Category Archives: Universal health care

Yes, Medicare for All is expensive. That’s not the point but who loses?

37913774_1639263202869999_2457300851903954944_nI’m more confused as I read more and more about Medicare for All. Who is telling the truth? Diane Archer, founder and former president of the Medicare Rights Center and president of JustCareUSA.org. recently wrote that something interesting is happening in the age of Trump: 63 percent of Americans support a national health insurance plan, or Medicare for All, in which the federal government would guarantee health insurance for everyone in the country.

Mounting support for Medicare for All has left conservatives hyperventilating. Commercial insurers and their Republican allies are working overtime to convince Congress and the electorate that we simply can’t “afford” Medicare for All. A report by the Mercatus Center’s Charles Blahous, who spearheaded President George W. Bush’s attempt to privatize Social Security, is the latest entry in this fuzzy math sweepstakes.

Happily, for those of us who seek health-care security for all Americans, Blahous and his friends miss the point. Our commercial health insurance system is crazy and unsustainable, and Medicare for All is the only realistic path to reduce national health spending and improve the quality of our health-care system.

Sen. Bernie Sanders’s Medicare for All proposal improves and expands the current Medicare program, replacing commercial health insurance with federally administered coverage for all Americans. The proposal eliminates premiums, deductibles, and co-pays, and includes new coverage for vision, hearing and dental care. It allows everyone to use the doctors and hospitals they know and trust, anywhere in the country, without the restrictive networks, arbitrary denials and high out-of-pocket costs that go hand in hand with commercial insurance.

Medicare for All, like Social Security, is social insurance, designed to pool and broadly distribute the costs of care across the entire population. At its core, Medicare for All gives doctors and hospitals the freedom to compete for patients without insurers getting in the way.

Blahous writes that Medicare for All is expensive. That’s correct, but it’s the wrong starting point. The current commercial health insurance system is much more expensive than Medicare for All and is unsustainable by any measure.

We spend more than $3.3 trillion a year on health care — about 18 percent of the gross domestic product. That’s twice as much per capita on health care as the average of other high-income countries. In return, we get health-care outcomes that rank dead last among our peers. Health-care costs in this country are projected to increase by 5.5 percent a year over the next eight years. You do the math: The status quo doesn’t work. Period.

Medicare for All, by contrast, provides a compelling path to keeping health-care costs in check. To begin with, Medicare for All would eliminate the administrative waste and profit margins created by the commercial insurance system with hundreds of insurers negotiating different agreements with thousands of health-care providers. Total annual savings on administrative costs under Medicare for All are estimated as high as $500 billion a year (far more than Blahous estimates in his report).

Most important, Medicare for All would empower the federal government to use the collective bargaining power of 330 million Americans to reduce the cost of health care, something that commercial insurers have been unable to do. Blahous himself estimates that the extension of current Medicare rates to all health-care services coupled with lower prescription drug prices under Medicare for All would eliminate $445 billion in annual costs in 2022.

In all, Blahous concedes that Medicare for All would reduce national health spending by $2 trillion over 10 years; even after accounting for the cost of guaranteeing everyone coverage and offering better benefits. (And again, many health economists would say Medicare for All would drive far greater savings.)

Blahous’s concern is that Medicare for All will transfer the rest of the cost of health care from the private sector to the federal government. Okay. So how will we pay for Medicare for All? The same way we pay for the defense budget and everything else: through taxes. Does that mean that ordinary Americans will pay more under Medicare for All that they pay for healthcare today? No.

Think about it. Today, the typical family of four spends more than $28,000 on health care a year. Individuals pay that cost indirectly through lower wages (which fund the employer’s share of health insurance) and directly through out-of-pocket costs. Under Medicare for All, the typical family will see higher wages and lower expenses and spend much less on health care than it does today.

To be sure, the transition to Medicare for All will disrupt the health-care marketplace. Insurers will wind down. Pharmaceutical companies and medical device manufacturers likely will see their profits drop. Hospitals and doctors will need to work smarter and more efficiently; they will see an overall reduction in their rates, but they will save on administrative costs and their bills will all be paid.

There are always winners and losers in policy reform. Today, commercial insurers and other corporate interests in the health-care industry are the winners, and the American people are the losers. Medicare for All flips that paradigm. We can’t afford to live without it.

