Towards Universal Health Coverage
This op-ed appeared on the New York Times website on April 5, 2012 and in print on April 6, 2012, in The International Herald Tribune.
by David de Ferranti, president of the Results for Development Institute in Washington and Julio Frenk, former minister of health in Mexico, and dean of the Harvard School of Public Health.
Two recent events underscore the disparity between the United States and the rest of the world on health coverage. Last week, American reactions to the Supreme Court hearings showed how deeply divided the nation is on the subject. This week, at an international forum in Mexico City, country delegates from around the globe made clear that they are not only aiming for universal coverage but also rapidly getting there.
Except for the United States, the 25 wealthiest nations now have some form of it. Others are not far behind, including Brazil and Thailand. Even nations at lower income levels, such as the Philippines, Vietnam, Rwanda and Ghana are working toward it. India, South Africa, China and Colombia are on the move, too.
Mexico has just crossed the goal line. Its reformers would be the first to say that many more improvements are needed, but their accomplishment is nonetheless noteworthy because they faced challenges no less daunting than the United States does today — and had fewer resources to draw on (Mexico’s economy is one tenth the size of the United States’). Special interests resisted change, dysfunctional fragmentation impeded progress, and poor, highly needy groups dispersed in remote locations had to be reached.
One of the hardest challenges was that many Mexicans — from top leaders to ordinary citizens — were skeptical that any solution would help. So the reformers had to find powerful evidence, which included pilot-testing of their proposals. Also key was a strategy that combined expansion of coverage with two other initiatives. A new means of paying doctors and hospitals ended incentives to provide as many services as possible. An emphasis on prevention helped avert illness and its high costs. All three were essential: If the latter two elements had been absent, expansion of coverage would have been too expensive.
The United States now faces this same problem. If the Supreme Court strikes down the Obama law, there could still be a hefty expansion in coverage because much of that expansion has already happened, and voters would resist having it taken away. But the cost-containment components in the law would be killed, so costs overall could shoot up — the exact opposite of what many opponents of the bill want.
What other lessons are there from Mexico’s and other countries’ efforts?
For starters, the ABCDE of successful reform is crucial.
A — agenda — means that a compelling case has to be made, linking health improvement to other societal concerns, such as economic growth, job creation and political stability.
B — budget — is about securing adequate resources, though the United States, which spends far more on health already than others do per person, needs to focus on spending more efficiently.
C — capacity — is about ensuring that the right infrastructure is in place to meet the expanded demand.
D — deliverables — means that the reforms have to deliver on their promises if support for them is to be sustained.
E — evidence and evaluation — stresses the importance of continuously probing for ways to improve.
Another lesson is that universal coverage cannot be achieved through employer plans alone, since they don’t reach the large numbers of self-employed, unemployed, retired people and those who work in small businesses.
Still another lesson is that one size definitely does not fit all. A country’s culture and politics matters. Take, for instance, the roles of government and the private sector. The fears some Americans have about big government are not borne out by results in other countries, where the private sector continues to have a vibrant roles, especially in the provision of services, while the government concentrates more on financing, stewardship of the whole system and ensuring a level playing field.
The U.S. health care system already has much more of a public-private mix than is commonly realized — in some ways far more that in less developed countries. Also, success doesn’t come overnight: An eight-year transition period was needed in Mexico, and some countries have taken longer.
Historically, many things that today people everywhere agree should be collective responsibilities were once purely private matters. The United States, for example, led the way in making education universal long before most other countries did.
Experiences from elsewhere — including lessons about what not to do — can help the United States to better craft whatever is best for its own unique needs and preferences. They can also suggest ways to use American ingenuity to get beyond rancor and ideology and get down to the nuts and bolts.
The trend elsewhere toward universal coverage and Mexico’s achievement this week stand as reminders of how much the United States can attain if it finds its way again to the problem-solving leadership role