Uhc Form 27: Fill & Download for Free

1. IntroductionUniversal healthcare (UHC), sometimes referred to as universal health coverage, universal coverage or universal care, usually refers to a healthcare system, which provides healthcare and financial protection to all citizens of a particular country. It is organised 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 [1]. The World Health Organization (WHO) defines a universal health system as one where ‘all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’. In Ireland, the definition used in current policy for the introduction of UHC does not mention the issue of affordability but instead places the emphasis on access based on clinical need [2]. This is contrary to a key underlying tenet of UHC which is risk protection. Health payments are a heavy financial burden for millions around the world. Financial risk protection is concerned with safeguarding people against the financial hardship associated with paying for health services. The concept of financial risk protection, or conversely the absence of a risk of financial hardship, has been the focus of interest to economists and researchers for many years, and measuring the ability of a health system to protect people against the financial hardship associated with paying for health services has become an important issue for research and analysis across countries at all income levels [3]. It is unclear why health policy in Ireland has chosen to adopt a definition of UHC which is silent on the issue of affordability.The WHO has advocated UHC as the best means of improving global health. However, achieving UHC is not without challenges: from defining the goal of UHC to identifying the most appropriate methods to achieve it. The idea of UHC can be seen in the 1948 WHO Constitution [4] of which Ireland is a signatory. The concept of UHC was first introduced in Ireland through the 1948 Health Act [5]. UHC is also embedded in the 1978 Alma-Ata declaration that contains a number of important principles in relation to health. It specifies that all people regardless of race, religion, political belief, economic or social condition be entitled to enjoy the highest attainable standard of health as a fundamental right. In 2005 [6], 2011 [7] and 2013 [1] UHC has become the focus of various WHO campaigns as the importance and benefits of universal coverage become ever more apparent.Over recent years funding for the health service in Ireland has declined, amidst the most severe economic crisis since the 1930s, while the demands for care and patient expectations have increased [8], [9]. The health system managed ‘to do more with less’ from 2008 to 2012, achieved mostly by transferring the cost of care onto people and by significant resource cuts [10]. This is evident in reduced home care hours, increased wait-times, expensive agency staffing and accentuated inequities of access for patients within the health system. Alongside this there was a growing discourse in society to have a health system that is accountable, effective, efficient and capable of responding to the emerging and on-going needs of the public. This has been illustrated through debates on UHC internationally [11] and in Ireland [2].The structure of the Irish healthcare system has a number of unusual features [12] and is commonly referred to as a ‘two-tiered’ system. ‘Two-tier’ refers to the fact that people who can pay privately or have private health insurance (PHI) can get a diagnosis quicker and can secure faster hospital treatment, even in public hospitals, because they can afford the monthly premiums [13]. About 46% of the population have PHI [14]. Those who cannot afford PHI must often face long waiting lists for acute care [10], for example longer waiting times for minor operations and diagnostics such as CT scans [15]. About two fifths of the population have medical cards under the General Medical Services (GMS) scheme, which are means tested and mostly allocated on the basis of income. These cards enable people on low or no income to access general practice (GP) and hospital care without charge and medicines at a low cost. Healthcare financing relies predominantly on general taxation, which accounted for an estimated 69 per cent of total financing in 2015, with out-of –pocket payments by individuals and PHI contributing an estimated 13 per cent each [16]. Ireland is unusual amongst its European neighbours in not having universal access to primary care [17]. A recent analysis conducted by the European Observatory on Health Systems and Policies found that the highest formal payments in any primary care system exist in Ireland, where patients without a medical card (e.g. when income rises above a specified threshold) pay between €45 and €65 for each GP visit, with no reimbursement [17]. According to recent OECD data on 34 countries, Ireland is in the bottom third for both out-of-pocket expenditure and also unmet medical needs particularly in relation to medical examinations [18], whereby people indicated that they need medical treatment in the previous 12 months but did not receive it [18]. Cross sectional analysis of health seeking behaviour within primary care in Ireland revealed that those who had to pay out-of-pocket payments to see a GP were more likely to put off going to the doctor than those with a GMS card [19]. Similarly analysis on the impact of the introduction of copayments on prescriptions reported a reduction in medication adherence [20]. An antidote to this inequitable two-tiered system is UHC. Possible options for the implementation of UHC, including funding and restructuring as well as dealing with possible positive and negative outcomes are outlined in the Slaintecare report [2]. Details of the complicated nature of the Irish health system are explained in a recent analyses [21].In more recent years Ireland has recommitted its intention to introduce UHC by looking to change the underlying funding model to an insurance based system – universal health insurance (UHI). The 2011-16 Programme for Government states, “under this system there will be no discrimination between patients on the grounds of income or insurance status” [22]. In the final days of the previous Government, UHI became seriously delayed and abandoned in the run up to the 2016 General Election, with the Minister for Health indicating on foot of the publication of costings for UHI that the multi-payer model of private competing insurance companies is not viable stating it was ‘not acceptable, either now or any time in the future’[23]. More recently the Government has formed a cross-party committee, the primary role of which is to ‘establish a universal single tier service where patients are treated on the basis of health need rather than on ability to pay’ [24]. This committee, called the Oireachtas Committee on the Future of Healthcare, published its report entitled Slaintecare in May 2017 outlining a ten year plan for the introduction of UHC in Ireland [2].The issue around universalisation has therefore been an ongoing background debate for decades and periodically comes to the fore when the standing Government seeks to institute reforms. Despite these commitments by Ireland at international and national level, the two-tiered system still exists. This begs the question as to why?The legitimacy and sustainability of any major policy decision increasingly depends on how well it reflects the underlying values of the public. Experts and stakeholders provide essential technical input but their role is distinct from that of the citizen and cannot replace it. It is increasingly understood that citizens should be a stakeholder in framing health policy decisions [25] and it is recognised that citizens’ values should define the boundaries of action in healthcare in any democracy[26], [27], [28], [29]. This is particularly the case for UHC as patients and the public have been identified as key enablers for the implementation of any universal programme [30]. According to the OECD the general public bring new ideas and experiences to the decision-making process; encourage policy makers to think more carefully about the objectives of health services and to be more open and explicit about the choices being made [31].The call for public participation also suggests a shift in political philosophy about who has the democratic right to make healthcare decisions. The WHO have also used the language of rights when arguing that: ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care’ [32]. Members of the general public want to be involved in decision-making at the national level [33] and they overwhelmingly want their preferences to inform priority-setting decisions in healthcare [34].Public input into healthcare decision-making, at least in theory, is clearly advocated in Ireland. The importance of patient involvement has been