But at what cost to patient and caregiver?

Bernie Sanders Supporters Admit His Socialized Medicine Plan Will Ration Care

If Bernie Sanders wants to take a ‘victory lap’ for a study arguing that millions of health workers will receive the same amount of money for more work, I have four words: Good luck with that.

Christopher Jacobs noted that the move to enact single-payer health care in the United States always suffered from major math problems. This week, it revived another: Common sense.

On Monday, the Mercatus Center published an analysis of single-payer legislation like that promoted by socialist Sen. Bernie Sanders (I-VT). While conservatives highlighted the estimated $32.6 trillion price tag for the legislation, liberals rejoiced.

Sanders even released a video thanking Mercatus for its study, claiming that it showed how his bill would reduce overall national health expenditures by $2 trillion. In other words, Sanders claims his bill will provide more health care coverage to more Americans, and at less cost.

Riiiiiigggggggghhhhhhhhhttttt. As the old saying goes, if something sounds too good to be true, it usually is. Given that even single-payer supporters have now admitted that the plan will lead to rationing of health care, the public shouldn’t just walk away from Sanders’ plan—they should run.

National Versus Federal Health Spending

Sanders’ claim arises because of two different terms the Mercatus paper uses. While Mercatus emphasized the way the bill would increase federal health spending, Sanders chose to focus on the study’s estimates about national health spending.

Essentially, the $32.6 trillion figure—the amount of taxes that a single-payer bill must raise over its first decade—represents the cost of bringing the entire health-care system on to the federal government’s books. While bringing the health-care system on-budget will obviously require massive tax increases, the Mercatus paper assumes that doing so will cause overall national health spending to drop slightly.

Although it sounds large in absolute terms, the Mercatus paper assumes only a slight drop in health spending in relative terms. It estimates a total of $2.05 trillion in lower national health expenditures over a decade from single-payer. But national health expenditures would total $59.7 trillion over the same time span—meaning that, if Mercatus’ assumptions prove correct, single-payer would reduce national health expenditures by roughly 3.4 percent.

Four Favorable Assumptions Skew the Results

However, to arrive at their estimate that single-payer would reduce overall health spending, the Mercatus paper relies on four highly favorable assumptions. Removing any one of these assumptions could mean that instead of lowering health care spending, the single-payer legislation would instead raise it.

First, Mercatus adjusted projected health spending upward, to reflect that single-payer health care would cover all Americans. Because the Sanders plan would also abolish deductibles and co-payments for most procedures, study author Chuck Blahous added an additional factor reflecting induced demand by the currently insured, because patients will see the doctor more when they face no co-payments for doing so.

But the Mercatus study did not consider whether providing completely free health care to all U.S. residents will induce additional migration, adding even more costs to the system. As Hillary Clinton testified before Congress in 1993: “We do not think the comprehensive health care benefits should be extended to those who are undocumented workers and illegal aliens. We do not want to do anything to encourage more illegal immigration into this country. We know now that too many people come in for medical care, as it is.”

Second, the Mercatus study assumes that a single-payer plan can successfully use Medicare reimbursement rates. However, the non-partisan Medicare actuary has concluded that those rates already will cause half of the hospitals to have overall negative total facility margins by 2040, jeopardizing access to care for seniors.

Expanding these lower payment rates to all patients would jeopardize even more hospitals’ financial solvency. But paying doctors and hospitals market-level reimbursement rates for patients would raise the cost of a single-payer system by $5.4 trillion over ten years—more than wiping away any supposed “savings” from the bill.

Third, by its own admission, Mercatus assumes “virtually perfect success” for a single-payer system in replacing brand-name drug usage with generics. If the government cannot achieve “virtually perfect success” in increasing generic drug utilization—and a cynic might ask whether the government has achieved even imperfect success in anything—or greater government “negotiating” power has little effect in jawboning down prices, then the estimated costs of single-payer will rise.

Finally, the Mercatus paper “assumes substantial administrative cost savings,” relying on “an aggressive estimate” that replacing private insurance with one single-payer system will lower health spending. Mercatus made such an assumption even though spending on administrative costs increased by nearly $26 billion, or more than 12.3 percent, in 2014, Obamacare’s first year of full implementation.

