers and employees. This would replace the private health insurance premiums currently paid by employees and companies.[62]Hawaii[edit]In 2009, the Hawaii state legislature passed a single-payer healthcare bill that was vetoed by Republican Governor Linda Lingle. While the veto was overridden by the legislature, the bill was not implemented.[63]Illinois[edit]In 2007, the Health Care for All Illinois Act was introduced and the Illinois House of Representatives' Health Availability Access Committee passed the single-payer bill favorably out of committee by an 8–4 vote. The legislation was eventually referred back to the House rules committee and not taken up again during that session.[64]Massachusetts[edit]Massachusetts had passed a universal healthcare program in 1986, but budget constraints and partisan control of the legislature resulted in its repeal before the legislation could be enacted.[65]Question 4, a nonbinding referendum, was on the ballot in 14 state districts in November 2010, asking voters, "[S]hall the representative from this district be instructed to support legislation that would establish healthcare as a human right regardless of age, state of health or employment status, by creating a single payer health insurance system like Medicare that is comprehensive, cost effective, and publicly provided to all residents of Massachusetts?" The ballot question passed in all 14 districts that offered the question.[66][67]Minnesota[edit]The Minnesota Health Act, which would establish a statewide single payer health plan, has been presented to the Minnesota legislature regularly since 2009. The bill was passed out of both the Senate Health Housing and Family Security Committee[68] and the Senate Commerce and Consumer Protection Committee[69] in 2009, but the House version was ultimately tabled.[70]In 2010, the bill passed the Senate Judiciary Committee on a voice vote[71] as well as the House Health Care & Human Services Policy and Oversight Committee.[72]In 2011, the bill was introduced as a two-year bill in both the Senate[73] and House,[74] but did not progress. It has been introduced again in the 2013 session in both chambers.[75][76]Montana[edit]In September 2011, Governor Brian Schweitzer announced his intention to seek a waiver from the federal government allowing Montana to set up a single payer healthcare system.[77]Governor Schweitzer was unable to implement single-payer health care in Montana, but did make moves to open government-run clinics[78] and, in his final budget as governor, increased coverage for lower-income Montana residents.[79]New York[edit]New York State has been attempting passage of the New York Health Act, which would establish a statewide single-payer health plan, since 1992. The New York Health Act has passed the Assembly twice, once in 1992 and again in 2015, but has failed to advance through the Senate after referrals to the Health Committee. On both occasions, the legislation passed the Assembly by an almost two-to-one ratio of support.[80]Oregon[edit]The state of Oregon attempted to pass single payer healthcare via Oregon Ballot Measure 23 in 2002, and the measure was rejected by a significant majority.[81]Previous bills, including the Affordable Health Care for All Oregon Act, have been introduced in the legislature but have never left committee. The Affordable Health Care Act may be reintroduced in the 2013 session.[82]Pennsylvania[edit]The Family Business and Healthcare Security Act has been introduced in the Pennsylvania legislature numerous times, but has never been able to pass.[83][84][85]Vermont[edit]In December 2014, Vermont canceled its plan for single payer healthcare.[42]Vermont passed legislation in 2011 creating Green Mountain Care.[86]When Governor Peter Shumlin signed the bill into law, Vermont became the first state to functionally have a single payer health care system.[87]While the bill is considered a single-payer bill, private insurers can continue to operate in the state indefinitely, meaning it does not fit the strict definition of single-payer. Representative Mark Larson, the initial sponsor of the bill, has described Green Mountain Care's provisions "as close as we can get [to single-payer] at the state level."[88][89]Vermont abandoned the plan in 2014, citing costs and tax increases as too high to implement.[90]Public opinion[edit]Advocates for single payer point to support in polls, although the polling is mixed depending on how the question is asked.[91]Polls from Harvard University in 1988,[92] the Los Angeles Times in 1990,[93] and the Wall Street Journal in 1991[94] all showed strong support for a health care system comparable to the system in Canada. More recently, however, polling support has declined.[91][95]A 2007 Yahoo/AP poll showed a majority of respondents considered themselves supporters of "single-payer health care,"[96] and a plurality of respondents in a 2009 poll for Time Magazine showed support for "a national single-payer plan similar to Medicare for all."[97]Polls by Rasmussen Reports in 2011[98] and 2012[99] showed pluralities opposed to single payer health care.A 2001 article in the public health journal Health Affairs studied fifty years of American public opinion of various health care plans and concluded that, while there appears to be general support of a "national health care plan," poll respondents "remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan."[95]Politifact rated a statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care." According to Politifact, responses on these polls largely depend on the wording. For example, people respond more favorably when they are asked if they want a system "like Medicare."[91]Advocacy groups[edit]This section needs to be updated. Please update this article to reflect recent events or newly available information. (February 2014)Physicians for a National Health Program[100] the American Medical Student Association[101] and the California Nurses Association[102] are among advocacy groups that have called for the introduction of a single payer healthcare program in the United States. A study published in the Annals of Internal Medicine found that 59% of physicians "supported legislation to establish national health insurance" while 9% were neutral on the topic, and 32% opposed it.[103]Universal health coverage by countryFrom Wikipedia, the free encyclopediaSee also: Health systems by country 58 countries with universal health care in 2009.[1]58 countries with legislation mandating universal health care, along with >90% health insurance coverage, and >90% skilled birth attendance.Main article: Universal health careUniversal health coverage is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards. Most implement universal health care through legislation, regulation and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis. Usually some costs are borne by the patient at the time of consumption but the bulk of costs come from a combination of compulsory insurance and tax revenues. Some programs are paid for entirely out of tax revenues. In others tax revenues are used either to fund insurance for the very poor or for those needing long term chronic care. The UK government's National Audit Office in 2003 published an international comparison of ten different health care systems in ten developed countries, nine universal systems against one non-universal system (the U.S.), and their relative costs and key health outcomes.[2]A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004[3]In some cases, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care.The UN has adopted a resolution on universal health care. It may be the next stage after the Millennium Development Goals.[4]Africa[edit]Algeria[edit]Algeria operates a public healthcare system. A network of hospitals, clinics, and dispensaries provide treatment to the population, with the Social Security system funding health services, although many people must still cover part of their costs due to the rates paid by the Social Security system unchanged since 1987. The poor are generally entitled to health services free of charge, while the wealthy pay for treatment according to a sliding scale.[5][6]Botswana[edit]Botswana operates a system of public medical centers, with 98% of health facilities in the country run by the government. All citizens are entitled to be treated in public facilities free of charge, though a nominal fee of $70 is typically charged for public health services except for sexual reproductive health services and antiretroviral therapy services, which are free.