acknowledged in numerous policy documents such as ‘A Vision for Change: Report of the expert group on mental health policy’ [35], ‘The National Health Strategy: Quality and fairness – a health system for you’[36], the Madden Report [37] and most recently in ‘Healthy Ireland – A Framework for Improved Health and Wellbeing 2013–2025 [38], as well as in numerous Health Service Executive (HSE) national service plans [39], [40], [41]. In Ireland researcher-administered questionnaires with 738 patients and family members attending outpatient services reported that 86.2% were supportive of greater patient participation in national level healthcare design, delivery and policy [42].The key prevailing issue relating to the Irish health system is how to end the inequitable two-tiered health system that exists. There has been one formal assessment of the general public’s views and opinions on universalisation in Ireland, however, this study included a convenience sample of patients attending for treatment in a primary care setting[43]. Beyond the media headlines little is actually known about the general public’s views on universal healthcare. We sought to identify what demographic factors and opinions influence the support of the general public for the introduction of universal healthcare (UHC) in Ireland.2. Materials and methods2.1. DesignA cross-sectional survey on the views and opinions of the general public on the introduction of UHC in Ireland.2.2. SamplingA sample of 972 participants were recruited. This provided a 3% margin of error with a 95% confidence level and total population of 4,757,976 based on the 2016 National Census [44].Random sampling was employed with random digit dialling of 85% mobile numbers and 15% landline numbers. This ensured listed and non-listed numbers have the same probability of being contacted. To ensure a representative sample soft quotas for age, gender, location, and social class were monitored. The data was weighted at analysis stage. Weightings were based on data from the 2011 Census and the Joint National Listenership Research (JNLR). The JNLR includes a sample of over 16,000 respondents aged over 15 conducted annually over 50 weeks of the year [45]. This was used alongside Census data to keep weightings as up to date as possible.2.3. ProceduresData collection took place over a two-week period in December 2016. A market research company who specialise in healthcare research were contracted to conduct questionnaires over the phone as part of an omnibus poll. The research team provided the data collectors with definitions for all key terms used in the questionnaire and meetings took place to ensure in depth understanding of the topic and questionnaire. All data collectors were provided with a full day of training, a briefing on the project and 10–15% of interviewer calls were monitored for quality control.The questionnaire was anonymous and researcher-administered over the phone. Consent was implied in completing the questionnaire.Ethical approval was provided by the School of Medicine Level 1 Research Ethics Committee in Trinity College Dublin (reference 20160208).2.4. MeasuresThe questionnaire was developed based on a literature review with standardised questions employed where possible. For example, Question 3b, ‘The government should prioritise spending on healthcare rather than reducing taxes’, was based on work by the Think-tank for Action on Social Change (TASC) which asked about investing in public services in general [46]. A definition of UHC based on the WHO definition was read out to participants after question one (‘I feel well informed about universal healthcare’) was answered. The definition provided was ‘“Universal Healthcare” is that all people have access to the health services they need (prevention, promotion, treatment, rehabilitation and palliative care) free at the point of access.’ (See Supplementary File A: Questionnaire). Further explanation was provided as required throughout the questionnaire after question one was answered. The questionnaire was piloted with 384 members of the general public in two locations in Dublin, Ireland with contrasting levels of deprivation in a face-to-face researcher-administered format. The pilot data was not included in the current paper as the data were collected through different mediums (telephone versus face-to-face) and also a convenience sample was utilised in the pilot.2.4.1. DemographicsParticipants were asked about their age, gender, where in the country they live (location) and level of education. Self reported health, level of healthcare cover, social class and knowledge of UHC were also recorded.Self-reported health (SRH)SRH was assessed by the answer to a single item ‘How is your health in general?’. There were five response categories: ‘very good, “good”, ‘fair’, ‘bad’, and ‘very bad’. This question has become a standard measure for SRH and due to its format can be compared with Irish and international data [47]. For analysis this variable was collapsed into ‘good self-rating of health’ including ‘very good’ and ‘good’ and ‘poor self-rating of health’ consisting of ‘fair’, ‘bad’ and ‘very bad’.2.4.2. Level of healthcare coverWhether the participant was eligible for the GMS scheme, had private health insurance or neither. Due to small numbers for analysis PHI and neither were collapsed together.2.4.3. Social classThe social grading classification system from The British National Readership Survey (NRS) has been well established and used since the 1960s and was employed in this study [48]. This was determined based on a series of questions about the chief income earner of the household in which the participant resides. This included questions on their employment status, type of employer, occupation, role and qualifications. Social class was divided into 5 categories; AB upper/middle class, C1 lower middle class, C2 skilled working class, DE other working class and F farmers.2.4.4. Knowledge of UHCParticipants were asked to indicate how much they agreed with the following statement on a 5-point scale from ‘strongly agree’ to ‘strongly disagree’. ‘I feel well informed about universal healthcare’. Participants were asked to answer this question before being provided with the definition of UHC. Categories were collapsed down to ‘agree’ (which included ‘strongly agree’ and ‘agree’) and ‘ disagree/neither’ (which included ‘neither’, ‘disagree’ and ‘strongly disagree’). The collapse of the answer categories was determined by those participants who indicated that they did not definitely ‘agree’ or ‘strongly agree’.2.4.5. Opinions and views on UHCParticipants were asked to indicate how much they agreed with the following statements on a 5-point scale from ‘strongly agree’ to ‘strongly disagree’. ‘Having the health service as a public system is important’, ‘The government should prioritise spending on healthcare rather than reducing taxes’, ‘I want healthcare free at the point of access’, ‘People who can pay for healthcare should pay’, ‘I am prepared to pay higher taxes for healthcare free at the point of access’. During analysis categories were collapsed down to ‘agree’ (which included ‘strongly agree’ and ‘agree’) and ‘ disagree/neither’ (which included ‘neither’, ‘disagree’ and ‘strongly disagree’). The collapse of the answer categories was determined by those participants who indicated that they did not definitely ‘agree’ or ‘strongly agree’.2.5. AnalysesA weighted logistic regression model was employed to assess the odds of participants who did not support the introduction of UHC in Ireland versus the odds of participants who did support the introduction of UHC in Ireland, taking demographic factors and opinions into account.Contingency tables were examined to ensure adequate sample size for each parameter. The final logistic regression model was selected based on the lowest Akaike’s information criterion (AIC). Interactions were checked for and none found. Tolerance and generalised variance inflation factors (GVIF) for independent variables were assessed to determine the presence of multicollinearity. All values were within acceptable limits with tolerance values lower than 1 [49] and GVIF values less than 2 [50].Results are displayed in terms of odds ratios (OR) and 95% confidence intervals (CI). ORs range from 0 to infinity with 1.0 meaning no difference in odds and ORs greater than 1.0 meaning that the ratio of those who support the introduction of UHC versus those who do not support the introduction of UHC in the selected group is greater than the reference group. If the 95% CI for OR crosses 1 this indicates that there is no evidence to suggest that there is any difference between the reference and selected group when comparing those who do and do not support the introduction of UHC in Ireland.Analysis was conducted using statistical software SPSS Version 22.3. Results3.1. Response rateA total of 1102 people were invited to complete the questionnaire on UHC after random digit dialling and eligibility checks. From this 972 participants completed the questionnaire providing a response rate of 88.2% as illustrated in Fig. 1: Flowchart of participants.Download high-res image (434KB)Download full-size imageFig. 