Likewise, government programs, unlike private insurance, have less incentive to fight fraud, as only the latter face financial ruin from it. The $60 billion problem of fraud in Medicare provides more than enough reason to doubt many administrative savings from a single-payer system.

Apply the Common Sense Test

But put all the technical arguments aside for a moment. As I noted above, whether a single-payer health-care system will reduce overall health expenses rests on a relatively simple question: Will doctors and hospitals agree to provide more care to more patients for the same amount of money?

Whether single-payer will lead to less paperwork for doctors remains an open question. Given the amount of time people spend filing their taxes every year, I have my doubts that a fully government-run system would generate major improvements.

But regardless of whether providers get any paperwork relief from single-payer, the additional patients will come to their doors seeking care, and existing patients will demand more services once the government provides them for “free.” Yet doctors and hospitals won’t get paid any more for providing those additional services. The Mercatus study estimates that spending reductions due to the application of Medicare’s price controls to the entire population will all but wipe out the increase in spending from new patient demand.

If Sanders wants to take a “victory lap” for a study arguing that millions of health care workers will receive the same amount of money for doing more work, I have four words for him: Good luck with that.

Also, consider the health care workers, especially the physicians.                        Libertarian think tank: Providers would pay for Medicare for All                     Susannah Luthi reviewed libertarian take on the Medicare for All concept further and found that the Medicare for All plan backed by Sen. Bernie Sanders would put the brunt of the proposals costs on provider pay cuts.
In a white paper released Monday by the Mercatus Center of George Mason University, senior research strategist Charles Blahous claimed healthcare spending constraints laid out in the plan from the Vermont independent senator fall almost totally on providers. The plan could save the U.S. more than $2 trillion over 10 years in national health care spending but could increase the federal government’s costs to nearly $33 trillion above current levels, according to Blahous’ calculations.
Nearly all the savings for national health spending come from across-the-board Medicare rate cuts, which Blahous projects would reduce provider payments by $384 billion in the first year, and by nearly $660 billion in 2030.
This analysis will likely push single-payer advocates to hone their message on healthcare pricing to make their proposal viable, said Benedict Ippolito, a health economist with the right-leaning American Enterprise Institute.
“Provider payment cuts are doing a lot of heavy lifting here,” Ippolito said. “Changes to provider payments, whether you love them or not, have real consequences. And those real consequences extend beyond a budgetary score.”
While the U.S. healthcare system does need to grapple with the “right price to pay for healthcare,” Ippolito said, proponents of the Sanders plan and others like it need to determine what the right rate could be and how it will impact provider behavior, which determines major components of the healthcare system—investments in equipment and buildings, patient access and health outcomes.
“It’s easy to think about prices as one piece of a broader market, but the thing that’s special about prices is that it’s the key that unlocks the whole thing,” he added. “Whatever price you set will be highly consequential for the entire market. The decision you make for good or bad is extremely consequential, and you can’t get around that.”
Single-payer advocates lauded the paper’s findings that the projected provider cuts would roughly pay for universal coverage. The Mercatus analysis also estimated the health care system would save billions every year on drug spending since the Sanders Medicare for All plan allows the HHS secretary to negotiate prescription drug prices with the manufacturers—and presumably refuse to buy certain high-priced drugs.
But Blahous warned that the Sanders blueprint for coverage would likely lead to a huge spike in overall healthcare utilization, not only because more people would automatically be covered for services like dental and vision care but also because it bans any co-pays or deductibles.
“As a general rule, the greater the percentage of an individual’s health care that is paid by insurance … the more healthcare services an individual tends to buy,” Blahous wrote.
Blahous maintained that the jury is still out on whether MACRA effectively reins in provider costs, warning that the Medicare for All transition could disrupt access to health care as universal coverage goes into effect. He also noted that while some Medicaid-dependent providers would see a pay boost in the early years as their traditionally much-lower Medicaid reimbursements would rise to Medicare rates, they would start losing money soon after.
To back up his warning, Blahous cited the CMS’ Office of the Actuary’s projections that current payments would lead to negative operating margins for nearly half of hospitals by 2040. By 2019, over 80% of hospitals will lose money treating Medicare patients. A dramatic structural change to reimbursement structure could shutter many provider doors, Blahous wrote.
The paper acknowledged that phasing out employer-sponsored health care would translate into a huge increase in taxable wages, as it would free individuals, families, and employers from hefty healthcare spending. States would also no longer have to fund Medicaid, consistently their largest budget item.
“These offsetting effects should be considered when weighing the implications of requiring federal taxpayers to finance the enormous federal expenditure increases under M4A,” Blahous wrote. “These estimates should be understood as projecting the added federal cost commitments under M4A, as distinct from its net effect on the federal deficit. To the extent that the cost of M4A is financed by new payroll taxes, premium collections, or other revenue increases, the net effect on the federal budget deficit would be substantially less.”
The picture the Mercatus study paints for utilization in the healthcare system runs counter to the latest House Republican push to leverage health savings accounts to cut spending on superfluous services.
Last week, the House passed a packet of bills originally projected to cost more than $90 billion to expand the use of HSAs. In a subsequent speech before the conservative Heritage Foundation, HHS Secretary Alex Azar praised HSAs as a way to lower unnecessary spending, saying that from his own behavior when he had an HSA he was much more cautious about the number and manner of services on which he was willing to spend a limited number of dollars.
The Democratic Party at large is keeping Sanders’ Medicare for All plan at arm’s length, but its principles are gaining traction within the party. Prominent Democratic senators including Elizabeth Warren of Massachusetts, Kamala Harris of California and New Jersey’s Cory Booker have signed onto Sanders’ bill.
In the House, progressive Washington Democrat Pramila Jayapal founded a Medicare for All caucus to try to hammer out a comprehensive, streamlined platform over the next conference. More than 60 House Democrats have joined Jayapal’s group.
But Ippolito said the new paper highlights that single-payer proponents will need to acknowledge the political fight on their hands.
“In my time of listening to these single-payer proposals, a lot of emphases is on administrative savings—they appeal to that because they don’t rile up constituencies,” he said. “But going after provider payment rates means taking on one of the most well-organized constituencies in domestic policy. When I read this, it struck me as: this really wants to pick a fight. It promises the moon, but it does set up, surely, that something’s got to give here.”                                                                                                                                Health Care Rationing Ahead                                                                                                       I’ll give the last word too, of all things, a “socialist perspective.” One blog post yesterday actually claimed the Mercatus study underestimated the potential savings under single-payer: “[The study] assumes utilization of health services will increase by 11 percent, but aggregate health service utilization is ultimately dependent on the capacity to provide services, meaning utilization could hit a hard limit below the level [it] projects” (emphasis mine).                                                                                                                                 In other words, spending will fall because so many will demand “free” health care that the government will have to ration it. To socialists who yearningly long to exercise such power over their fellow citizens, such rationing sounds like their utopian dream. But therein lies their logic problem, for any American with common sense.