[7]Burkina Faso[edit]Burkina Faso operates a scheme called Universal Health Insurance (AMU) which provides universal healthcare to citizens. It is administered by two separate bodies, one for civilians and the other for the armed forces.[8]Egypt[edit]Egypt operates a system of public hospitals and clinics through the Ministry of Health. Egyptian citizens can receive treatment at these facilities free of charge. However, those Egyptians who can afford it prefer to pay out of pocket for private healthcare.[9]Ghana[edit]Ghana operates the National Health Insurance Scheme to provide citizens with health insurance. The level of premiums citizens must pay varies according to their level of income. Most medical facilities are run directly by the Ministry of Health or Ghana Health Service.[10]Mauritius[edit]The Government of Mauritius operates a system of medical facilities that provide treatment to citizens free of charge.[11]Morocco[edit]Morocco operates a public health sector run by the government that operates 85% of the country's hospital beds. It deals mainly with the poor and rural populations, who cannot afford private healthcare. In addition, there is a non-profit health sector operated by the National Social Security Fund which covers 16% of the population. There is also a private sector for those who can afford it.[12]Rwanda[edit]Rwanda operates a system of universal health insurance through the Ministry of Health called Mutuelle de Santé (Mutual Health), a system of community-based insurance where people pay premiums based on their income level into local health insurance funds, with the wealthiest paying the highest premiums and required to cover a small percentage of their medical expenses, while those at the lowest income levels are exempt from paying premiums and can still utilize the services of their local health fund. In 2012, this system insured all but 4% of the population.[13]South Africa[edit]South Africa has a public healthcare system that provides services to the vast majority of the population, though it is chronically underfunded and understaffed, and a private system that is far better equipped, which covers the wealthier sectors of society.[14]Tunisia[edit]Tunisia operates a public healthcare system under the National Health Insurance Fund (Caisse Nationale d'Assurance Maladie). All Tunisian citizens and residents can receive treatment in state-run hospitals and clinics free of charge.[15]Asia[edit]Countries that provide public healthcare in Asia include Bhutan,[16]Bahrain,[17]China, Hong Kong, India, Iran,[18]Israel[19](see below), Jordan,[20]Kazakhstan,[21]Macau (see below), Malaysia,[22]Mongolia,[23]Oman,[24][25]Singapore, Sri Lanka,[26]Syria,[27]Taiwan (R.O.C.)[28](see below), Tajikistan,[29]Thailand (see below), Turkey,[30]and Turkmenistan[31]have universal health care.Bhutan[edit]The Royal Government of Bhutan maintains a policy of free and universal access to primary health care. As hospital facilities in the country are limited, patients with diseases that cannot be treated in Bhutan, such as cancer, are normally referred to hospitals in India for treatment. Such referral treatment is also carried out at the cost of the Royal Government.[32]Hong Kong[edit]Hong Kong has early health education, professional health services, and well-developed health care and medication system. The life expectancy is 84 for females and 78 for males,[33]which is the second highest in the world, and 2.94 infant mortality rate, the fourth lowest in the world.[34][35]There are two medical schools in Hong Kong, and several schools offering courses in traditional Chinese medicine. The Hospital Authority is a statutory body that operates and manages all public hospitals. Hong Kong has high standards of medical practice. It has contributed to the development of liver transplantation, being the first in the world to carry out an adult to adult live donor liver transplant in 1993.[36]India[edit]India's healthcare system is dominated by the private sector, although there are various public healthcare systems like Rajiv Gandhi Jeevandayee Arogya Yojana in Maharashtra that provides free healthcare to those below the poverty line.[37][38]Currently, the majority of Indian citizens do not have health insurance, and must pay out of pocket for treatment. There are government hospitals that provide treatment at taxpayer expense. Some essential drugs are offered free of charge in these hospitals.An outpatient card at AIIMS costs a one-time fee of 10 rupees (around 20 cents U.S.) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on the financial condition of the patient and the facilities utilized, but are usually much less than the private sector. For instance, a patient is waived treatment costs if their income is below the poverty line. However, getting treatment at high quality government hospitals is very tough due to the high number of people needing healthcare and the lack of sufficient facilities.Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These hospitals provide treatment free of cost, but only if they are functional. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses.Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals).Now organizations like Hindustan Latex Family Planning Promotional Trust and other private organizations have started creating hospitals and clinics in India, which also provide free or subsidized health care and subsidized insurance plans.The government-run healthcare suffers from a lack of hygiene; the rich avoid the government hospitals and go to private hospitals. With the advent of privatized healthcare, this situation has changed. India now has medical tourism for people from other countries while its own poor find high-quality healthcare either inaccessible or unaffordable.The current Indian government is planning to unveil a national universal healthcare system called the National Health Assurance Mission, which will provide all Indian citizens with insurance coverage for serious illnesses, and free drugs and diagnostic treatments.[39]Israel[edit]Health care in Israel as a percentage of GDPIsrael has a system of universal healthcare as set out by the 1995 National Health Insurance Law. The state is responsible for providing health services to all residents of the country, who can register with one of the four national health service funds. To be eligible, a citizen must pay a health insurance tax. Coverage includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, preventive dental care for children, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.[40]In Israel, the National Health Insurance Law (or National Health Insurance Act) is the legal framework which enables and facilitates basic, compulsory universal health care. The Law was put into effect by the Knesset on January 1, 1995, and was based on recommendations put forward by a National Committee of Inquiry headed by Shoshana Netanyahu which examined restructuring the health care system in Israel in the late 1980s. Prior to the law's passage over 90% of the population was already covered by voluntarily belonging to one of four nationwide, not-for-profit sickness funds which operated some of their own medical facilities and were funded in part by employers and the government and in part by the insured by levies which varied according to income. However, there were three problems associated with this arrangement. First, membership in the largest fund, Clalit, required one to belong to the Histadrut labor organization, even if a person did not wish to (or could not) have such an affiliation while other funds restricted entry to new members based on age, pre-existing conditions or other factors. Second, different funds provided different levels of benefit coverage or services to their members and lastly was the issue mentioned above whereby a certain percentage of the population, albeit a small one, did not have health insurance coverage at all.Before the law went into effect, all the funds collected premiums directly from members. However, upon passage of the law, a new progressive national health insurance tax was levied through Israel's social security agency which then re-distributes the proceeds to the sickness