1. Flowchart of Participants.3.2. Descriptive analysesA demographic description of the sample is provided in Table 1 (non-weighted) and Table 2 (weighted). These are broken down by support for the introduction of UHC in Ireland. An overview of opinions relating to UHC in Ireland are also illustrated.Table 1. Non-weighted demographic description broken down by agreement with UHC.CovariateAgreeDisagreeNeitherTotal84687.0%656.7%616.3%972100.0%Age18–249110.823.1711.510010.325–4428033.12030.82744.332733.645–6430636.22436.92134.435136.165+16920.01929.269.819420.0Missing––––––––GenderMale45954.34467.73659.053955.5Female38745.72132.32541.043344.5Missing––––––––ProvinceDublin24328.71624.61219.727127.9Rest of Leinster22927.11929.21931.126727.5Munster23327.51726.21829.526827.6Connaght/Ulster14116.71320.01219.716617.1Missing––––––––EducationSecondary level or lowera39246.83250.01626.244044.7Third levelb44553.23250.04573.852254.3Missing––––––101.0GMS StatuscGMSd21225.11116.9711.523023.7Private health insurance46655.14467.74472.155457.0Neither16819.91015.41016.418819.3Missing––––––––Social ClassUpper middle class13816.31015.42032.816817.3Lower middle class23227.42132.31829.527127.9Skilled working class13816.3710.8813.115315.7Other working class29635.02436.91016.433034.0Farmers425.034.658.2505.1Missing––––––––Having the health service as a public system is importantAgree80595.24975.45386.990793.3Disagree/Neither414.81624.6813.1656.7Missing––––––––The government should prioritise spending on healthcare rather than reduce taxesAgree73186.42944.63760.779782.0Disagree/Neither11513.63655.42439.317518.0Missing––––––––I want healthcare free at the point of accessAgree73086.33146.22947.578981.2Disagree/Neither11613.73553.83252.518318.8Missing––––––––People who can pay for healthcare should payAgree56767.01523.14268.965967.8Disagree/Neither27933.05076.91931.131332.2Missing––––––––I am prepared to pay higher taxes for healthcare free at the point of accessAgree56666.91929.22642.661162.9Disagree/Neither28033.14670.83557.436137.1Missing––––––––I feel well informed about UHCAgree42149.82335.41118.045546.8Disagree/neither42550.24264.65082.051753.2Missing––––––––Self-reported healthPoor16920.01624.669.819119.7Good67780.04975.45590.278180.3Missing––––––––– = Not applicable.aSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.bThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.cParticipants could select more than one method of health cover. A total of 74 (7.6%) participants indicated having private health insurance as well as some form of a GMS card. These participants were included within the GMS category.dThe state provides a general medical services (GMS) card primarily based on income but also for other criteria such as age and other government schemes (HSE, 2015). This provides free at the point of contact access to healthcare services.Table 2. Weighted demographic description broken down by agreement with UHC.CovariateAgreeDisagreeNeitherTotal84887.5%616.3%606.2%969100.0%Age969100.018–249711.423.3711.710610.925–4432938.82236.13050.038139.345–6427232.12032.81830.031032.065+15017.71727.858.317217.8Missing––––––––Gender969100.0Male40647.93861.33355.047749.2Female44152.12438.72745.049250.8Missing––––––––Province969100.0Dublin25129.61727.41322.028129.0Rest of Leinster22726.81625.81728.826026.9Munster22927.11625.81627.226127.0Connaght/Ulster14016.51321.01322.016617.0Missing10.1Education969100.0Secondary level or lowera38646.03151.71626.743344.6Third levelb45354.02948.34473.352654.2Missing101.2GMS Statusc969100.0GMSd22426.41219.7811.924425.1Private health insurance44452.33963.94067.852354.0Neither18021.31016.41220.320220.9MissingSocial Class969100.0Upper middle class10212.0711.51525.912412.8Lower middle class23227.42032.81931.727128.0Skilled working class17720.9914.81016.719620.3Other working class28633.82236.11016.731832.8Farmers505.934.9610.0596.0Missing10.1Having the health service as a public system is important970100.0Agree80795.34775.85488.590893.6Disagree/Neither404.71524.2711.5626.4Missing––––––––The government should prioritise spending on healthcare rather than reduce taxes969100.0Agree73086.22947.53660.079582.0Disagree/Neither11713.83252.52440.017317.9Missing10.1I want healthcare free at the point of access969100.0Agree73887.13150.82948.379882.4Disagree/Neither10912.93049.23151.717017.5Missing10.1People who can pay for healthcare should pay970100.0Agree55965.94674.24066.764566.5Disagree/Neither28934.11625.82033.332533.5Missing––––––––I am prepared to pay higher taxes for healthcare free at the point of access970100.0Agree56066.12032.32744.360762.6Disagree/Neither28733.94267.73455.736337.4Missing––––––––I fell well informed about UHC969100Agree40748.12134.41118.043945.3Disagree/Neither44051.94065.65082.053054.7Missing––––––––Self-reported health970100.0Poor16919.91524.2610.019019.6Good67980.14775.85490.078080.4Missing––––––––– = Not applicable.aSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.bThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.cParticipants could select more than one method of health cover. A total of 65 (6.7%) participants indicated having private health insurance as well as some form of a GMS card. These participants were included within the GMS category.dThe state provides a general medical services (GMS) card primarily based on income but also for other criteria such as age and other government schemes (HSE, 2015). This provides free at the point of contact access to healthcare services.Examination of Table 1 (non-weighted) shows that females account for 44.5% (n = 433) of the sample, 33.6% (n = 327) were aged between 25 and 44, 54.3% (n = 522) had a third level qualification and 57.0% (n = 554) of participants had PHI.The introduction of UHC in Ireland was supported by 87.0% (n = 846) of participants. The majority of participants also supported the Government prioritising spending on healthcare rather than reducing taxes (82.0%; n = 797), healthcare free at the point of access (81.2%; n = 789) and that having the health system as a public service is important (93.3%; n = 907).3.3. Regression analysesThe final logistic regression model as determined by the AIC is presented in Table 3 with crude and adjusted ORs for participants who support the introduction of UHC in Ireland compared with those who do not support the introduction of UHC in Ireland (‘disagree’ or ‘neither’). The model was statistically significant and fit the data well [x2[20] = 159.712, p < 0.001; Hosmer and Lemeshow, p > 0.05]. This was the most parsimonious model with the lowest AIC.Table 3. Factors Associated With Agreeing With the Introduction of UHC in Ireland (n = 962; 99.0%).Independent variablesCrude OR95% CIAdjusted ORa95% CIAge18–24BaseBase25–440.69(0.31,1.54)0.64(0.24, 1.67)45–641.10(0.64, 1.89)0.88(0.41, 1.87)65+0.98(0.55, 1.72)0.84(0.31, 1.74)GenderMaleBaseBaseFemale1.52(1.03, 2.24)e1.10(0.70, 1.74)ProvinceDublin1.32(0.76, 2.31)2.16(1.13, 4.11)eRest of Leinster0.84(0.49, 1.43)0.78(0.42, 1.46)Munster1.05(0.62, 1.76)1.14(0.62, 2.10)Connaght/UlsterBaseBaseEducationSecondary level or lowerbBaseBaseThird levelc0.73(0.49, 1.08)0.90(0.54, 1.48)GMS StatusGMSdBaseBasePrivate health insurance/Neither0.54(0.32, 0.89)0.53(0.28, 0.99)*Social ClassUpper middle classBaseBaseLower middle class1.16(0.50, 2.72)1.57(0.59, 4.20)Skilled working class0.91(0.41, 2.01)1.52(0.62, 3.74)Other working class0.61(0.26, 1.43)1.09(0.41, 2.84)Farmers0.61(0.27, 1.35)1.18(0.46, 3.01)Having the health service as a public system is importantAgree4.31(2.45, 7.57)e1.65(0.81, 3.34)Disagree/NeitherBaseBaseThe government should prioritise spending on healthcare rather than reduce taxesAgree5.35(3.56, 8.04)e3.43(2.12, 5.57)eDisagree/NeitherBaseBaseI want healthcare free at the point of accessAgree6.80(4.52,10.23)e4.72(2.95, 7.54)eDisagree/NeitherBaseBasePeople who can pay for healthcare should payAgree0.82(0.54, 1.24)0.72(0.44, 1.19)Disagree/NeitherBaseBaseI am prepared to pay higher taxes for healthcare free at the point of accessAgree3.15(2.13, 4.67)e1.91(1.21, 3.03)eDisagree/NeitherBaseBaseI feel well informed about UHCAgree2.62(1.71, 4.02)e2.13(1.32, 3.44)eDisagree/NeitherBaseBaseSelf-reported healthPoorBaseBaseGood0.85(0.51, 1.40)1.21(0.68, 2.17)aLogistic regression- adjusting for other factors included in the model.bSecondary level education includes primary school education (up to the age of 12) and secondary school education (up to the age of 18) and is equivalent to A Levels.cThird level education is any qualification above school e.g. undergraduate degree, postgraduate