More to follow next week as we get closer to the truth.

First Boys Rescued From Thailand Cave as Rest of Youth Soccer Team Awaits Safety. But What About the Thai Health Care System?

Untitled.Extra

Karen Mizoguchi of People magazine reported this morning that rescue operations have begun for the 12 boys and their coach trapped at the Thailand cave for more than two weeks.

On Sunday, after at least eight hours since a team of divers started rescue efforts, at least four boys have emerged from the cave, as reported by multiple news outlets. The Thai Navy SEAL official Facebook page also confirmed four players were evacuated.

In addition, two ambulances were seen leaving the site with one boy believed to be in each. A team of 13 international cave diving experts and five Thai Navy SEALs entered the cave with the mission of accompanying each boy one by one through the flooded tunnels, that claimed the life of a former Thai Navy SEAL diver on Friday.

“Two kids are out. They are currently at the field hospital near the cave,” Tossathep Boonthong, chief of Chiang Rai’s health department and part of the rescue team, told Reuters. “We are giving them a physical examination. They have not been moved to Chiang Rai hospital yet.”

The bobbleheads then when on to taut the wonder of the Thai healthcare and how wonderful it is and that it is free universal health care.

Well, even as I have only one or two more edits on my original post for the week on Bernie Sanders and his Medicare for All policy, I thought that I would look at the Thai health care system. Is it as great as the commentators have been suggesting?