funds based on their membership and its demographic makeup. This ensured that all citizens would now have health coverage. While membership in one of the funds now became compulsory for all, free choice was introduced into movement of members between funds (a change is allowed once every six months), effectively making the various sickness funds compete equally for members among the populace. Annually, a committee appointed by the ministry of health publishes a "basket" or uniform package of medical services and prescription formulary which all funds must provide as a minimum service to all their members. Achieving this level of equality ensured that all citizens are guaranteed to receive basic healthcare regardless of their fund affiliation which was one of the principal aims of the law. An appeals process was put in place to handle rejection of treatments and procedures by the funds and evaluating cases falling outside the "basket" of services or prescription formulary.While the law is generally considered a success and Israeli citizens enjoy a high standard of medical care comparatively, with more competition having been introduced into the field of health care in the country, and order having been brought into what was once a somewhat disorganized system, the law nevertheless does have its critics. First and foremost among the criticisms raised is that the "basket" may not provide enough coverage. To partly address this issue, the HMOs and insurance companies began offering additional "supplementary" insurance to cover certain additional services not included in the basket. However, since this insurance is optional (though usually very modestly priced, costing the equivalent of about US$10 to $20 a month), critics argue that it goes against the spirit of the new law which stressed equality among all citizens with respect to healthcare. Another criticism is that in order to provide universal coverage to all, the tax income base amount (the maximum amount of yearly earnings that are subject to the tax) was set rather high, causing many high-income taxpayers to see the amount they pay for their health premiums (now health tax) skyrocket. Finally, some complain about the constantly rising costs of copayments for certain services.Macau[edit]Macau offers universally accessible single-payer system funded by taxes. Health care is provided by the Bureau for Health.People's Republic of China[edit]Since the founding of the People's Republic of China, the goal of health care programs has been to provide care to every member of the population and to make maximum use of limited health-care personnel, equipment, and financial resources.China is undertaking a reform on its health care system, which was largely privatized in the 1990s. The New Rural Co-operative Medical Care System (NRCMCS), is a new 2005 initiative to overhaul the healthcare system, particularly intended to make it more affordable for the rural poor. Under the NRCMCS, the annual cost of medical coverage is 50 yuan (US$7) per person. Of that, 20 yuan is paid in by the central government, 20 yuan by the provincial government and a contribution of 10 yuan is made by the patient. As of September 2007, around 80% of the whole rural population of China had signed up (about 685 million people). The system is tiered, depending on the location. If patients go to a small hospital or clinic in their local town, the scheme will cover from 70–80% of their bill. If they go to a county one, the percentage of the cost being covered falls to about 60%. And if they need specialist help in a large modern city hospital, they have to bear most of the cost themselves, the scheme would cover about 30% of the bill.[41]On January 21, 2009, the Chinese government announced that a total of 850 billion yuan (US$127.5 billion) will be provided between 2009 and 2011 in order to improve the existing health care system.[42]At the end of 2008, the government published its reform plan clarifying government's responsibility by saying that it would play a dominant role in providing public health and basic medical service. It declared "Both central and local governments should increase health funding. The percentage of government's input in total health expenditure should be increased gradually so that the financial burden of individuals can be reduced," The plan listed public health, rural areas, city community health services and basic medical insurance as four key areas for government investment. It also promised to tighten government control over medical fees in public hospitals and to set up a "basic medicine system" to quell public complaints of rising drug costs.[43]The plan was passed by the Chinese Cabinet in January 2009. The long-awaited medical reform plan promised to spend 850 billion yuan by 2011 to provide universal medical service and that measures would be taken to provide basic medical security to all Chinese.[44]Singapore[edit]Singapore has a universal health care system where government ensures affordability, largely through compulsory savings and price controls, while the private sector provides most care. Overall spending on health care amounts to only 3% of annual GDP. Of that, 66% comes from private sources.[45]Singapore currently has the second lowest infant mortality rate in the world and among the highest life expectancies from birth, according to the World Health Organization.[46]Singapore has "one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes," according to an analysis by global consulting firm Watson Wyatt.[47]Singapore's system uses a combination of compulsory savings from payroll deductions (funded by both employers and workers) a nationalized health insurance plan, and government subsidies, as well as "actively regulating the supply and prices of healthcare services in the country" to keep costs in check; the specific features have been described as potentially a "very difficult system to replicate in many other countries." Many Singaporeans also have supplemental private health insurance (often provided by employers) for services not covered by the government's programs.[47]Taiwan[edit]The current health care system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health care dollars. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[48]NHI is mainly financed through premiums, which are based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers.NHI delivers universal coverage offered by a government-run insurer. The working population pays premiums split with their employers, others pay a flat rate with government help and the poor or veterans are fully subsidized.[49]Under this model, citizens have free range to choose hospitals and physicians without using a gatekeeper and do not have to worry about waiting lists. NHI offers a comprehensive benefit package that covers preventive medical services, prescription drugs, dentalservices, Chinese medicine, home nurse visits and many more. Since NHI, the previously uninsured have increased their usage of medical services. Most preventive services are free such as annual checkups and maternal and child care. Regular office visits have co-payments as low as US $5 per visit. Co-payments are fixed and unvaried by the person's income.[50]Thailand[edit]Thailand introduced universal coverage reforms in 2001, becoming one of only a handful of lower-middle income countries to do so at the time. Means-tested health care for low income households was replaced by a new and more comprehensive insurance scheme, originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card which allows them to access services in their health district, and, if necessary, be referred for specialist treatment elsewhere. The bulk of finance comes from public revenues, with funding allocated to Contracting Units for Primary Care annually on a population basis. According to the WHO, 65% of Thailand's health care expenditure in 2004 came from the government, 35% was from private sources.[45]Although the reforms have received a good deal of critical comment, they have proved popular with poorer Thais, especially in rural areas, and survived the change of government after the 2006 military coup. The then Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the UC scheme free. It is not yet clear whether the scheme will be modified further under the coalition government that came to power in January 2008.