diploma.dThe state provides a general medical services (GMS) card to households on low income. This provides free at the point of contact access to healthcare services.eStatistically significant.Statistically significant factors associated with support for UHC included location, GMS status and attitudinal related factors (e.g., ‘The government should prioritise spending on healthcare rather than reduce taxes’, ‘I want healthcare free at the point of access’, ‘I am prepared to pay higher taxes for healthcare free at the point of access’ and ‘I feel well informed about UHC’).Adjusting for the effects of other factors, the odds of participants living in Dublin agreeing with the introduction of UHC were greater than those living in Connacht or Ulster (OR 2.16, 95% CI (1.13, 4.11)). The odds for those who do not have a GMS card agreeing with the introduction of UHC were lower than the odds of those who have a GMS card (OR 0.53, 95% CI (0.29, 0.99)). The odds for those who agreed that the Government should prioritise spending on healthcare rather than reducing taxes were greater than the odds of those who indicated ‘disagree’ or ‘neither’ (OR 3.43, 95% CI (2.12, 5.57)). The odds of participants who agreed that they wanted healthcare free at the point of access were greater than the odds of those who did not want healthcare free at the point of access (OR 4.72, 95% CI (2.95, 7.54)). The odds of those prepared to pay higher taxes for healthcare free at the point of access were greater than the odds of those who were not prepared to pay higher taxes for healthcare free at the point of access (OR 1.91, 95% CI (1.21, 3.03)). The odds of those who felt well informed about UHC agreeing with the introduction of UHC were greater than the odds of those who did not feel well informed about UHC (OR 2.13, 95% CI (1.32, 3.44)).4. DiscussionGeneral public support for the introduction of UHC is influenced by demographic factors and related attitudinal factors. The introduction of UHC in Ireland was supported by 87.0% (n = 846) of participants. Of those that supported the introduction of UHC, this was influenced by factors including location, GMS status, opinions on the government prioritising spending on healthcare, healthcare being free at the point of access, taxes being increased to provide care free at the point of access and feeling informed about UHC.Differences in context and reform proposals generate differences in the interests of stakeholders and their positioning on reform making it difficult to make cross-national comparisons [30]. However, in the absence of general population information on this topic it would appear that the high level of support for UHC reported in this study is reflective of support for UHC demonstrated internationally. Web-based surveys with 2241 medical students revealed that 86.8% were supportive of UHC in Ontario and 51.1% in California [51]. A similar sentiment was reported from postal surveys with 1675 physicians in the United States with 89% agreeing that all Americans should receive needed medical care regardless of ability to pay [52].When asked if Government should prioritise spending on healthcare rather than reducing income taxes 82.0% (n = 797) of participants agreed with this statement. The 2015 Behaviour and Attitudes Survey asked a similar question but focused on public services in general rather than just health services. A total of 69% of participants agreed with focusing on spending on public services [46]. This is lower than the support for prioritising spending on healthcare perhaps illustrating the importance placed on healthcare and the support for improving services in this area. This is of importance for health policy leaders and makers, particularly in Ireland, as recent examples of protest and demonstrations from the public have been proven to be effective. For example, public outcry against the removal of the GMS card for those over the age of 70, and the attempted removal of GMS cards to very sick children resulted in a rolling back of these policies during the economic recession.Higher socioeconomic status was the principal determining factor for the willingness of members of the general public to support participating in national health insurance in a cross sectional study in St Vincent and the Grenadines [53]. An examination of individual level dynamics in healthcare attitudes toward UHC between 2008 and 2010 in the United States revealed that respondents did not take a position towards UHC reflective of their income [54]. Similarly in the current study social class was not a significant factor influencing support for the introduction of UHC.The current two-tier system has been shown to be ineffective for all groups, GMS and private, with GMS patients facing long waiting times and private patients high insurance premiums and out of pocket payments for both groups [55]. Despite the system not working for any group GMS status influenced participants’ opinions on the introduction of UHC with those with GMS cards slightly more likely to support the introduction of UHC. This is to be expected as those who have PHI nor neither PHI nor a GMS card could be the ones who experience the most change from the introduction of UHC, and may anticipate that not all change will be positive. For example, the creation of a single tier service may mean that those currently with PHI could experience longer waiting times for hospital treatment under UHC than they currently do, but lower out of pocket payments for primary care services.The current research had a number of strengths and limitations. This is a nationally representative sample with 972 participants (response rate of 88%) providing the views and opinions of the general public on UHC at a time when one of the question marks over the implementation of a plan for healthcare in Ireland centres around public opinion. The questionnaire included questions that have been previously used and extensive piloting was conducted. Data collectors were trained and the data collection process was monitored for quality. However, the sample was not weighted in terms of GMS status with the proportion of GMS holders accounting for 23.7% (n = 230) of the sample versus 36% of the general population. Focusing on level of education 54.3% (n = 522) of the sample had a third level education or higher. This is comparison to 34% of the general population aged between 15 and 64 [56]. Additionally, caution must be taken when interpreting results as the number of respondents who selected the ‘disagree’ or ‘neither’ category for the introduction of UHC was substantially lower that the number of respondents whom agreed with the introduction of UHC.5. ConclusionThis paper is relevant and timely for policy leaders both in Ireland and internationally. In Ireland the Slaintecare Report [2] has been published outlining a ten year plan for the introduction of UHC in Ireland and implementation remaining the key question now. Internationally, these findings are of interest as countries with UHC, such as the United Kingdom, are facing difficulties maintaining health services in the public realm with ongoing debate on the privatisation of the NHS [57] and other countries, such as the United States, are debating universal elements for their healthcare system. The current study provides a template that can be used to explore public opinions of UHC in other countries. There is a high level of support for the introduction of UHC in Ireland, which is influenced by demographic, and related attitudinal factors. Patients and the general public have been acknowledged as having a key role to play in all areas of healthcare. This research provides timely information from a representative sample for the ongoing debate on the future of healthcare in Ireland. Future research should explore what people want to obtain from the introduction of UHC and what they are willing to contribute to ensure that the voice of patients and the public is heard at all stages of developments. It would be interesting for this to be explored from a number of different stakeholder groups such as clinicians.