So, what is the health care system in Thailand all about?

Wikipedia states that Thailand has had “a long and successful history of health development,” according to the World Health Organization. Life expectancy is averaged at seventy years and a system providing universal health care for Thai nationals has been established since 2002.

Health and medical care are overseen by the Ministry of Public Health (MOPH), along with several other non-ministerial government agencies, with total national expenditures on health amounting to 4.3 percent of GDP in 2009.

Non-communicable diseases form the major burden of morbidity and mortality, while infectious diseases including malaria and tuberculosis, as well as traffic accidents, are also important public health issues.

Infrastructure                                                                                                                               Most services in Thailand are delivered by the public sector, which by 2010, included 1,002 hospitals and 9,765 health stations. Universal health care is provided through three programs: the civil service welfare system for civil servants and their families, Social Security for private employees, and the universal coverage scheme that is theoretically available to all other Thai nationals. Some private hospitals are participants in the programs, but most are financed by patient self-payment and private insurance. According to the World Bank, under Thailand’s health schemes, 99.5 percent of the population have health protection coverage.

The MOPH oversees national health policy and also operates most government health facilities. The National Health Security Office (NHSO) allocates funding through the universal coverage program. Other health-related government agencies include the Health System Research Institute (HSRI), Thai Health Promotion Foundation (“ThaiHealth”), National Health Commission Office (NHCO), and the Emergency Medical Institute of Thailand (EMIT). Although there have been national policies for decentralization, there has been resistance in implementing such changes and the MOPH still directly controls most aspects of health care.

Thailand introduced universal coverage reforms in 2001, one of only a handful of lower-middle income countries to do so. Means-tested health care for low-income households was replaced by a new and more comprehensive insurance scheme, originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card, which allows them to access services in their health district and, if necessary, to be referred for specialist treatment elsewhere.

The bulk of health financing comes from public revenues, with funding allocated to contracting units for primary care annually on a population basis. According to the WHO, 65 percent of Thailand’s healthcare expenditure in 2004 came from the government, while 35 percent was from private sources. Thailand achieved universal coverage with relatively low levels of spending on health, but it faces significant challenges: rising costs, inequalities, and duplication of resources.

Although the reforms have received a good deal of criticism, they have proved popular with poorer Thais, especially in rural areas, and they survived the change of government after the 2006 military coup. Then, the Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the scheme free. It is not yet clear whether the scheme will be modified further under the military government that came to power in May 2014.

In 2009, annual spending on health care amounted to 345 international dollars per person in purchasing power parity (PPP). Total expenditures represented about 4.3 percent of gross domestic product (GDP). Of this amount, 75.8 percent came from public sources and 24.2 percent from private sources. Physician density was 2.98 per 10,000 population in 2004, with 22 hospital beds per 100,000 population in 2002

Data for utilization of health services in 2008 include 81 percent contraceptive prevalence, 80 percent antenatal care coverage with at least four visits, 99 percent of births attended by skilled health personnel, 98 percent measles immunization coverage among one-year-olds, and 82 percent success in the treatment of smear-positive tuberculosis. Improved drinking-water sources were available to 98 percent of the population, and 96 percent were using improved sanitation facilities (2008).

Most hospitals in Thailand are operated by the Ministry of Public Health. Private hospitals are regulated by the Medical Registration Division. Other government units and public organizations also operate hospitals, including the military, universities, local governments, and the Red Cross.

Government Health Services                                                                                                            In Thailand, government-funded health care is funded by the Department of Medical Services at the Ministry of Public Health. The Ministry is in charge of public health services, government hospitals, and medical services. Public health facilities in Thailand offer good medical services, but government hospitals are often crowded, which means waiting times can be long. In addition, facilities in public hospitals may not be as good as those in private hospitals in Thailand. Treatment is completely free for Thai citizens holding a Universal Coverage Health card, except on Saturdays, when a charge is made. The National Health Security Office issues this Universal Coverage Health card. Normal charges apply for non-Thais, but these charges will be less than in a private hospital.

Private Medical Sector                                                                                                            Thailand is one of the leading medical tourism destinations in Asia. Most of the private hospitals in Thailand have excellent medical facilities and staff.