[51][52][53]Europe[edit]Virtually all of Europe has either publicly sponsored and regulated universal health care or publicly provided universal healthcare. The public plans in some countries provide basic or "sick" coverage only, with their citizens being able to purchase supplemental insurance for additional coverage. Countries with universal health care include Austria, Belarus,[54]Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Malta, Moldova,[55]the Netherlands, Norway, Portugal,[56]Romania, Russia, Serbia, Spain, Sweden, Switzerland, Ukraine,[57]and the United Kingdom.[58]Austria[edit]Healthcare in Austria is universal for residents of Austria as well as those from other EU countries.[59]Austria has a two-tier health care system in which many individuals receive publicly funded care; they also have the option to purchase supplementary private health insurance.Croatia[edit]Croatia has a universal health care system that provides high quality medical services and is coordinated by the Ministry of Health. The population is covered by a basic health insurance plan provided by statute and optional insurance and administered by the Croatian Health Insurance Fund. In 2012, annual compulsory healthcare related expenditures reached 21.0 billion kunas (c. 2.8 billion euro). There are hundreds of healthcare institutions in Croatia, including 79 hospitals and clinics with 25,285 beds, caring for more than 760 thousand patients per year, 5,792 private practice offices and 79 emergency medical service units.Czech Republic[edit]Czech Republic has a universal public health system paid largely from taxation. Private health care systems do co-exist freely alongside public ones, sometimes offering better quality or faster service. Almost all medical services are covered by health insurance and insurance companies, though certain services such as prescription drugs or vision and dental care are only covered partially.Denmark[edit]Denmark has a universal public health system paid largely from taxation with local municipalities delivering health care services in the same way as other Scandinavian countries. Primary care is provided by a general practitioner service run by private doctors contracting with the local municipalities with payment on a mixed per capita and fee for service basis. Most hospitals are run by the municipalities (only 1% of hospital beds are in the private sector).Finland[edit]In Finland, public medical services at clinics and hospitals are run by the municipalities (local government) and are funded 76% by taxation, 20% by patients through access charges, and 4% by others. Private provision is mainly in the primary care sector. There are a few private hospitals.[60]The main hospitals are either municipally owned (funded from local taxes) or run by the medical teaching universities (funded jointly by the municipalities and the national government). According to a survey published by the European Commission in 2000, Finland's is in the top 4 of EU countries in terms of satisfaction with their hospital care system: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[61]Finnish health care expenditures are below the European average.[62]The private medical sector accounts for about 14 percent of total health care spending. Only 8% of doctors choose to work in private practice, and some of these also choose to do some work in the public sector.Taxation funding is partly local and partly nationally based. The national social insurance institution KELA reimburses part of patients prescription costs and makes a contribution towards private medical costs (including dentistry) if they choose to be treated in the private sector rather than the public sector. Patient access charges are subject to annual caps. For example, GP visits cost €11 per visit with annual €33 cap; hospital outpatient treatment €22 per visit; a hospital stay, including food, medical care and medicines €26 per 24 hours, or €12 if in a psychiatric hospital. After a patient has spent €590 per year on public medical services (including prescription drugs), all treatment and medications thereafter in that year are free.Finland has a highly decentralized three-level public system of health care and alongside this, a much smaller private health-care system.[63]Overall, the municipalities (funded by taxation, local and national) meet about two thirds of all medical-care costs, with the remaining one third paid by the national insurance system (nationally funded), and by private finance (either employer-funded or met by patients themselves).[63]Private inpatient care forms about 3–4% of all inpatient care.[63]In 1999 only 17 per cent of total funding for health care came from insurance, comprising 14.9% statutory (government) insurance and 2.1% private health insurance. Spectacles are not publicly subsidized at all, although dentistry is available as a municipal service or can be obtained privately with partial reimbursement from the state.[63]The government announced in 2009 that Kela would re-imburse the cost of private dental-hygiene work, starting in 2010.[64]The percentage of total health expenditure financed by taxation in Finland (78%)[65]is above the OECD average and similar to the levels seen in Germany (77%) and France (80%) but below the level seen in the UK (87%). The quality of service in Finnish health care, as measured by patient satisfaction, is excellent. According to a survey published by the European Commission in 2000, Finland has one of the highest ratings of patient satisfaction with their hospital care system in the EU: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[66]There are caps on total medical expenses that are met out-of-pocket for drugs and hospital treatments. The National Insurance system pays all necessary costs over these caps. Public spending on health care in 2006 was 13.6 billion euros (equivalent to US$338 per person per month). The increase over 2005 at 8.2 per cent was below the OECD average of 9 percent. Household budgets directly met 18.7 per cent of all health-care costs.[67]France[edit]France has a system of universal health care largely financed by government through a system of national health insurance. It is consistently ranked as one of the best in the world.[68]Germany[edit]Germany has the world's oldest national social health insurance system,[69][70][71]with origins dating back to Otto von Bismarck's Sickness Insurance Law of 1883.[72][73]The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population is covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher income workers sometimes choose to pay a tax and opt out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status.[74]Historically, the level of provider reimbursement for specific services is determined through negotiations between regional physician's associations and sickness funds. Since 1976 the government has convened an annual commission, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries.[75]The commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. In 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. Although reimbursement of providers is on a fee-for-service basis the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. Capitated care, such as that provided by U.S. health maintenance organizations, has been considered as a cost containment mechanism but would require consent of regional medical associations, and has not materialized.[76]Copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).[77][78]The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[79]Greece[edit]The Greek healthcare system provides high quality medical services to insured citizens and is coordinated by the Ministry for Health and Social Solidarity. Public health services are provided by the National Healthcare Service, or ESY (Greek: Εθνικό Σύστημα Υγείας, ΕΣΥ). In 2010 there were 35,000 hospital beds and 131 hospitals in the country.The Greek healthcare system has received high rankings by the World Health Organization, ranked 14th in the overall assessment and 11th in quality of service in a 2000 report by the WHO.Guernsey / Jersey[edit]The medical care system in the Channel Islands is very similar to that of the UK in that many of the doctors and nurses have been trained from the UK health perspective. There is universal health care for residents of the islands.