essay on universal health coverage

Point Turning Point: the Case for Universal Health Care

An argument that the COVID-19 pandemic might be the turning point for universal health care.

Why the U.S. Needs Universal Health Care

As we all grapple with our new reality, it's difficult to think of anything beyond the basics. How do we keep our families safe? Are we washing our hands enough ? Do we really have to sanitize the doorknobs and surfaces every day? How do we get our cats to stop videobombing our Zoom meetings? Do we have enough toilet paper?

Win McNamee | Getty Images

The more we read the headlines, the more we feel the need to do something, or at least say something. Change is happening – ready or not. Maybe talking about some of these important issues can lead to action that will help us steer out of this skid.

Historically, Americans have found ways to meet their circumstances with intention, moving in mass to make heretofore unimaginable change that has sustained and improved our lives to this day. The Great Depression lead to the creation of the New Deal and Social Security. The Triangle Shirtwaist Factory fire brought about change in labor conditions. The Cuyahoga River fire lead to the founding of the Environmental Protection Agency.

Could the COVID-19 pandemic be the turning point for universal health care? We can't think of a more propitious time. In the first two weeks of April, 5.2 million Americans filed for unemployment. Economists believe that 30% unemployment is possible by fall. For most Americans, our health care is tied to our employment, and because of this, millions of Americans are losing their health care just when they may need it the most. Economists predict that health insurance premiums will likely increase by 40% in the next year due to less payers and more who are in need of care and the eventual collapse of private health care insurance .

Our current circumstances have illustrated the need for universal health care in a way that is obvious and undeniable. Below we have listed the most frequent arguments in opposition followed by an evidence-based rebuttal.

1. Point: "Governments are wasteful and shouldn't be in charge of health care."

Counterpoint: In 2017, the U.S. spent twice as much on health care (17.1% of GDP) as comparable Organization for Economic Co-Operation and Development countries (OECD) (8.8% of GDP), all of whom have universal health care. The country with the second highest expenditure after the U.S. is Switzerland at 12.3%, nearly 5% less. Of all these countries, the U.S. has the highest portion of private insurance. In terms of dollars spent, the average per capita health care spending of OECD countries is $3,558, while in the U.S. it's $10,207 – nearly three times as costly.

Bottom line: Among industrialized countries with comparable levels of economic development, government-provided health care is much more efficient and more economical than the U.S. system of private insurance.

2. Point: "U.S. health care is superior to the care offered by countries with universal health care."

Counterpoint: According to the Commonwealth Health Fund , in the U.S., infant mortality is higher and the life span is shorter than among all comparable economies that provide universal health care. Maternal mortality in the U.S. is 30 per 100,000 births and 6.4 per 100,000 births on average in comparable countries, which is nearly five times worse.

In addition, the U.S. has the highest chronic disease burden (e.g., diabetes, hypertension) and an obesity rate that is two times higher than the OECD average. In part due to these neglected conditions, in comparison to comparable countries, the U.S. (as of 2016) had among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.

The Peterson-Kaiser Health System Tracker , which is a collaborative effort to monitor the quality and cost of U.S. health care, shows that among comparable countries with universal health care, mortality rate is lower across the board on everything from heart attacks to child birth. The U.S. also has higher rates of medical, medication and lab errors relative to similar countries with universal health care.

Bottom line: With our largely privately funded health care system, we are paying more than twice as much as other countries for worse outcomes.

3. Point: "Universal health care would be more expensive."

Counterpoint: The main reason U.S. health care costs are so high is because we don't have universal health care. Unlike other first world countries, the health care system in the U.S. is, to a great extent, run through a group of businesses. Pharmaceutical companies are businesses. Insurance companies are businesses. Hospital conglomerates are businesses. Even doctors' offices are businesses.

Businesses are driven to streamline and to cut costs because their primary goal is to make a profit. If they don't do this, they can't stay in business. It could mean that in the process of "streamlining," they would be tempted to cut costs by cutting care. Under the current system, a share of our health care dollars goes to dividends rather than to pay for care, hospitals are considered a "financial asset" rather than a public service entity and a large portion of their budgets are dedicated to marketing rather than patient care.

Given all these business expenses, it shouldn't be surprising that the business-oriented privately funded health care system we have is more expensive and less effective than a government provided universal system. In addition, for the health care system as a whole, universal health care would mean a massive paperwork reduction. A universal system would eliminate the need to deal with all the different insurance forms and the negotiations over provider limitations. As a result, this would eliminate a large expense for both doctors and hospitals.