Non-Profit Health Organizations                                                                                                      A variety of agencies exist in Thailand to help disadvantaged people. These agencies include the Red Cross, World Vision, and Médecins Sans Frontières.

Doctors in Thailand                                                                                                                        Most of the doctors in Thailand are specialists. For this reason, it may be difficult for you to find a reliable general practitioner to treat you for minor medical issues. At a general hospital, a doctor who is a specialist in a certain field will most likely examine you. It may be difficult for this specialist to deal with a number of smaller medical conditions that you might have. The best idea for you might be to seek an internist as your first resort.

Please note that there are still major hospitals in Thailand that employ family doctors or medical practitioners. In addition, most doctors in Thailand do not have one specific place of work. Thai surgeons and physicians are employed at different hospitals that can be spread all over the city. Some of these doctors also have private clinics. For this reason, doctors in Thailand are likely to go from hospital to hospital to do their rounds. Some issues arise from this. For example, if you have just had surgery and a problem arises, your surgeon may have already left for another hospital and may have to deal with your situation over the phone.

Emergency Transport Facilities                                                                                       Emergency transport facilities in Thailand are unfortunately somewhat lacking. Although large hospitals in Thailand do have mobile intensive care units, you will rarely see an ambulance racing through the streets of Bangkok. Traffic accidents are attended to by volunteer organizations. The main obstacle in terms of emergency transport is the traffic in Bangkok; cars do not generally move out of the way for an ambulance.

Thailand has had a universal health-care coverage scheme since 2002. Apiradee Treerutkuarkul examines how renal-replacement therapy for the chronic end-stage renal disease is straining the scheme’s resources.

In 1998 21-year-old Thunyalak Boonsumlit fell ill so her worried parents took her to hospital. “I thought I had food poisoning,” she recalls. The doctor, however, told her she had acute kidney disease and would die without immediate treatment. There was more bad news: although her parents were insured by Thailand’s Civil Servant Medical Benefit Scheme, this scheme only covers dependents up to the age of 20. Boonsumlit was treated for a month and sent home.

In 2002 Thailand reformed its public health financing system. This extended the scope of coverage to 18 million people who were uninsured and to a further 29 million who were previously covered by less-comprehensive schemes.

It was the realization of a project that had been a quarter of a century in the making, starting with the creation of a social welfare scheme for the poor in 1975. The new scheme offered comprehensive health care that included not just basics, such as free prescription drugs, outpatient care, hospitalization and disease prevention, but more expensive medical services, such as radiotherapy, surgery and critical care for accidents and emergencies. But it did not cover renal-replacement therapy due to budget constraints. Boonsumlit and thousands of fellow sufferers were on their own.

“There was a concern that renal-replacement therapy could burden the system. Major health risks leading to kidney diseases, such as diabetes and hypertension, were still not well controlled,” says Dr. Prateep Dhanakijcharoen, deputy secretary general of the National Health Security Office, which oversees the Universal Coverage Scheme. And renal replacement therapy is expensive. The cost of hemodialysis is about 400,000 baht (US$ 12,100) per year. This is four times higher than the 100,000 baht (US$ 3,000) per quality-adjusted life year threshold set by the National Health Security Office’s benefits package subcommittee for drugs and treatments. This threshold was adopted as a national benchmark.

Dhanakijcharoen believes that the Universal Coverage Scheme plan should have included kidney disease from the outset, a view shared by Dr. Viroj Tangcharoensathien, director of the International Health Policy Programme at the Ministry of Public Health. It was a simple matter of fairness: “There are three health-care schemes in Thailand,” he says. “Only the Universal Coverage Scheme did not include renal-replacement therapy.”

In 2005 Boonsumlit became ill again and was diagnosed with end-stage renal disease. For a year her parents had to pay 400,000 baht (US$ 12,100) to cover her dialysis. This time she was told that if a suitable donor could be found, a kidney transplant was the best option. The procedure cost 300,000 baht (US$ 9,000). Boonsumlit’s mother donated a kidney, and once again she and her husband paid all the bills, including the cost of post-transplant medication required to prevent the rejection of a new kidney.