[80]Iceland[edit]Iceland has a universal public health system paid largely from taxation with local municipalities delivering health care services in the same way as other Scandinavian countries. Iceland's entire population has equal access to health care services.Ireland[edit]The public health care system of the Republic of Ireland is governed by the Health Act 2004,[81]which established a new body to be responsible for providing health and personal social services to everyone living in Ireland – the Health Service Executive. The new national health service came into being officially on January 1, 2005; however the new structures are currently in the process of being established as the reform program continues. In addition to the public-sector, there is also a large private health care market.Isle of Man[edit]The Isle of Man provides universal public health coverage to its residents.[82]Italy[edit]Italy has a public health care service for all the residents called "Servizio Sanitario Nazionale" or SSN (National Health Service) which is similar to the UK National Health Service. It is publicly run and funded mostly from taxation: some services requires small co-pays, while other services (like the emergency medicine and the general doctor) are completely free of charge. Like the UK, there is a small parallel private health care system, especially in the field of Dental Medicine.Luxembourg[edit]Luxembourg provides universal health care coverage to all residents (Luxembourgers and foreigners) by the National Health Insurance (CNS - Caisse nationale de santé (French) or National Gesondheetskeess (Luxembourgish)) which is funded by mandatory contributions of employers and the workforce and by government subsidies for insuring jobseekers, the poor and for financing medical infrastructure. It exists as well a mandatory public long-term care insurance.[83][84]Netherlands[edit]The Netherlands has a dual-level system. All primary and curative care (i.e. the family doctor service and hospitals and clinics) is financed from private compulsory insurance. Long term care for the elderly, the dying, the long term mentally ill etc. is covered by social insurance funded from taxation. According to the WHO, the health care system in the Netherlands was 62% government funded and 38% privately funded as of 2004.[45]Insurance companies must offer a core universal insurance package for the universal primary, curative care which includes the cost of all prescription medicines. They must do this at a fixed price for all. The same premium is paid whether young or old, healthy or sick. It is illegal in The Netherlands for insurers to refuse an application for health insurance, to impose special conditions (e.g. exclusions, deductibles, co-pays etc., or refuse to fund treatments which a doctor has determined to be medically necessary). The system is 50% financed from payroll taxes paid by employers to a fund controlled by the Health regulator. The government contributes an additional 5% to the regulator's fund. The remaining 45% is collected as premiums paid by the insured directly to the insurance company. Some employers negotiate bulk deals with health insurers and some even pay the employees' premiums as an employment benefit). All insurance companies receive additional funding from the regulator's fund. The regulator has sight of the claims made by policyholders and therefore can redistribute the funds its holds on the basis of relative claims made by policy holders. Thus insurers with high payouts will receive more from the regulator than those with low payouts. Thus insurance companies have no incentive to deter high cost individuals from taking insurance and are compensated if they have to pay out more than might be expected. Insurance companies compete with each other on price for the 45% direct premium part of the funding and try to negotiate deals with hospitals to keep costs low and quality high. The competition regulator is charged with checking for abuse of dominant market positions and the creation of cartels that act against the consumer interests. An insurance regulator ensures that all basic policies have identical coverage rules so that no person is medically disadvantaged by his or her choice of insurer.Hospitals in the Netherlands are also regulated and inspected but are mostly privately run and not for profit, as are many of the insurance companies. Patients can choose where they want to be treated and have access to information on the internet about the performance and waiting times at each hospital. Patients dissatisfied with their insurer and choice of hospital can cancel at any time but must make a new agreement with another insurer.Insurance companies can offer additional services at extra cost over and above the universal system laid down by the regulator, e.g. for dental care. The standard monthly premium for health care paid by individual adults is about €100 per month. Persons on low incomes can get assistance from the government if they cannot afford these payments. Children under 18 are insured by the system at no additional cost to them or their families because the insurance company receives the cost of this from the regulator's fund. There is a fixed yearly threshold of €375 for each adult person, excluding first visits for diagnosis to general physicians.Norway[edit]Norway has a universal public health system paid largely from taxation in the same way as other Scandinavian countries. Norway's entire population has equal access to health care services. The Norwegian health care system is government-funded and heavily decentralized. The health care system in Norway is financed primarily through taxes levied by county councils and municipalities. Dental care is included for children until 18 years old, and is covered for adults for some ailments.[85]Norway regularly comes top or close to the top of worldwide healthcare rankings.Portugal[edit]Portugal's National Healthcare Service, known nationally as Serviço Nacional de Saúde (SNS), is a universal and free healthcare service, provided nationwide since 1979, and is available to both Portuguese and foreigner residents. In 2014, Portugal SNS ranked 13th best healthcare service in Europe.[86]The National Medical Emergency Institute (INEM) is the main emergency medical serviced and can be activated by calling 112.Romania[edit]According to Article 34 of the Constitution of Romania, the state is obliged "to guarantee the protection of healthcare". Romania has a fully universal health care system, which covers up medical check-ups, any surgical interventions, and any post-operator medical care, as well as free or subsidized medicine for a range of diseases. The state is also obliged to fund public hospitals and clinics. Dental care is not funded by the state, although there are public dental clinics in some hospitals, which treat patients free of charge. However, due to inadequate funding and corruption, it is estimated that a third of medical expenses are, in some cases, supported by the patient.[87][clarification needed]Furthermore, Romania spends, per capita, less than any other EU state on medical care.Russia and Soviet Union[edit]In the Soviet Union, the preferred term was "socialist medicine"; the Russian language has no term to distinguish between "socialist" and "socialized" (other than "public", Rus: obshchestvenniy/общественный, sometimes "collectivized" or "nationalized", Rus: obobshchestvlenniy/обобществленный).[88][89]Russia in Soviet times (between 1917 and the early 1990s) had a totally socialist model of health care with a centralised, integrated, hierarchically organised with the government providing free health care to all citizens. Initially successful at combating infectious diseases, the effectiveness of the socialized model declined with underinvestment. Despite a doubling in the number of hospital beds and doctors per capita between 1950 and 1980, the quality of care began to decline by the early 1980s and medical care and health outcomes were below western standards.The new mixed economy Russia has switched to a mixed model of health care with private financing and provision running alongside state financing and provision. The OECD reported that unfortunately, none of this has worked out as planned and the reforms have in many respects made the system worse.