The whole is greater than the sum of its parts: the importance of integrated, universal, and equitable healthcare coverage

This article is related to:

Determinants of private health insurance coverage among Mexican American men 2010–2013

Introduction

A Cypriot farmer, back in the 1850s, unearthed an ancient tablet. Little did he know that this artefact was the embodiment of the first unofficial health insurance scheme. This tablet was engraved in 450 BC by King Stasiκypros, thus sealing an agreement with doctor Onisilos, to provide healthcare for his soldiers, who were defending his under-siege Kingdom. In return, the king would reimburse the required medical services with gold plates. All details of this first-reported health insurance were delineated on the brass artefact, thus emerging as the first documented health coverage scheme. In order to attest the agreement, the tablet was deposited at Athena’s temple. Any potential infringement of the agreement would incite the rage of the Goddess, which also documents that Athena was literally the first appointed medical auditor.

Many centuries later, the World Health Organization (WHO) underpinned the profound significance of an Universal Health Coverage (UHC), which is epitomized in its declaration affirming that a universal healthcare coverage is “the most powerful concept that public health has to offer”¹.

Health systems exist in diverging designs, each one moulded and carved by the corresponding country’s history, social norms, and even geography. Indicatively, as many Europeans were bereaved by the end of the second world war, this prompted authorities to introduce universal health coverage systems to alleviate suffering. Nevertheless, despite the diversity, all systems abide by the principles of equity, financial protection, efficiency, and quality.

A health system can be appraised via the assessment of the three core dimensions of provided universal coverage, namely its depth (percentage of population covered), its breadth (the multitude of provided services), and its height (the proportion of total costs covered by pre-payment)^2,3. In certain cases, a significant gap exists between the discordant actual and the perceived attributes. Factors such as an ageing population, the introduction of new and expensive treatment modalities, over-diagnosis, and the asymmetry of information which deprives patients from the ability to perform informed decision-making are to be blamed for this phenomenon.

The determinants for healthcare coverage should be void of socioeconomic factors, and all patients should enjoy the same, timely, and equitable coverage. Equity emerged as the pinnacle of a health system, and it comprises absence of avoidable or remediable differences among groups of people, pertinent to distinct social, economic, demographical, or geographical criteria and timely access^2,3.

Nevertheless, several authors outlined that patients, primarily enrolled in multi-payer systems, experience inequity pertaining to optimum health coverage^3–6. The relentless rise in healthcare costs spirals to higher deductibles, and increased patient cost-sharing, thus exposing patients to a potential catastrophic financial effect, in tandem with a restrained range of benefits⁴. This is further compounded by obstinate differences stemming out of socio-economic status, which have permeated in the provision of healthcare, and in some cases have acquired a dominant role. Therefore, a significant proportion of insured patients are actually under-insured, since the confluence of the aforementioned attributes impede timely access.

Health inequalities perpetuate to significant health outcome discrepancies, which erode the core tenets of a UHC. In a recent systematic review, it was underscored that the insurance type was a determinant of survival in advanced stage colorectal lung, prostate, and breast cancer⁵. Such disparities were described in many healthcare sectors such as orthopaedic care, paediatrics, and cardiology. These results aligned with corresponding findings hailing from the EU, which delineated that beneficiaries enrolled in public schemes are consistency marginalized⁶. Discrimination against patients enrolled in public insurance was proved to be profitable for hospitals, and a positive correlation was substantiated⁷. Moreover, even switching between insurances, an alleged advantage of a multi-payer system, is largely obstructed by benefit loss costs, sunk costs, and learning costs, to no avail of the legal actions that European (EU) countries have taken, in order to facilitate a switch⁸.

In the first issue of Volume 21 (2018) of Journal of Medical Economics, van der Goes & Santo⁹ cast light to the determinants of health insurance coverage for Mexican Americans, a testament to the profound inequities of health systems. They concluded that “although most Americans obtain health insurance through the workplace, employed Mexican American men are the least likely to have private health insurance coverage”. While not lagging in hours worked per week, compared to the general population, Mexican American enjoyed less coverage. The authors corroborate that Mexican American men have systematic and persistent lower health insurance coverage through private health insurance (PHI).

What’s the road forward?

An ambitious plan to implement a single-payer healthcare system, which has notched significant interest, in Vermont was aborted in 2014. This could have signalled the first single-payer entity in the US, and could have paved the way for further dissemination of single payer systems. Critics of single payer systems expostulate that this would jeopardize Vermont’s fiscal integrity. Primarily, the feasibility of the single payer system merits additional elucidation. The relevant costs should be decomposed in order to reach the core of a single-payer financing outlook. Even though the final decision reported that the “system was untenable and an unwise choice”, this scheme would reduce Vermont’s overall health spending and lower costs for the 90% of Vermont families with household incomes under $150,000. Despite divergent projections and estimates (three assessments provided deviating results: from immediate system wide savings of 8–12% and an additional 12–14% over time, or more than $2 billion over 10 years, and requirements for new payroll taxes of 9.4% for employers and new income taxes of 3.1% for individuals to replace health insurance premiums, to 1.6% savings over 5 years, and foresaw required new taxes of 11.5% for employers and up to 9.5% for individuals) all three studies demonstrated that a single payer entity was economically feasible, and its critics dissuaded authorities from its implementation pawning on legitimate political considerations¹⁰. Some contend that new taxes would be glaringly evident on every Vermonter’s tax bill, while few contemplate that these new taxes would have replaced soaring private insurances premiums and would culminate to a marginal—if any at all—monetary burden. Therefore, the context of new taxes comprises a pre-text rather than a genuine fiscal threat. Ultimately, while the additional projected costs, germane to additional health services, would have been higher stemming out from the provision of healthcare to the whole population, a commensurate reduction of administrative costs could have been rendered. This would yield net savings of 35 million by 2017, while, at the same time, a comprehensive and integrated care to all residents would have been attained.

These assumptions have been materialized in the South Korea paradigm, which reported a reduction of managerial costs (from 8.5% in 1997 to 2.4% in 2008), attributed to the standardization of operational processes as the country implemented a single payer health system¹¹. Taiwan’s transition to a single payer system generated savings that have virtually offset the incremental cost ascribed to the provision of healthcare to the whole population¹².

Capitalizing on the findings of van der Goes & Santo⁹ and contemplating on Vermont’s case, to all intents and purposes ensnared by politics and failure to embrace the public, there is still a chance to recuperate and yield control of limited access to the necessary healthcare. Nearly half of the health insurance coverage gap between Mexican American men and non-Hispanic men can be explained—and it is imputed—to human capital characteristics such as education, language, and immigration status.

Moreover, their reduced income constitutes the single biggest determinant to their health insurance gap. These findings further bolster the overarching need for a universal and integrated health system, which could redistribute needs and resources and, most importantly, shield the poorer and sicker from disproportionate health expenses, relative to their income. Vermont could serve as a building block to assuage critics that a single payer is feasible, and extrapolating from recent advances in countries such as Taiwan, we can rule out a devastating effect of the single payer system, as many people have beguiled by this. van der Goes and Santo⁹ clearly highlight the imperative need to act, since the ramifications of inequity obtrude along the trajectory of healthcare provision.

Transparency

Declaration of funding

There is no funding to report.

Declaration of financial/other relationships

The author has disclosed that he has no significant relationships with, or financial interests in, any commercial companies related to this article. JME peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgements

None reported.