But there was increasing community pressure for change. People like Subil Noksakul, who had spent his life savings on medical treatment over a period of 19 years, were tired of being treated like pariahs. “I once managed to save 7 million baht. But all my savings are now all gone,” he says. Like everyone else, he found it unacceptable that the Civil Servant Medical Benefit Scheme and the Social Security Scheme, which rely on public funds, both offered treatment for kidney disease while the Universal Coverage Scheme did not.

In 2006 Noksakul founded the Thai Kidney Club, which raised kidney patients’ awareness of their rights and put pressure on the National Health Security Office to provide treatment. Finally, in January 2008, the then public health minister, Mongkol Na Songkhla, bowed to public pressure and included renal-replacement therapy in the scheme. For Boonsumlit, Noksakul and thousands of other kidney patients, it was a watershed moment.

Unsurprisingly, since 2008, demand for treatment has spiraled. According to Dhanakijcharoen, 2.5 billion baht (US$ 76 million) of the total annual National Health Security Office budget of 120 billion baht (US$ 3.62 billion) has been allocated to renal-replacement therapy with 8,000 patients receiving haemodialysis and 4000 receiving peritoneal dialysis: to meet the full need, this treatment would require a huge increase in funding.

“The cost of renal replacement therapy is still less than 2% of the total budget,” he says, but warns the cost could blow out should Thailand fail to focus on prevention and reduce new cases.

The Ministry of Public Health’s Tangcharoensathien paints an even starker picture: “Without alternatives, renal-replacement therapy, when fully scaled up to target end-stage kidney patients, could consume more than 12% of the Universal Coverage Scheme annual budget, and push it to the verge of financial crisis,” he says.

The National Health Security Office is trying to reduce some costs by encouraging patients to perform their own peritoneal dialysis at home. This is dialysis in which patients filter their own blood by periodically injecting fluid into the abdominal cavity, which is later drained. Tangcharoensathien believes nurses can play a crucial role in training patients and family members to use equipment that is provided free of charge under universal coverage. Meanwhile, those patients who continue with the more expensive hemodialysis must now pay one-third of the total cost of treatment.

It is debatable whether home-treatment would have a big impact on costs, given the increased risk of infection and subsequent expenses associated with peritoneal dialysis, which costs up to 240,000 baht (US$ 7,300) annually. However, it would save rural patients the twice-weekly fares to visit a hemodialysis center in a provincial city, which poor patients cannot afford. The National Health Security Office aims to reduce the cost of peritoneal dialysis to about 200,000 baht (US$ 6000) per year.

More promising perhaps is the government’s broader campaign to improve the nation’s renal health. Screening for diabetes and hypertension, as part of a 2.5 billion baht (US$ 76 million project) is due to start this year. According to the National Health Security Office’s Dhanakijcharoen, the project will cover 5500 communities and municipalities nationwide. “Although the current health-promotion fund is still insufficient, it is a good start for prevention and early detection of diabetes and hypertension among local residents,” Dhanakijcharoen says, adding that encouraging healthier lifestyles will also help to reduce the cost of chronic disease and the burden it places on the health budget.

Tangcharoensathien concurs: “If the government allocated more budget to run the scheme, the National Health Security Office would be able to invest more in reducing health risks, and people would not end up with kidney disease in the first place.”

Both men are eager to see the latest universal coverage initiative succeed. They are proud of what has been achieved on total health expenditure equivalent to 4% of gross domestic product (GDP) – compared to the world median of 6.2% of GDP and 4.5% for lower-middle income countries. Dhanakijcharoen says, “We would like to let the world know that it’s not necessary to launch a universal health-care system only when the money is there; what is important is to work steadily on it. But dedication is a must.”

The Question is what Thailand can teach the world about universal healthcare

The Asian nation proves that a well-researched system with dedicated leadership can improve health, affordably. In 10 years, its plan reduced infant mortality, decreased worker sick days and lightened families’ financial burdens

While countries all over the world are moving toward universal healthcare, for many it remains just a goal. But a handful of them have rolled out universal health coverage schemes, and there’s plenty to learn from these nations. Consider Thailand, where leaders successfully implemented sweeping healthcare reform without breaking the bank.