[90]The population's health has deteriorated on virtually every measure. The resulting system is overly complex and very inefficient. It has little in common with the model envisaged by the reformers. Although there are more than 300 private insurers and numerous public ones in the market, real competition for patients is rare leaving most patients with little or no effective choice of insurer, and in many places, no choice of health care provider either. The insurance companies have failed to develop as active, informed purchasers of health care services. Most are passive intermediaries, making money by simply channelling funds from regional OMS funds to healthcare providers.Article 41 of the Constitution of the Russian Federation confirms a citizen's right to state healthcare and medical assistance free of charge.[91]This is achieved through state compulsory medical insurance (OMS) which is free to Russian citizens, funded by obligatory medical insurance payments made by companies and government subsidies.[92][93]Introduction in 1993 reform of new free market providers in addition to the state-run institutions intended to promote both efficiency and patient choice. A purchaser-provider split help facilitate the restructuring of care, as resources would migrate to where there was greatest demand, reduce the excess capacity in the hospital sector and stimulate the development of primary care. Russian Prime Minister Vladimir Putin announced a new large-scale health care reform in 2011 and pledged to allocate more than 300 billion rubles ($10 billion) in the next few years to improve health care in the country.[94]He also said that obligatory medical insurance tax paid by companies will increase from current 3.1% to 5.1% starting from 2011.[94]Serbia[edit]The Constitution of the Republic of Serbia states that it is a right of every citizen to seek medical assistance free of charge.[95]This is achieved by mutual contribution to the Compulsory Social Healthcare Fund of RZZO (Republički Zavod za Zdravstveno Osiguranje or National Health Insurance Institution). The amount of contribution depends on the amount of money the person is making. During the 1990s, Serbia's healthcare system has been of a poor quality due to severe underfunding. In the recent years, however, that has changed and the Serbian government has invested heavily in new medical infrastructure, completely remodeling existing hospitals and building two new hospitals in Novi Sad and Kragujevac.Sweden[edit]Sweden has a universal public health system paid largely from taxation in the same way as other Scandinavian countries. Sweden's entire population has equal access to health care services. The Swedish public health system is funded through taxes levied by the county councils, but partly run by private companies. Government-paid dental care for children under 21 years old is included in the system, and dental care for adults is somewhat subsidised by it.Sweden also has a smaller private health care sector, mainly in larger cities or as centers for preventive health care financed by employers.Sweden regularly comes in top in worldwide healthcare rankings.[96]Switzerland[edit]Healthcare in Switzerland is universal and is regulated by the Federal Health Insurance Act of 1994. Basic health insurance is mandatory for all persons residing in Switzerland (within three months of taking up residence or being born in the country). Insurers are required to offer insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans.[97]United Kingdom[edit]Each of the Countries of the United Kingdom has a National Health Service that provides public healthcare to all UK permanent residents that was originally designed to be free at the point of need and paid for from general taxation; but changes included introducing charging for prescription medicines and dentistry (those below 16 and those on certain benefits may still get free treatment). However, since Health is now a devolved matter, considerable differences are developing between the systems in each of the countries as for example Scotland abolished prescription charges.[98]Private healthcare companies are free to operate alongside the public one.England[edit]Norfolk and Norwich University Hospital, a National Health Service hospital.The National Health Service (NHS), created by the National Health Service Act 1946, has provided the majority of healthcare in England since its launch on 5 July 1948.The NHS Constitution for England documents, at high level, the objectives of the NHS, the legal rights and responsibilities of the various parties (patients, staff, NHS trust boards), and the guiding principles which govern the service.[99]The NHS constitution makes it clear that it provides a comprehensive service, available to all irrespective of age, gender, disability, race, sexual orientation, religion, or belief; that access to NHS services is based on clinical need and not an individual's ability to pay; and that care is never refused on unreasonable grounds. Patient choice in terms of doctor, care, treatments, and place of treatment is an important aspect of the NHS's ambition, and in some cases patients can elect for treatment in other European countries at the NHS's expense. Waiting times are low, with most people able to see their primary care doctor on the same day or the following day.[100]Only 36.1% of hospital admissions are from a waiting list, with the remainder being either emergencies admitted immediately or else pre-booked admissions or the like (e.g., child birth).[101]One of the main goals of care management is to ensure that patients do not experience a delay of more than 18 weeks from initial hospital referral to final treatment, inclusive of time for all associated investigative tests and consultations.102]At present, two-thirds of patients are treated in under 12 weeks.[103]Although centrally funded, the NHS is not managed by a large central bureaucracy. Responsibility is highly devolved to geographical areas through Strategic Health Authorities and even more locally through NHS primary care trusts, NHS hospital trusts and increasingly to NHS foundation trusts which are providing even more decentralized services within the NHS framework, with more decision making taken by local people, patients, and staff. The central government office, the Department of Health, is not involved in day-to-day decision making in either the Strategic Health Authorities or the individual local trusts (primarily health, hospital, or ambulance) or the national specialist trusts such as NHS Blood and Transplant, but it does lay down general guidelines for them to follow. Local trusts are accountable to their local populations, whilst government ministers are accountable to Parliament for the service overall.The NHS provides, among other things, primary care, in-patient care, long-term healthcare, psychiatric care and treatments, ophthalmology, and dentistry. All treatment is free with the exception of certain charges for prescriptions, dentistry and ophthalmology (which themselves are free to children, certain students in full-time education, the elderly, the unemployed and those on low incomes). Around 89 pc of NHS prescriptions are obtained free of charge, mostly for children, pensioners, and pregnant women. Others pay a flat rate of £8.20,[104]and others may cap their annual charges by purchasing an NHS Prescription Prepayment Certificate. Private health care has continued parallel to the NHS, paid for largely by private insurance. Private insurance accounts for only 4 percent of health expenditure and covers little more than a tenth of the population.[105]Private insurers in the UK only cover acute care from specialists. They do not cover generalist consultations, pre-existing conditions, medical emergencies, organ transplants, chronic conditions such as diabetes, or conditions such as pregnancy or HIV.[106]Most NHS general practitioners are private doctors who contract to provide NHS services, but most hospitals are publicly owned and run through NHS Trusts. A few NHS medical services (such as "surgicentres") are sub-contracted to private providers[107]as are some non-medical services (such as catering). Some capital projects such as new hospitals have been funded through the Private Finance Initiative, enabling investment without (in the short term) increasing the public sector borrowing requirement, because long-term contractually obligated PFI spending commitments are not counted as government liabilities.Northern Ireland[edit]Health and Social Care in Northern Ireland is the designation of the national public health service in Northern Ireland.Scotland[edit]The Royal Aberdeen Children's Hospitalis a specialist children's hospital within NHS Scotland.NHS Scotland, created by the National Health Service (Scotland) Act 1947, was also launched on 5 July 1948, although it has always been a separate organization. Since devolution, NHS Scotland has followed the policies and priorities of the Scottish Government, including the phasing out of all prescription charges by 2011.