UHC is not really about life expectancy. It's about Quality of Life.Yes, an increase in Health overall, decrease in infant mortality, decrease in preventable deaths from disease or lack of trauma care, better treatment for the elderly, better diets, adaquate nutrition, and all the other benefits that UHC can bring will undoubtedly increase overall life expectancy.Here is an excellent article about UHC. Perhaps it can answer your questions about what UHC is, and perhaps more importantly, what it is not.Universal Health Coverage: an Overview and Lessons from AsiaTsung-Mei Cheng, JD, MA, Woodrow Wilson School of Public and International Affairs, Princeton UniversityOn December 12, 2012, the United Nations General Assembly passed a landmark resolution on Universal Health Coverage (UHC) in response to calls from a growing number of countries around the world for comprehensive health reforms towards universal health coverage. UHC became a key global health objective, and both the World Bank and WHO have urged nations to prioritize UHC to achieve sustainable development and global security.In the two years since then, the global movement towards UHC has continued to gain momentum, culminating in the launch of the first-ever “Universal Health Coverage Day” on 12 December 2014, an effort sponsored by a global coalition whose members include the Rockefeller Foundation, the WHO, the World Bank, and more than 500 organizations from around the globe. The coalition’s main objective is to “stress the importance of universal access to health services for saving lives, ending extreme poverty, building resilience against the health effects of climate change and ending deadly epidemics such as Ebola.”1Why Is UHC Important?UHC for a country may be defined as access, on equal terms, for all citizens to a specified package of the highest quality health care that country can afford without any citizens suffering financial hardship as a result. It does not preclude citizens from purchasing – with their own funds—additional, elective services such as cosmetic surgery, orthodontics, private hospital rooms, et cetera.UHC is important as a means to fight poverty in the age of deepening income inequality worldwide, recently highlighted dramatically in the important work on wealth and income inequality by the French economist Thomas Piketty in his 2014 book,Capital in the Twenty-First Century. Despite progress in the fight against lethal global diseases such as HIV/AIDS, malaria and other infectious diseases, each year the number of people falling into poverty due to the cost of medical care are growing. It is estimated that each year around 100 million people fall into the poverty trap because of illnesses, and that around one billion people cannot even access needed health care, paving the way for the spread of disease outbreaks around the globe,2 and a vicious cycle of poverty, disease and threat to global health securityLike education, UHC is an important investment in human capital, which is necessary for economic growth and development; UHC lays the framework of opportunity for what Aristotle called “human flourishing,” an idea that has been elaborated by Nobel Prize-winning economist Amartya Sen.3In today’s world of global mobility everyone has a stake in fighting infectious diseases wherever they arise, especially should some infectious diseases become drug-resistant. Nations go to great lengths and spare no financial resources to fight terrorism. Someday even the well off and well insured may come to realize that drug-resistant infectious diseases are biological terrorists. In a real sense, fighting this enemy should be viewed as part of national defense and global health security.Some Caveats in the Use of the Term “UHC”While the general goal UHC is laudable, a note of caution may be in order, because pursuing unrealistic goals will lead to inevitable subsequent disillusionment and barriers to what can be achieved realistically with a more modest agenda. It can also lead to a serious misallocation of resources.First, UHC does not require a universally applicable package of health care services that must be covered. Access to health care in the U.S. means something very different from access to health care in Uganda. Put another way, universal access to health care in a country with a per capita GDP of $50,000 means something different from access to health care in a country with a per capita GDP of $2,000 or less.Second, there is the problem that equal financial access that may be facilitated by health insurance does not necessarily mean equal physical access to high quality health care. Health insurance holds an empty promise if there are physical barriers to health care, high quality or not.Third, it is not clear that the egalitarian precepts that are relevant and economically feasible in countries with a high per-capita income and a low inequality (or Gini coefficient), that is, a relatively equal distribution of income—as in Taiwan, for example—can arbitrarily be imposed on countries with lower GDP per capita but high Gini coefficients, a combination prevalent in much of the developing world, including China. A multi-tier health system with an adequate level of care for the poor may be better than an ideal, egalitarian system that cannot be achieved.These are more than pedantic points. Far too much effort has been made by the governments of western developed countries, and by profit seeking enterprises, to bring to low- and middle-income countries highly sophisticated but also highly expensive health care that those countries simply cannot afford. It could even be said that devoting a nation’s scarce public financial resources to, for example, the construction of highly sophisticated hospitals meeting modern day Western standards actually may harm the health of poor people who then are neglected, all for want of access to much cheaper primary care. Economists recognize this as the age-old concept of opportunity costs, a concept which has become increasingly familiar to health policy makers also. The opportunity cost of highly sophisticated health care within resource-constrained health systems may be high morbidity and premature death among poor people.Health policy analysts and policy makers must be realistic when working within socio-economic constraints. Practically, in terms of global health programs, this means that the approach should be Rawlsian.4 It means that the concern should be mainly over how well the poorest within a country fare and less over whether the distribution of health care in countries conforms to egalitarian ideals.A focus mainly on low-income families within countries would have two consequences.First, it would stress the important role of public health and primary care in improving the health status of the population. Second, it would put into sharper focus the importance of the non-medical determinants of health. There is a well-known trade-off between health care proper and education, especially the education of women, as Chicago economist and Nobel laureate James Heckman would argue. A focus mainly on the plight of the poor in health care also would draw attention to the crucial importance of maternal and child health and nutrition in driving the health of populations.Moving Towards UHCWith the preceding having been duly noted, it can be asked how best to approach UHC for specified benefit packages and in a specific social, economic and political context.One begins this process by clearly articulating the distributional ethic that the health system is supposed to observe. As noted, that ethic is apt to depend on the degree of income inequality in a country.Second, there has to be a clear definition on the package of benefits that is to be financed through insurance coverage.Financing UHCIn regards to financing, one must note that neither government nor employers nor commercial health insurance companies actually ever finance anything. They may pay health care providers for health care delivered, but they will always recoup these outlays fully from private households in the forms of taxes, premiums, or reduction in take-home pay.5All financing originates in private households, unless external (foreign) aid is a major source of a nation’s financing for health care.Developing a financing scheme for UHC is complex. One must consider all possible sources of financing first, and then examine the economic, administrative and ethical merits of each source.The major sources of financing are taxes, premiums, philanthropy within countries, foreign aid, or self-pay by patients. Each of these major categories has several subgroups that differ quite substantially in terms of their ethical implications and behavioral effects. For example “premiums,” a major source of financing, can be based on ability to pay in the form of a fixed percentage of payroll (as in Germany) or charged per capita (as in Switzerland) or based on the individual’s health status (as in the market for individually purchased health insurance in the U.S. prior to the full implementation of the Affordable Care Act of 2010 in 2014.)Different governments may select differing financing sources based on: (a) the administrative feasibility of tapping that source (for example, collection of taxes and premiums), (b) the stability of the base for that financing, (c) the impact on the economic behavior, that is, the manner in which raising the finances might alter economic incentives within the economy, and (d) the fairness of the financing in terms of the distributional ethic posited for the health system.There is no ideal, one-size-fits-all