The economist Robert Kuttner critiques the system this way: "For-profit chains … claim to increase efficiencies by centralizing administration, cutting waste, buying supplies in bulk at discounted rates, negotiating discounted fees with medical professionals, shifting to less wasteful forms of care and consolidating duplicative facilities." As he points out, "using that logic, the most efficient 'chain' of all is a universal national system."

Evidence to support these points can be found in a recent Yale University study that showed that single-payer Medicare For All would result in a 13% savings in national health-care expenditures. This would save the country $450 billion annually.

Bottom line: Universal health care would be less expensive overall, and an added benefit would be that health care decisions would be put in the hands of doctors rather than insurance companies, which have allegiances to shareholders instead of patient care.

4. Point: "I have to take care of my own family. I can't afford to worry about other people."

Counterpoint: It is in all of our best interests to take care of everyone. Aside from the fact that it is the compassionate and moral thing to do, viruses do not discriminate. When people don't have insurance, they won't go to the doctor unless they're gravely ill. Then, they're more likely to spread illness to you and your family members while they delay getting the care they need.

In addition, when people wait for care or don't get the prophylactic care then need, they end up in the emergency room worse off with more costly complications and requiring more resources than if they had been treated earlier. Taxpayers currently cover this cost. This affects everyone, insured or not. Why not prevent the delay upfront and make it easy for the patient to get treatment early and, as an added bonus, cost everyone less money?

In addition, the health of the economy impacts everyone. Healthy workers are essential to healthy businesses and thus a healthy economy. According to the Harvard School of Public Health , people who are able to maintain their health are more likely to spend their money on goods and services that drive the economy.

Bottom line: The health of others is relevant to the health of our families either through containment of infectious diseases such as COVID-19 or through the stability of the economy. Capitalism works best with a healthy workforce.

5. Point: "Entrepreneurship and innovation is what makes the U.S. a world leader."

Counterpoint: Imagine how many people in the U.S. could start their own businesses or bring their ideas to market if they didn't have to worry about maintaining health care for their families. So many people stay tethered to jobs they hate just so their family has health care. With workers not needing to stay in jobs they don't like in order to secure health insurance, universal healthcare would enable people to acquire jobs where they would be happier and more productive. Workers who wanted to start their own business could more easily do so, allowing them to enter the most creative and innovative part of our economy – small businesses.

In his book, "Everything for Sale," economist Robert Kuttner asserts that it's important to understand that businesses outside of the U.S. don't have to provide health care for their employees, which makes them more competitive. From a business point of view, American companies, released from the burden of paying employee insurance, would be more competitive internationally. They would also be more profitable as they wouldn't have to do all the paperwork and the negotiating involved with being the intermediary between employees and insurance companies.

Bottom line: Unburdening businesses from the responsibility of providing health insurance for their employees would increase competitiveness as well as encourage entrepreneurship and innovation, and allow small businesses room to thrive.

6. Point: "The wait times are too long in countries with universal health care."

Counterpoint: The wait times on average are no longer in countries with universal healthcare than they are in the U.S., according to the Peterson-Kaiser Health System Tracker . In some cases, the wait times are longer in the U.S., with insurance companies using valuable time with their requirements to obtain referrals and approvals for sometimes urgently needed treatments. On average, residents of Germany, France, UK, Australia, and the Netherlands reported shorter wait times relative to the U.S.

Bottom line: Wait times are longer in the U.S. when compared with many countries with a universal health care system.

7. Point: "My insurance is working just fine, so why change anything?"

Counterpoint: A comprehensive study conducted in 2018 found that 62% of bankruptcies are due to medical bills and, of those, 75% were insured at the time. Most people who have insurance are insufficiently covered and are one accident, cancer diagnosis or heart attack away from going bankrupt and losing everything. The U.S. is the only industrialized country in the world whose citizens go bankrupt due to medical bills. And, if you survive a serious illness and don't go bankrupt, you may end up buried in bills and paperwork from your insurance company and medical providers. All of this takes time and energy that would be better spent healing or caring for our loved ones. Besides, we don't need to abolish private health insurance. Some countries like Germany have a two-tiered system that provides basic non-profit care for all but also allows citizens to purchase premium plans through private companies.

Bottom line: Private insurance does not protect against medical bankruptcy, but universal health care does. The residents of countries with universal health care do not go bankrupt due to medical bills.