[citation needed]Wales[edit]NHS Wales was originally formed as part of the same NHS structure created by the National Health Service Act 1946 but powers over the NHS in Wales came under the Secretary of State for Wales in 1969,[108]in turn being transferred under devolution to what is now the Welsh Government.North America[edit]The Bahamas,Barbados, Canada, Costa Rica, Cuba, Mexico, Panama, and Trinidad and Tobago all provide some level of universal health coverage.The Bahamas[edit]The Bahamas approved the National Health Insurance Act in August 2016. The legislation allows for the establishment of a universal health coverage system that will begin with universal coverage of primary health care services and later expand to include a wide set of benefits including all specialized care. The system will all for universal coverage of a basic benefit package and for voluntary insurance to be purchased as a top up policy to cover services or amenities that are not included in the government plan.[109]Canada[edit]In 1984, the Canada Health Act was passed, which prohibited extra billing by doctors on patients while at the same time billing the public insurance system. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."[110]The system is for the most part publicly funded, yet most of the services are provided by private enterprises or private corporations, although most hospitals are public. Most doctors do not receive an annual salary, but receive a fee per visit or service.[111]About 29% of Canadians' health care is paid for by the private sector or individuals.[112]This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and vision care.[113]Many Canadians have private health insurance, often through their employers, that cover these expenses.[114]The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine.[115][116]The legality of the ban was considered in a decision of the Supreme Court of Canada which ruled in Chaoulli v. Quebec that "the prohibition on obtaining private health insurance, while it might be constitutional in circumstances where health care services are reasonable as to both quality and timeliness, is not constitutional where the public system fails to deliver reasonable services." The appellant contended that waiting times in Quebec violated a right to life and security in the Quebec Charter of Human Rights and Freedoms. The Court agreed, but acknowledged the importance and validity of the Canada Health Act, and at least four of the seven judges explicitly recognized the right of governments to enact laws and policies which favour the public over the private system and preserve the integrity of the public system.Costa Rica[edit]Universal healthcare and pensions are run by the Caja Costarricense de Seguro Social (CCSS). In 1941, Costa Rica established Caja Costarricense de Seguro Social (CCSS), a social security insurance system for wage-earning workers. In 1961, coverage was expanded to include workers’ dependents and from 1961 to 1975, a series of expansions extended coverage for primary care and outpatient and inpatient specialized services to people in rural areas, the low-income population, and certain vulnerable populations. Further expansions during the late 1970s extended insurance coverage to farmers, peasants, and independent contract workers. Additionally, CCSS mandates free health service provision to mothers, children, indigenous people, the elderly, and people living with disabilities, regardless of insurance coverage. By 2000, 82 percent of the population was eligible for CCSS, which has continued to expand in the ensuing period. By covering all population groups through the same system, Costa Rica has avoided social insurance stratification and inequity common in many other countries in the region.[117]CCSS is funded by a 15 percent payroll tax, as well as payments from retiree pensions [6]. Taxes on luxury goods, alcohol, soda, and imported products also help to cover poor households who do otherwise pay into the system. All CCSS funds are merged into a single pool, which is managed by the central financial administration of CCSS. In 1973, the Ministry of Health decided to move away from direct service provision and adopt a steering role. Responsibility for the provision of most care was transferred to the CCSS, although the Ministry retained responsibility for disease control, food and drug regulation, environmental sanitation, child nutrition, and primary care for the poor. Through the CCSS, health care is now essentially free to nearly all Costa Ricans. Private health care is also widely available and INS offers private health insurance plans to supplement CCSS insurance.[118]Cuba[edit]The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of all its citizens. There are no private hospitals or clinics as all health services are government-run. The present Minister for Public Health is Roberto Morales Ojeda. However, although the coverage is wide, the system is underfunded and recently also understaffed. The government organized medical missions in other countries has taken a very significant amount of doctors and other personal. In 2005 there were 25000 Cuban doctors only in Venezuela.Mexico[edit]Public health care delivery is accomplished via an elaborate provisioning and delivery system instituted by the Mexican Federal Government. Public health care is provided to all Mexican citizens as guaranteed via Article 4 of the Constitution. Public care is either fully or partially subsidized by the federal government, depending on the person's (Spanish: derechohabiente's) employment status. All Mexican citizens are eligible for subsidized health care regardless of their work status via a system of health care facilities operating under the federal Secretariat of Health (formerly the Secretaria de Salubridad y Asistencia, or SSA) agency. Employed citizens and their dependents, however, are further eligible to use the health care program administered and operated by the Instituto Mexicano del Seguro Social (IMSS) (English: Mexican Social Security Institute). The IMSS health care program is a tripartite system funded equally by the employee, its private employer, and the federal government. The IMSS does not provide service to employees of the public sector. Employees in the public sector are serviced by the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) (English: Institute for Social Security and Services for State Workers), which attends to the health and social care needs of government employees. This includes local, state, and federal government employees. The government of the states in Mexico also provide health services independently of those services provided by the federal government programs. In most states, the state government has established free or subsidized healthcare to all their citizens.On December 1, 2006, the Mexican government created the Health Insurance for a New Generation also known as "life insurance for babies".[119][120][121]On May 16, 2009, Mexico to Achieve Universal Health Coverage by 2011.[122]On May 28, 2009, Mexico announced Universal Care Coverage for Pregnant Women.[123]On August 2012 Mexico installed a universal healthcare system.[124]Trinidad and Tobago[edit]Main article: Healthcare in Trinidad and TobagoA universal health care system is used in Trinidad and Tobago and is the primary form of health-care available in the country. It is used by the majority of the population seeking medical assistance, as it is free for all citizens.United States[edit]Main article: Patient Protection and Affordable Care ActSee also: Health care reform in the United States and Health care in the United StatesThe United States does not have a universal health care system. However, the Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act of 2010, seeks to have expanded insurance coverage to legal residents by 2014. It provides for federally mandated health insurance to be implemented in the United States during the 2010–2019 decade with the Federal government subsidizing legal resident households with income up to 400% of the Federal poverty level.