In 2000, about one-quarter of people in Thailand were uninsured, and many other people had policies that granted incomplete protection. As a result, the country was in a healthcare crisis. More than 17,000 children younger than five died that year, about two-thirds of them from easily preventable infectious diseases. And about 20% of the poorest Thai homes fell into poverty from out-of-pocket healthcare spending.

In 2001, Thailand introduced the Universal Coverage Scheme (UCS). It’s described as “one of the most ambitious healthcare reforms ever undertaken in a developing country” in the book Millions Saved: New The Center for Global Development reviewed the Thai healthcare system and found Cases of Proven Success in Global Health. The UCS, which spread to all provinces the following year, provides outpatient, inpatient and emergency care, available to all according to need. By 2011, the program covered 48 million Thais or 98% of the population.

Several things worked in favor of Thailand’s UCS, including a sustained support system and a broad reach. Reformers from the 2001 general election’s winning political party, Thai Rak Thai, held leadership positions, and they were able to help back the program. As described by Dr. Suwit Wibulpolprasert, the program’s policy director and Thailand’s deputy secretary of the ministry of health at the time, the UCS had to go wide quickly. “The challenge was to implement it fast,” he says. “It couldn’t be done over 10 years because there was huge political pressure.”

Thailand’s UCS was implemented in every province by January 2002, but this level of comprehensive care had taken decades to develop. Since the 1970s, free medical care had been available to some people in poverty, but the country had a range of health insurance schemes that left many without coverage. Developing infrastructure – hospitals, clinics, and trained staff – to support universal coverage took years.

According to Dr. Sara Bennett, associate professor at Johns Hopkins Bloomberg School of Public Health, quality is the most challenging aspect of universal healthcare in developing countries. Government-funded healthcare is often free, but it can be geographically inaccessible, limited to a few facilities and administered by poorly trained staff. In addition, what works in urban areas might not be suited to rural contexts and vice versa.

When Thailand established solid health infrastructure, universal healthcare “totally changed the relationship between patients and doctors”, Wibulpolprasert says. Before, patients paid a fee to their doctors when they visited the hospital. After 2001, the government paid hospitals, including salaries for staff, and financially incentivized medical professionals to serve unpopular rural areas.

The lessons in Thailand: a well-researched system with a dedicated leadership can improve health, and in an affordable way. As of 2011, the country’s health scheme cost just $80 per person annually, primarily funded by general income tax; it effectively reduced infant mortality, decreased worker sick days and lightened families’ financial burden for healthcare.

Meanwhile, in the US, securing agreement from political leadership is one of the most contentious issues over universal healthcare. The Patient Protection and Affordable Health Care Act, also known as Obamacare, was signed into law in 2010, yet is still embroiled in political controversy. However, the plan is paying off: more people than ever are insured and out-of-pocket spending has dramatically declined among those insured.

Around the world, many low- and middle-income countries are also moving toward universal care. “They are covering more people, who are paying less out of pocket and have access to a broader array of services,” Bennett says. “Many countries are making significant strides towards this, including the poorest.”

Paying for universal health care remains a challenge. In South Korea, for instance, care is funded by compulsory health insurance from all citizens and covers about 97% of the population. However, the country’s health system is in growing deficit.

Listen carefully, in Thailand, affordability is not currently an issue, though the cost of the program as a proportion of general income tax is rising yearly. The cost and payment for the system have to be considered in our country of the U.S.A. if we want a universal health care system of any type! Still, the UCS continues to have wide support from the country’s government, health workers, and the wider population.

“The challenge is to make it more efficient, to get more for less money, particularly with the introduction of new technology and new drugs,” Wibulpolprasert says.

According to Carolyn Hart, Washington office director at health consultancy John Snow Inc, a multisectoral approach is a key to global healthcare. “We are looking at the need to develop channels at all price points including free, subsidized and pay as you go, which could be insurance,” she says.

“How can [countries] afford not to invest in the health of their people?” she adds. “Poor health holds you back so badly.”

We just have to decide to make the right decisions and what the correct design of our health care system and how we are going to pay for it. There are many differences here as there are in many of the countries that have a universal health care system and we have to examine which we can adapt to create a successful, caring and sustainable system.

Onward to discuss Bernie’s proposal and luck and prayers to the divers and Thai children and their coach.