8. Point: "I don't worry about losing my insurance because if I lose my job, I can just get another one."

Counterpoint: We can't predict what will happen with the economy and whether another job will be available to us. This pandemic has proven that it can all go bad overnight. In addition, if you lose your job, there is less and less guarantee that you will find a new job that provides insurance . Providing insurance, because it is so expensive, has become an increasingly difficult thing for companies to do. Even if you're able to find a company that provides health care when you change jobs, you would be relying on your employer to choose your health plan. This means that the employee assumes that the company has his or her best interests in mind when making that choice, rather than prioritizing the bottom line for the benefit of the business. Even if they're not trying to maximize their profit, many companies have been forced to reduce the quality of the insurance they provide to their workers, simply out of the need to be more competitive or maintain solvency.

Bottom line: There are too many factors beyond our control (e.g., pandemic, disability, economic recession) to ensure anyone's employment and, thus, health care. Universal health care would guarantee basic care. Nobody would have to go without care due to a job loss, there would be greater control over costs and businesses would not have to fold due to the exorbitant and rising cost of providing health insurance to their employees.

9. Point: "Pharmaceutical companies need to charge so much because of research and development."

Counterpoint: It's usually not the pharmaceutical companies developing new drugs. They develop similar drugs that are variations on existing drugs, altered slightly so that they can claim a new patent. Or they buy out smaller companies that developed new drugs, thus minimizing their own R&D costs. Most commonly, they manufacture drugs developed under funding from the National Institutes of Health, and thus, the tax payers are the greatest funder of drug development via NIH grants provided to university labs.

Oddly, this investment in R&D does not appear to extend any discount to the tax payers themselves. In "The Deadly Costs of Insulin, " the author writes that insulin was developed in a university lab in 1936. In 1996, the cost of a vial of insulin was $21. Today, the cost of a vial of insulin could be as much as $500, causing some without insurance to risk their lives by rationing or going without. The cost of manufacturing the drug has not gone up during that time. So, what accounts for the huge increase in price? In " The Truth About Drug Companies ," the author demonstrates that drug companies use the bulk of their profits for advertising, not R&D or manufacturing. A universal health care system would not only not need to advertise, but would also be more effective at negotiating fair drug prices. Essentially, the government as a very large entity could negotiate price much more effectively as one large system with the government as the largest purchaser.

Bottom line: Taxpayers contribute most of the money that goes into drug development. Shouldn't they also reap some of the benefits of their contribution to R&D? Americans should not have to decide between their heart medication and putting food on the table when their tax dollars have paid for the development of many of these medications.

10. Point: "I don't want my taxes to go up."

Counterpoint: Health care costs and deductibles will go down to zero and more than compensate for any increase in taxes, and overall health care needs will be paid for, not just catastrophic health events. According to the New York Times , “…when an American family earns around $43,000, half of the average compensation when including cash wages plus employer payroll tax and premium contributions, 37% of that ends up going to taxes and health care premiums. In high-tax Finland, the same type of family pays 23% of their compensation in labor taxes, which includes taxes they pay to support universal health care. In France, it’s 2%. In the United Kingdom and Canada, it is less than 0% after government benefits.”

Bottom line: With a universal health care system, health care costs and deductibles will be eliminated and compensate for any increase in taxes.

11. Point: "I don't want to have to pay for health care for people making bad choices or to cover their pre-existing conditions."

Counterpoint: Many of the health problems on the pre-existing conditions list are common, genetically influenced and often unavoidable. One estimate indicates that up to 50% – half! – of all (non-elderly) adults have a pre-existing condition. Conditions on the list include anxiety, arthritis, asthma, cancer, depression, heart defect, menstrual irregularities, stroke and even pregnancy. With universal health care, no one would be denied coverage.

It's easy to assume that your health is under your control, until you get into an accident, are diagnosed with cancer or have a child born prematurely. All of a sudden, your own or your child's life may rely on health care that costs thousands or even millions of dollars. The health insurance that you once thought of as "good enough" may no longer suffice, bankruptcy may become unavoidable and you (or your child) will forever have a pre-existing condition. Some people may seem careless with their health, but who's to judge what an avoidable health problem is, vs. one that was beyond their control?

For the sake of argument, let's say that there are some folks in the mix who are engaging in poor health-related behaviors. Do we really want to withhold quality care from everyone because some don't take care of their health in the way we think they should? Extending that supposition, we would withhold public education just because not everyone takes it seriously.

Bottom line: In 2014, protections for pre-existing conditions were put in place under the Affordable Care Act. This protection is under continuous threat as insurance company profits are placed above patient care. Universal health care would ensure that everyone was eligible for care regardless of any conditions they may have.

And, if universal health care is so awful, why has every other first-world nation implemented it? These countries include: Australia, Austria, Bahrain, Belgium, Brunei, Canada, Cyprus, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Singapore, Slovenia, South Korea, Spain, Sweden, