Universal healthcare (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized around providing either all residents or only those who cannot afford on their own with either health services or the means to acquire them, with the end goal of improving health outcomes.
Universal healthcare does not imply coverage for all cases and for all people – only that all people have access to healthcare. Some universal healthcare systems are government-funded, while others are based on a requirement that all citizens purchase private health insurance. Universal healthcare can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered. It is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship. The Director General of WHO describes universal health coverage as the “single most powerful concept that public health has to offer” since it unifies “services and delivers them in a comprehensive and integrated way”. One of the goals with universal healthcare is to create a system of protection which provides equality of opportunity for people to enjoy the highest possible level of health.
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 established a fully public and centralized health care system in 1920. However, it was not a truly universal system at that point, as rural residents were not covered.
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), Iceland (1956), Norway (1956), Denmark (1961), and Finland (1964). 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. The Soviet Union extended universal health care to its rural residents in 1969. Italy introduced its Servizio Sanitario Nazionale (National Health Service) in 1978. Universal health insurance was implemented in Australia beginning with the Medibank system which led to universal coverage under the Medicare system, introduced in 1975.
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. In addition, universal health coverage was introduced in some Asian countries, including South Korea (1989), Taiwan (1995), Israel (1995), and Thailand (2001).
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 and Brazil's SUS which improved coverage up to 80% of the population. 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.
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 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. Most universal health care systems are funded primarily by tax revenue (as in Portugal, Spain, Denmark and Sweden). Some nations, such as Germany, France, and Japan, employ a multipayer system in which health care is funded by private and public contributions. However, much of the non-government funding comes from contributions from 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 medications are paid for by a state agency. A paper by Sherry A. Glied from Columbia University found that universal health care systems are modestly redistributive and that the progressivity of health care financing has limited implications for overall income inequality.
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 the Canadian provinces). Healthcare in Switzerland is based on compulsory insurance.
In some European countries where 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 in eliminating 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.
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 much less expensive 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, withdrew from the Irish market.
In Poland, people are obliged to pay a percentage of the average monthly wage to the state if they are not covered by private insurance.
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 by limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.
Single-payer health care is a system in which the government, rather than private insurers, pays for all health care costs. Single-payer systems may contract for healthcare services from private organizations (as in Canada) or own and employ healthcare resources and personnel (as was the case in England before the introduction 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.
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, New Zealand, Italy, Spain, Brazil, Portugal 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
In a social health insurance system, contributions from workers, the self-employed, enterprises and governments are pooled into a single or multiple funds on a compulsory basis. This is based on risk pooling. The social health insurance model is also referred to as the Bismarck Model, after Chancellor Otto von Bismarck, who introduced the first universal health care system in Germany in the 19th century. 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. Social health insurance is used in a number of Western European countries and increasingly in Eastern Europe as well as in Israel and Japan.
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.
In some countries with universal coverage, private insurance often excludes certain health conditions that are expensive and the state health care system can provide coverage. 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, most of which are routinely provided by the National Health Service. In the United States, dialysis treatment for end stage kidney failure is generally paid for by government and not by the insurance industry. Those with privatized Medicare (Medicare Advantage) are the exception and must get their dialysis paid for through their insurance company. However, those with end stage kidney failure generally cannot buy Medicare Advantage plans. In the Netherlands, which has regulated competition for its main insurance system (but is subject to a budget cap), insurers must cover a basic package for all enrollees, but may choose which additional services they offer in supplementary plans (which most people possess - citation needed).
The Planning Commission of India has also suggested that the country should embrace insurance to achieve universal health coverage. General tax revenue is currently used to meet the essential health requirements of all people.
Community-based health insurance
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 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
Universal health care systems vary according to the degree of government involvement in providing care or health insurance. In some countries, such as Canada, 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 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.
A critical concept in the delivery of universal healthcare is that of population healthcare. This is a way of organising the delivery, and allocating resources, of healthcare (and potentially social care) based on populations in a given geography with a common need (such as asthma, end of life, urgent care). Rather than focus on institutions such as hospitals, primary care, community care etc. the system focuses on the population with a common as a whole. This includes people currently being treated, and those that are not being treated but should be (i.e. where there is health inequity). This approach encourages integrated care and a more effective use of resources.
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. A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004. 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.
- Global health
- Healthcare reform debate in the United States
- Health insurance cooperative
- List of countries by health insurance coverage
- National health insurance
- Primary healthcare
- Public health
- Publicly funded health care
- Right to health
- Single-payer healthcare
- Socialized medicine
- Two-tier healthcare
- World Health Organization (November 22, 2010). The world health report: health systems financing: the path to universal coverage. Geneva: World Health Organization. ISBN 978-92-4-156402-1. Retrieved April 11, 2012.
- "Universal health coverage (UHC)". Retrieved November 30, 2016.
- Matheson, Don * (January 1, 2015). "Will Universal Health Coverage (UHC) Lead to the Freedom to Lead Flourishing and Healthy Lives? Comment on "Inequities in the Freedom to Lead a Flourishing and Healthy Life: Issues for Healthy Public Policy"". International Journal of Health Policy and Management. 4 (1): 49–51. doi:10.15171/ijhpm.2015.09. PMC 4289038. PMID 25584354.
- Abiiro, Gilbert Abotisem; De Allegri, Manuela (July 4, 2015). "Universal health coverage from multiple perspectives: a synthesis of conceptual literature and global debates". BMC International Health and Human Rights. 15: 17. doi:10.1186/s12914-015-0056-9. ISSN 1472-698X. PMC 4491257. PMID 26141806.
- "Universal health coverage (UHC)". World Health Organization. December 12, 2016. Retrieved September 14, 2017.
- Rowland, Diane; Telyukov, Alexandre V. (Fall 1991). "Soviet Healthcare From Two Perspectives" (PDF). Health Affairs. 10 (3): 71–86. doi:10.1377/hlthaff.10.3.71. PMID 1748393.
- "OECD Reviews of Health Systems OECD Reviews of Health Systems: Russian Federation 2012": 38. Cite journal requires
- Abel-Smith, Brian (1987). "Social welfare; Social security; Benefits in kind; National health schemes". The new Encyclopædia Britannica (15th ed.). Chicago: Encyclopædia Britannica. ISBN 978-0-85229-443-7. Retrieved September 30, 2013.
- Richards, Raymond (1993). "Two Social Security Acts". Closing the door to destitution: the shaping of the Social Security Acts of the United States and New Zealand. University Park: Pennsylvania State University Press. p. 14. ISBN 978-0-271-02665-7. Retrieved March 11, 2013.
Mein Smith, Philippa (2012). "Making New Zealand 1930–1949". A concise history of New Zealand (2nd ed.). Cambridge: Cambridge University Press. pp. 164–65. ISBN 978-1-107-40217-1. Retrieved March 11, 2013.
- Serner, Uncas (1980). "Swedish health legislation: milestones in reorganisation since 1945". In Heidenheimer, Arnold J.; Elvander, Nils; Hultén, Charly (eds.). The shaping of the Swedish health system. New York: St. Martin's Press. p. 103. ISBN 978-0-312-71627-1.
Universal and comprehensive health insurance was debated at intervals all through the Second World War, and in 1946 such a bill was voted in Parliament. For financial and other reasons, its promulgation was delayed until 1955, at which time coverage was extended to include drugs and sickness compensation, as well.
- Kuhnle, Stein; Hort, Sven E.O. (September 1, 2004). "The developmental welfare state in Scandinavia: lessons to the developing world". Geneva: United Nations Research Institute for Social Development. p. 7. Retrieved March 11, 2013.
- Evang, Karl (1970). Health services in Norway. English version by Dorothy Burton Skårdal (3rd ed.). Oslo: Norwegian Joint Committee on International Social Policy. p. 23. OCLC 141033.
Since 2 July 1956 the entire population of Norway has been included under the obligatory health national insurance program.
- Gannik, Dorte; Holst, Erik; Wagner, Mardsen (1976). "Primary health care". The national health system in Denmark. Bethesda: National Institutes of Health. pp. 43–44. hdl:2027/pur1.32754081249264.
- Alestalo, Matti; Uusitalo, Hannu (1987). "Finland". In Flora, Peter (ed.). Growth to limits: the Western European welfare states since World War II, Vol. 4 Appendix (synopses, bibliographies, tables). Berlin: Walter de Gruyter. pp. 137–40. ISBN 978-3-11-011133-0. Retrieved March 11, 2013.
- Taylor, Malcolm G. (1990). "Saskatchewan medical care insurance". Insuring national health care: the Canadian experience. Chapel Hill: University of North Carolina Press. pp. 96–130. ISBN 978-0-8078-1934-0.
Maioni, Antonia (1998). "The 1960s: the political battle". Parting at the crossroads: the emergence of health insurance in the United States and Canada. Princeton: Princeton University Press. pp. 121–22. ISBN 978-0-691-05796-5. Retrieved September 30, 2013.
- Kaser, Michael (1976). "The USSR". Health care in the Soviet Union and Eastern Europe. Boulder, Colo.: Westview Press. pp. 38–39, 43. ISBN 978-0-89158-604-3.
Roemer, Milton Irwin (1993). "Social security for medical care". National health systems of the world: Volume II: The issues. Oxford: Oxford University Press. p. 94. ISBN 978-0-19-507845-9. Retrieved September 30, 2013.
Denisova, Liubov N. (2010). "Protection of childhood and motherhood in the countryside". In Mukhina, Irina (ed.). Rural women in the Soviet Union and post-Soviet Russia. New York: Routledge. p. 167. ISBN 978-0-203-84684-1. Retrieved September 30, 2013.
- "Austerity and the Unraveling of European Universal Health Care". Dissent Magazine. Retrieved November 30, 2016.
- Bärnighausen, Till; Sauerborn, Rainer (May 2002). "One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries?". Social Science & Medicine. 54 (10): 1559–87. doi:10.1016/S0277-9536(01)00137-X. PMID 12061488.
Busse, Reinhard; Riesberg, Annette (2004). "Germany" (PDF). Health Care Systems in Transition. 6 (9). ISSN 1020-9077. Retrieved October 8, 2013.
Carrin, Guy; James, Chris (January 2005). "Social health insurance: key factors affecting the transition towards universal coverage" (PDF). International Social Security Review. 58 (1): 45–64. doi:10.1111/j.1468-246X.2005.00209.x. Retrieved October 8, 2013.
Hassenteufel, Patrick; Palier, Bruno (December 2007). "Towards neo-Bismarckian health care states? Comparing health insurance reforms in Bismarckian welfare systems" (PDF). Social Policy & Administration. 41 (6): 574–96. doi:10.1111/j.1467-9515.2007.00573.x. Retrieved October 8, 2013.
Green, David; Irvine, Benedict; Clarke, Emily; Bidgood, Elliot (January 23, 2013). "Healthcare systems: Germany" (PDF). London: Civitas. Archived from the original (PDF) on October 5, 2013. Retrieved October 8, 2013.
- "WHO - Rocky road from the Semashko to a new health model". Retrieved November 30, 2016.
- Yu, Hao (2015). "Universal health insurance coverage for 1.3 billion people: What accounts for China's success?". Health Policy. 119 (9): 1145–52. doi:10.1016/j.healthpol.2015.07.008. PMID 26251322.
- Gómez, Eduardo J. (July 13, 2012). "In Brazil, health care is a right". CNN. Retrieved August 20, 2018.
- Muzaka, Valbona (2017). "Lessons from Brazil: on the difficulties of building a universal health care system". Journal of Global Health. 7 (1): 010303. doi:10.7189/jogh.07.010303. ISSN 2047-2978. PMC 5344008. PMID 28382207.
- Eagle, William. "Developing Countries Strive to Provide Universal Health Care". Retrieved November 30, 2016.
- "Universal Healthcare on the rise in Latin America". Retrieved November 30, 2016.
- Bentes, Margarida; Dias, Carlos Matias; Sakellarides, Sakellarides; Bankauskaite, Vaida (2004). "Health care systems in transition: Portugal" (PDF). Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. Retrieved August 30, 2006.
- Physicians for a National Health Program (2004). "International health systems". Chicago: Physicians for a National Health Program. Retrieved November 7, 2006.
- Chua, Kao-Ping (February 10, 2006). "Single payer 101" (PDF). Sterling, Virginia: American Medical Student Association. Archived from the original (PDF) on October 24, 2006. Retrieved November 7, 2006.
- Glied, Sherry A. (March 2008). "Health Care Financing, Efficiency and Equity". NBER Working Paper No. 13881. doi:10.3386/w13881.
- Tomasky, Michael (March 21, 2010). "Healthcare vote: Barack Obama passes US health reform by narrow margin". Michael Tomasky's blog. London: The Guardian. Retrieved March 23, 2010.
- Roy, Avik. "Switzerland – a case study in consumer driven health care". Forbes.
- Varkevisser, Marco; van der Geest, Stéphanie (2002). "Competition among social health insurers: a case study for the Netherlands, Belgium and Germany" (PDF). Research in Healthcare Financial Management. 7 (1): 65–84. Archived from the original (PDF) on May 16, 2013. Retrieved November 28, 2007.
- "Ubezpieczenie dobrowolne".
- Rothschild, Michael; Stiglitz, Joseph (November 1976). "Equilibrium in competitive insurance markets: an essay on the economics of imperfect information" (PDF). Quarterly Journal of Economics. 90 (4): 629–49. doi:10.2307/1885326. JSTOR 1885326. Archived from the original (PDF) on December 3, 2008. Retrieved March 20, 2007.
- Belli, Paolo (March 2001). "How adverse election affects the health insurance market. Policy Research Working Paper 2574" (PDF). Washington, D.C.: World Bank. Retrieved March 20, 2007.
- single-payer, Merriam Webster Dictionary
- "Health Care Systems - Four Basic Models | Physicians for a National Health Program".
- Saltman, Richard B.; Busse, Reinhard; Figueras, Josep (eds.). "Social health insurance systems in western Europe" (PDF). Cite journal requires
- World Health Organization (2008). "Health financing mechanisms: private health insurance". Geneva: World Health Organization. Archived from the original on October 9, 2010. Retrieved April 11, 2012.
- Bupa (2010). "Individuals: Health and life cover: Health care select 1: Key features of this health insurance plan: What's covered? What's not covered?". London: Bupa. Archived from the original on April 9, 2010. Retrieved April 11, 2010.
- Centers for Medicare & Medicaid Services (2010). "Medicare coverage of kidney dialysis & kidney transplant services" (PDF). Baltimore: Centers for Medicare & Medicaid Services. Archived from the original (PDF) on May 27, 2010. Retrieved April 11, 2010.
- Varshney, Vibha; Gupta, Alok; Pallavi, Aparna (September 30, 2012). "Universal health scare". Down To Earth. New Delhi: Society for Environmental Communications. Retrieved September 25, 2012.
- Gray, M.; Pitini, E.; Kelley, T.; Bacon, N. (2017). "Managing population healthcare". Journal of the Royal Society of Medicine. 110 (11): 434–439. doi:10.1177/0141076817721099. PMC 5728616. PMID 29148874.
- National Audit Office (February 1, 2003). "International health comparisons: a compendium of published information on healthcare systems, the provision of health care and health achievement in 10 countries". London: National Audit Office. Retrieved November 7, 2007.
- Grosse-Tebbe, Susanne; Figueras, Josep (2004). "Snapshots of health systems: the state of affairs in 16 countries in summer 2004" (PDF). Copenhagen: World Health Organization on behalf of the European Observatory on Health Systems and Policies. Archived from the original (PDF) on September 26, 2007. Retrieved November 7, 2007.
|Wikimedia Commons has media related to Universal healthcare.|
- Achieving Universal Health Care (July 2011). MEDICC Review: International Journal of Cuban Health and Medicine 13 (3). Theme issue: authors from 19 countries on dimensions of the challenges of providing universal access to health care.
- Catalyzing Change: The System Reform Costs of Universal Health Coverage (November 15, 2010). New York: The Rockefeller Foundation. Report on the feasibility of establishing the systems and institutions needed to pursue UHC.
- Physicians for a National Health Program Chicago: PNHP. A group of physicians and health professionals who support single-payer reform.
- UHC Forward Washington, D.C.: Results for Development Institute. Portal on universal health coverage.