[125]This threshold varies according to State and household size, but for an average family of four, subsidies would be available for families whose income was about $88,000 or lower.[126]In June 2010 adults with pre-existing conditions became eligible to join a temporary high-risk pool.[127]In 2014, applicants of the same age began to be able to obtain health insurance at the same published rate regardless of health status — the first time in U.S. history that insurers no longer had the right to load the premium or deny coverage prior to contract, or cancel a policy after contractdue to an adverse health condition, or test result indicating that one may be imminent. The law prohibits insurers from capping their liability for a person's health care needs, a move which is expected to rectify medically induced bankruptcy. As of April 13, 2015, the U.S. uninsured rate fell to 11.9% from the 17.1% recorded at the end of the fourth quarter of 2013. This is the lowest quarterly average recorded since Gallup and Healthwaysbegan tracking the percentage of uninsured Americans in 2008. Gallup attributed this sharp decline to the Affordable Care Act's requirements for most Americans to have healthcare in the beginning of the first quarter of 2014.[128]The Congressional Budget Office and related government agencies scored the cost of a universal health care system several times since 1991, and have uniformly predicted cost savings,[129]partly from the elimination of insurance company overhead costs.[130]In 2009, a universal health care proposal was pending in Congress, the United States National Health Care Act (H.R. 676, formerly the "Medicare for All Act").The Congressional Budget Office (CBO) estimated that the bill would reduce the number of nonelderly people who are uninsured by about 32 million, leaving about 23 million nonelderly residents uninsured (about one-third of whom would be illegal immigrants). Under the legislation, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent in 2010 to about 94 percent by 2019.[131]In May 2011, the state of Vermont became the first state to pass legislation establishing a single-payer health care system. The legislation, known as Act 48, establishes health care in the state as a "human right" and lays the responsibility on the state to provide a health care system which best meets the needs of the citizens of Vermont. The proposal was shelved not long after the main provisions of the law took effect in 2014.[132]A revised estimate in July 2012 by the CBO stated 30 million people would gain access to health insurance under the law.[133]Discussion in the United States commonly uses the term socialized medicine to impart a pejorative meaning to the idea of universal health care.South America[edit]Argentina, Brazil, Chile, Colombia, Peru, Uruguay, and Venezuela all have public universal health care provided.Argentina[edit]Health care is provided through a combination of employer and labor union-sponsored plans (Obras Sociales), government insurance plans, public hospitals and clinics and through private health insurance plans. It costs almost 10% of GDP and is available to anyone regardless of ideology, beliefs, race or nationality.Brazil[edit]The universal health care system was adopted in Brazil in 1988 after the end of the military regime's rule. However, universalized/socialized health care was available many years before, in some cities, once the 27th amendment to the 1969 Constitution imposed the duty of applying 6% of their income in healthcare on the municipalities.[134]Chile[edit]Health care in Chile is provided by the government (via Fonasa) and by private insurers (via Isapre). All workers and pensioners are mandated to pay 7% of their income for health care insurance (the poorest pensioners are exempt from this payment). Workers who choose not to join an Isapre, are automatically covered by Fonasa. Fonasa also covers unemployed people receiving unemployment benefits, uninsured pregnant women, insured worker's dependant family, people with mental or physical disabilities and people who are considered poor or indigent.Fonasa costs vary depending on income, disability or age. Attention at public health facilities via Fonasa is free for low-income earners, people with mental or physical disabilities and people over the age of 60. Others pay 10% or 20% of the costs, depending on income and number of dependants. Fonasa beneficiaries may also seek attention in the private sector, for a designated fee.Additionally, there are a number of high-mortality illnesses (currently 69) that have special attention guarantees for both Isapre and Fonasa affiliates, in relation to access to treatment, waiting times, maximum costs and quality of service.Colombia[edit]In 1993 a reform transformed the health care system in Colombia, trying to provide a better, sustainable, health care system and to reach every Colombian citizen.Peru[edit]On April 10, 2009, the Government of Peru published the Law on Health Insurance to enable all Peruvians to access quality health services, and contribute to regulate the financing and supervision of these services. The law enables all population to access diverse health services to prevent illnesses, and promote and rehabilitate people, under a Health Basic Plan (PEAS).[135][136]On April 2, 2010, President Alan Garcia Perez on Friday signed a supreme ordinance approving the regulations for the framework law on the Universal Health Insurance, which seeks to provide access to quality health care for all Peruvian citizens.Peru's Universal Health Insurance law aims to increase access to timely and quality health care services, emphasizes maternal and child health promotion, and provides the poor with protection from financial ruin due to illness.[137]The regulation states that membership of the Universal Health Insurance (AUS for its Spanish acronym) is compulsory for the entire population living in the country. To that end, the Ministry of Health will approve, by supreme ordinance, the mechanisms leading to compulsory membership, as well as escalation and implementation.[138]Oceania[edit]Australia and New Zealand have universal health care.Australia[edit]In Australia, Medibank — as it was then known — was introduced, by the Whitlam Labor government on July 1, 1975, through the Health Insurance Act 1973. The Australian Senate rejected the changes multiple times and they were passed only after a joint sitting after the 1974 double dissolution election. However, Medibank was supported by the subsequent Fraser Coalition (Australia) government and became a key feature of Australia's public policy landscape. The exact structure of Medibank/Medicare, in terms of the size of the rebate to doctors and hospitals and the way it has administered, has varied over the years. The original Medibank program proposed a 1.35% levy (with low income exemptions) but these bills were rejected by the Senate, and so Medibank was funded from general taxation. In 1976, the Fraser Government introduced a 2.5% levy and split Medibank in two: a universal scheme called Medibank Public and a government-owned private health insurance company, Medibank Private.During the 1980s, Medibank Public was renamed Medicare by the Hawke Labor government, which also changed the funding model, to an income tax surcharge, known as the Medicare Levy, which was set at 1.5%, with exemptions for low income earners.[139]The Howard Coalition government introduced an additional levy of 1.0%, known as the Medicare Levy Surcharge, for those on high annual incomes ($70,000) and do not have adequate levels of private hospital coverage.[140]This was part of an effort by the Coalition to encourage take-up of private health insurance. According to WHO, government funding covered 67.5% of Australia's health care expenditures in 2004; private sources covered the remaining 32.5% of expenditures.[45]New Zealand[edit]As with Australia, New Zealand's healthcare system is funded through general taxation. According to the WHO, government sources covered 77.4% of New Zealand's health care costs in 2004; private expenditures covered the remaining 22.6%.[45]