healthcare financing system, because each system is the product of many tradeoffs, compromises and national conditions.The manner in which health care is financed actually is the most crucial vehicle for expressing the desired distributional ethic to govern access to a specified benefit package. Insurance coverage in effect amounts to a redistribution of purchasing power for health care in any given year. For that reason, the method of financing and risk pooling largely defines the degree of egalitarianism in financial, as distinct from physical, access of health care. The provision of physical access of health care to all segments of society is beyond the scope of this paper.As a rule of thumb, the more egalitarian a UHC system is, the more heavily government will have to be involved in the financing of care. It requires social health insurance. A health system that relies purely on private, commercial insurers cannot ever achieve access to health care on egalitarian principles. The market constraints faced by commercial insurance makes it incompatible with equitable access to health care and, in fact, quite natural lead to inequality. Unless they are expressly prohibited by government from doing so, commercial insurers have every financial incentives to base insurance premiums on health status and to reject relatively sick prospective clients unable to pay these “actuarially fair” premiums based on health status.Available evidence to date shows us that countries with social health insurance systems, regardless of whether the health care services are delivered by publicly or privately owned facilities or a mixture of the two, provide their citizens equitable access to affordable health care services, regardless of their citizens’ socio-economic status and ability to pay. Administering Health InsuranceThere are two alternatives for organizing the financing of health care in social health insurance systems: a single-payer approach or a multi-payer approach.Government-Run Single-Payer Systems: The administrative expense of government-run single payer systems (Taiwan, Korea, or each of the Canadian provinces) is usually the lowest attainable because these systems have common nomenclatures which facilitates the effective and efficient functioning of modern IT systems, and does not involve the cost to tax- or premium payers of marketing and profit taking. Single-payer systems also are the best platform for achieving an egalitarian distribution of financial access to health care and of the financial burden of poor health among populations.Social Insurance with Multiple Payers: In many health systems today, including the U.S. and China, there is a trend towards separating the financing and the administration of health insurance.In these health systems, while the government raises the financing of health care to assure an equitable distribution of the financial burden of health care among the population, the tasks of claims processing, quality monitoring and other forms of managed care, and paying provides are delegated to multiple commercial health insurers. Under the U.S. Medicare Advantage program, private insurers perform these functions for Medicare beneficiaries who prefer being served by private insurers. The U.S. Medicaid Managed Care program for the state-based Medicaid system for the poor perform these functions as well, as do the German, Swiss, and Dutch private insurers in their health systems.The arguments made by proponents for that task delegation are that commercial insurers are more “efficient” than are government-run insurance systems and thus are able to achieve substantial savings in the use of health care. The empirical evidence bearing on this assertion, however, remains mixed and unconvincing.6 So far one should treat it as purely a theoretical proposition.Relative to government-run insurance, which has low administrative costs, reliance on multiple commercial health insurers to perform claims processing and paying providers will entail higher administrative costs for marketing, administration, and profits. In the U.S., those costs are now constrained under President Obama’s Affordable Care Act (ACA) to no more than 15% of collected premiums for larger commercial insurers and 20% for small insurers.7Furthermore, lacking the market clout of large, government-run single-payer insurance systems, private insurers typically must pay the providers of health care higher prices for health care. Because private insurers must pay higher prices for health care services and incur higher administrative costs, they can perform the task of administering government-financed health insurance more cheaply than can government-run insurance only if they can reduce the use of health care per insured patient below the use-rate under government-run insurance, and do so without impairing the quality of medical treatments.SustainabilityJust as “UHC” has been a poorly defined term in health policy circles, so has the word “sustainability.” What do users of the term mean by it?There actually are two kinds of “sustainability” for health care systems: one refers to economic sustainability, the otherpolitical sustainability. A health system needs to be both economically and politicallysustainable to be truly sustainable over the long run.“Economic sustainability” means how much of its GDP a nation can afford to allocate to health care, given the many other human needs or desires, all of which seek claims on the nation’s resources. Economic sustainability also could refer to the adequacy over time of the health-care workforce. The issue arises as the dependency ratio – the ratio of the sum of young dependents and the elderly to the number of people of working age – continues to rise worldwide, albeit at different rates across countries. One can only hope that labor-saving technology in health care can come to the rescue here, as most likely it will.“Political sustainability,” on the other hand, means how much the better-off in society would be willing to pay, either with taxes or community-rated health insurance premiums, to help finance the health care needs of lower income citizens who cannot afford to pay for that care with their own resources. It is an aspect of a nation’s dominant social ethic, which is a product of history, contemporary culture and education.Political leadership and support at the top are necessary for building politically sustainable health systems. For example, China’s ambitious and comprehensive health reform that began in 2009, and is continuing and deepening today, would not have been possible without the sustained commitment of leadership at the top to the central value of solidarity and equity for all citizens, coupled with significant investments in the health care sector through public financing. Likewise, as noted above, Vietnam’s ongoing efforts towards UHC would not have been possible without the support and commitment of the country’s top leadership, once again coupled with significant investments in the health sector through public financing and commitment to the principle of solidarity and equity.8Taiwan’s well established universal National Health Insurance is thriving today, also in a fundamental way because of continued political support and commitment from the top, continued commitment to the principle of equity, accompanied by increasing government contributions to the health care sector. Lessons from AsiaThe Asian economies provide a rich pastiche of different approaches to health care systems. Experiences from, for example, Taiwan, South Korea, Hong Kong, China, and Vietnam may be informative.Taiwan and South Korea have adopted a single payer approach, with government-run health insurance system, that manages not only the financing, but also the claims processing, monitoring of quality, fee-negotiation and payment of provider.Both Taiwan and South Korea have tried to broaden the income base on which to levy premium to improve the fairness in financial contributions. Historically both systems have relied solely on payroll income on which to levy premiums.In January 2013 Taiwan implemented a new, supplemental financing scheme that added a 2% premium on six additional sources of non-payroll income (interest, dividend, rental income, professional fees, income from second jobs, and bonuses) to the basic payroll based premium base, levied at 4.91% of salary and wages.9 This reform significantly improved not only the financial status of the NHI, turning it from a status of large deficits to one with a solid surplus, but also the fairness in financial contributions by making the well-to-do pay a larger share of the premium burden.Of the single payer social health insurance systems in operation today, Taiwan’s National Health Insurance (NHI) stands out as an example of a well-functioning system that achieves equity and social solidarity, good cost control, and administrative efficiency. Accounting for 52.2% of Taiwan’s total national health spending of 6.6% of GDP (2013),10Taiwan’s NHI combines a government-administered social health insurance system with a predominantly private delivery system. It provides universal coverage to its 23.4 million citizens with a comprehensive and uniform national benefits package — primary (outpatient) care, inpatient care (including expensive cancer treatments and organ transplants), drugs, dental care, traditional Chinese medicine, dialysis, etc., without waiting lines, at an annual administrative cost of 1.06% of the total NHI budget, and with high public satisfaction (80%).11Going forward, one might conclude that Taiwan’s NHI is economically sustainable for the foreseeable future. At slightly over half of Taiwan’s national health spending of 6.6% of GDP, Taiwan’s NHI appears to have elbow room for growth given Taiwan’s high GDP per capita (PPP) of $41,539 (IMF 2013). In addition, the high public satisfaction the NHI enjoys and the political stability of Taiwan also make Taiwan’s UHC scheme politically sustainable for the foreseeable future.Korea’s single payer National Health Insurance, while quite similar to Taiwan’s single payer National Health Insurance in many respects, has not been able to control health spending growth as well. Among OECD countries, Korea has been the country with the highest rate of health spending growth.12Hong Kong under British rule transplanted the idea of a NHS in the form of the Hong Kong Hospital Authority which managed both the financing and delivery of health care. In that regard it resembles the U.S. Veterans Administration system. It is “socialized medicine” in its purest form.China can be said to be still in the early stages of moving towards UHC. Under Communist rule, prior to market reforms following reform and opening in 1978, there existed in China what might be called UHC for whatever health care benefits China could deliver at that time — primarily primary care and public health. With the market reforms that began in 1978, that system was destroyed. It gave way to a market-oriented health system in which just 55% of the urban and 21% of the rural population had any health care coverage in 2003.13 Those who had high income had coverage for ever more sophisticated health care. Prices for health care went through the roof, a fact also enjoyed by many manufacturers of health care products inside China and abroad.In 2009, China began a comprehensive health reform that addressed all the important areas that needed reform, namely, health insurance expansion, establishment of the essential drug list, expansion of capacity of the health-care delivery system focusing on grassroots health care facilities and workforce, expansion and equalization of public health services, and public hospital reform. Today most of China’s population has access to health insurance (more than 96% and 99-100% in some rural areas)14 for some benefit packages, although the specific health services vary significantly among provinces of varying wealth in urban and rural regions. The Chinese government’s ultimate goal is to bridge this chasm in benefits coverage. At the moment, China appears to be grappling with differentiating the roles of the public and private sectors and searching for the appropriate role of the private sector, for example, engaging private commercial insurers to perform the functions of claims processing, quality monitoring, and payment of providers. It is a work in progress, through trials and errors.It remains to be seen what China’s experimentation with delegating the tasks of claims processing, quality monitoring and paying providers will achieve in the longer run. The original intent of China’s health reform since 2009 has been to develop a “harmonious society” where “everyone enjoys equal access to basic health care and medical services.”15This would imply a roughly egalitarian health system with financing based on ability to pay, and access to health care provided on roughly equal terms. However, unless that reform effort is very closely monitored by government and kept channeled in that direction, the Chinese health care system may end up more like the U.S. system, which is a patchwork of quite distinct health insurance systems – socialized medicine for the veterans, a single payer for the elderly and the poor, and a health system substantially segmented by risk class for everyone else, and last but not least, a system that always will be very expensive and always will beget much waste.16Vietnam, which has recently entered the ranks of lower-middle-income countries, has made significant progress towards UHC under a government-run single payer health system whose core structure relies on a national network of primary care facilities and strong emphasis on public health. It should be noted that Vietnam’s ongoing efforts towards UHC and achievements so far would not have been possible without the support and commitment of the country’s top leadership, once again coupled with significant investments in the health sector through public financing and a firm commitment to the principle of solidarity and equity, and competent health care bureaucracy under the ministry of health.17Developing countries and emerging market countries seeking UHC may be well served to start with a single payer social health insurance system like Taiwan’s National Health Insurance for equity, good cost control, and administrative efficiency, and allow both public and private providers to compete and deliver health-care services. Taiwan’s approach followed the recommendation in 1989 of Princeton economist Uwe Reinhardt to adopt a single-payer health insurance system, a recommendation which the government adopted in 1990.18 According to Reinhardt, once the financing and administration are in the hands of government, market forces could be engaged where they are not counter-productive to the achievement of desired social goals – in Taiwan’s case, an egalitarian and affordable health system.Multi-payer social insurance systems tend to be more costly to run, as is the case with Germany’s social health insurance system, the Swiss system, or the U.S. Medicare Advantage system. Offering citizens a choice of insurance carriers – as distinct from freedom choice of providers of health care—is not a free lunch, it costs money.Summary and ConclusionThe world-wide drive by the World Bank, the World Health Organization, and hundreds of organizations devoted to the cause for UHC will entail a very long and very hard struggle. Health reform takes a long time in even the richest of countries (the U.S., Switzerland, the Netherlands, et cetera).For one, the task is technically quite complex, as has become abundantly apparent from the passage and the implementation of the ACA, which in fact addresses only a small part of the U.S. health care system.Second, the task faces an uphill struggle for political reasons because, however structured, UHC entails a significant redistribution of income from the well-to-do to the poor and from the healthy to the sick. People may endorse that redistribution at the rhetorical level but get serious second thoughts when it comes time to step up to the cashier’s window. We have witnessed that, too, in the wake of the passage of the ACA.As this author reported in a 2003 paper, “Taiwan’s New National Health Insurance: Genesis and Experience So Far,”19 a major lesson from Taiwan shows that so-called “windows of opportunity” should not be missed in efforts to move to UHC. This is a particularly important lesson for low-and middle-income countries. In Taiwan, that window of opportunity consisted of rapid economic growth averaging 9% a year through the 1980s, a budding democratic electoral system in which health reform had become a major plank in party platforms, a powerful leader willing to expend political capital on the issue, and a highly motivated and well-educated bureaucracy willing and able to embrace the complicated task of implementing the system. This confluence of factors made it possible for Taiwan to develop the blueprint for UHC in the short period of a little of over half a decade beginning in the late 1980s, pass the NHI Law in July 1994, and commence fullimplementation in March 1995, less than a year after the law’s passage and five years ahead of the scheduled implementation date of 2000.Had Taiwan not moved up the implementation when it did in 1995, it would have run into the Asian financial crisis of 1997 which might have put the break on the full implementation of the plan, perhaps even indefinitely as economic growth in Taiwan had slowed in the years since.For students of health policy and for health policy makers, Taiwan provides the textbook model on designing and implementing a system of UHC.It is possible to have, or build, universal, sustainable, 21st century health care systems. The world has seen how it could be done, and also how significant progress can be made with limited resources through judicious approaches to organizing the financing and delivery of essential health care services. Indeed, barring future global financial shocks like the 2008 financial crisis, countries seeking UHC may confidently walk the path towards UHC and provide their citizens health care and the opportunity for realizing their full human potential, not even to dwell on the contributions healthy people and healthy lives can make to a country’s economic growth and prosperity.The Rockefeller Foundation, World Health Organization, and World Bank Group. “500 Organizations Launch Global Coalition to Accelerate Access to Universal Health Coverage: On first-ever Universal Health Coverage Day, all countries urged to make quality health coverage accessible to everyone, everywhere.” universalhealthcoverageday.org. ↩The Rockefeller Foundation, World Health Organization, and World Bank Group. “500 Organizations Launch Global Coalition to Accelerate Access to Universal Health Coverage: On first-ever Universal Health Coverage Day, all countries urged to make quality health coverage accessible to everyone, everywhere.” universalhealthcoverageday.org ↩Amartya Sen. Equality of What? The Tanner Lecture on Human Values. Delivered at Stanford University. May 22, 1979. ↩John Rawls. A Theory of Justice. Cambridge, Massachusetts: Belknap Press of Harvard University Press, 1971. ↩Tsung-Mei Cheng and Uwe E. Reinhardt. Perspective on the Role of the Private Sector in Meeting Health Care Needs, in Benedict Clements, David Cody and Sanjeev Gupta, eds. The Economics of Public Health Care Reform in Advanced and Emerging Economies. International Monetary Fund. Washington, DC. (2012): 69-98. ↩Marsha Gold. Medicare Advantage – Lessons for Medicare’s Future. New England Journal of Medicine, vol. 366, 2012: 1174-77. ↩Suzanne M. Kirchoff. Medical Loss Ratio Requirements under the Patient Protection and Affordable Care Act (ACA): Issue for Congress. Congressional Research Service, 7-5700, R42735, August 26, 2014. ↩Tsung-Mei Cheng. Vietnam’s Health Care System Emphasizes Prevention and Pursues Universal Coverage.Health Affairs. November 2014. 33(11). 2057-2063. ↩Tsung-Mei Cheng. Reflections on the 20th Anniversary of Taiwan’s Single-Payer National Health Insurance System. Health Affairs 34, No. 3 (2015): 502-510. ↩Ministry of Health and Welfare. 2012 Health Statistical Trends. Chapter III-2. Ministry of Health and Welfare. Taiwan. Last update August 1, 2014. ↩Tsung-Mei Cheng. Reflections on the 20th Anniversary of Taiwan’s Single-Payer National Health Insurance System. Health Affairs 34, No. 3 (2015): 502-510. ↩Tsung-Mei Cheng. “Taiwan and Other Advanced Asian Economies,” Chapter 19, Part IV, What Can Canada Learn from the International Evidence,” in Gregory P. Machildon and Livio Di Matteo eds. Bending the Cost Curve in Health Care: Canada’s Provinces in International Perspective. University of Toronto Press, Toronto, Canada. 2015. 445-462. Data based on OECD Health Statistics 2013. 457. ↩Tsung-Mei Cheng. Early Results of China’s Historic Health Reforms: The View from Minister Chen Zhu.Health Affairs. Volume 31, No. 11 (2012): 2536-2544. ↩Author’s personal meeting with Chen Zhu, vice president of China’s National People’s Congress and former minister of health (2006-2013), in Beijing, China, March 19, 2015. ↩Tsung-Mei Cheng. China’s Latest Health Reforms: A Conversation with Chinese Health Minister Chen Zhu.Health Affairs. Volume 27, No. 4, July/August 2008. 1103-1110. ↩Institute of Medicine of the National Academies. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. The National Academy Press. September 2012. Table 3-1. ↩Tsung-Mei Cheng. Vietnam’s Health Care System Emphasizes Prevention and Pursues Universal Coverage.Health Affairs. November 2014. 33(11). 2057-2063. ↩National Health Insurance Planning Task Force, Council for Economic Planning and Development. Republic of China (Taiwan). A Summary of the National Health Insurance (NHI) Plan Adopted by the Republic of China (Taiwan). Council for Economic Planning and Development, Republic of China (Taiwan), June 25, 1990. Taipei, Taiwan. 9. ↩Tsung-Mei Cheng. Taiwan’s New National Health Insurance: Genesis and Experience So Far. Health Affairs.Volume 22, Number 3, May/June 2003. 61-76. ↩

Please read and you decide which is your preference. I made mine…If you move to the US, here is what you get:Statistics from WHO, UNICEF, the Global Competitiveness Report, and the Institute for Health Metrics and Evaluation (IHME)The GCR in fact said "The U.S. had an extraordinarily big number of very low rankings"Here’s where the US stands compared to the rest of the world:#10 most dangerous country for women#27 in overall education (down from #17 in 2017)#27 in human capital (level of education and health in a population — in 1990 the US was #6)#12 in university degrees#38 in quality of primary education#47 in quality of math and science education#47 in overall healthcare (down from #44 in 2017)LAST in healthcare “efficiency, equity and outcomes”#64 in life expectancy (down from #43 in 2017)#34 healthiest country — includes life expectancy, causes of death, and health risks (high blood pressure, tobacco use, malnutrition, availability of clean water, etc.)WORST rate of maternal death in the developed world#26 in infant mortality rates#47 in infant survival#26 in child well-being#25 in child poverty#14 in per capita murders#7 in quality of life#80 in soundness of banks#14 in availability of latest technology#24 in internet access in schools#19 in national satisfaction#67 in slavery (yes that’s TODAY)#30 in reliability of police services#7 in broadband internet availability (even Korea ranks higher)#33 in internet speed (even Romania ranks higher)#23 in gender equality#46 in freedom of the press (this was before trump — we’ll drop like a stone now)#23 in housing#125 in literacy#17 in happiness#8 in quality of older adult life#99 in peacefulness#24 in freedom from corruption (again this was before trump)#9 in retirement security#10 in economic freedom#23 in wage distribution#11 in minimum wage#25 in GDP per capita#7 in homicides#12 in prosperity#25 in overall infrastructure#33 in quality of electricity supply#99 in mobile telephone subscriptions#20 in quality of roadsThe US does rank #1 or #2 in these things:#1 in percentage of population in prison#1 in teen pregnancies#1 in CO2 emissions#1 in gun deaths#1 in drug overdose deaths#1 in healthcare costs#1 in small arms imports#1 in rape#1 in divorces#1 heart attacks#1 in total crimes#1 in rate of income inequality in the developed world#1 most unequal developed nation (as of 2019)#2 in child poverty#2 in general ignoranceCanada:Health Data:Canadaand this…:Canada is the 6th richest nation on earth consistently rated as one of the top 4 nations on earth to live; often number one or 2. The US never makes it past 15th placeWe live longer than Americans, have less violence, lower maternal and infant mortality, less people in jail per capita than the US and a lower crime rate overall.We have a larger middle class and less disparity between rich and poor.Our inner cities are livable and you can walk, safely, in almost any of them at midnight.We have less mental illness and better supports for those that are ill.We have less homelessness per capita than the US.We don’t have ghettos.Our population is better educated. Our literacy rate is higher than the US by almost 10 %; 98.4 % as apposed to 89 %. Imagine—the US has more than 30 million people that can’t read and write.We have UHC and never have to worry about paying medical bills because there are none.If not covered by insurance our drugs cost less than 20 percent of US costs.If not covered by insurance our dental is less than 50 percent of US costs.We have a more stable banking system, the envy of the world, that allowed us to weather the 2008 recession without a major meltdown and will allow us to weather the 2020 recession without major pain. Indeed many countries are now trying to emulate our financial system.The US lives to work and we work to live making us less money grubbing and more interested in living comfortably. We don’t want to be rich but rather have enough to enjoy our families and country. We will take lifestyle over money every time.In Canada the dollar isn’t everything whereas in the US it is almost everything.We are peace loving and polite and respected throughout the world as peacekeepers.We don’t have the rampant racism of the US.We do not hold your religion or sexual orientation against you. We really don’t care as we don’t see that as important.Our election cycle is about 6 to 8 weeks long rather than 2 years allowing our elected reps to actually govern instead of campaigning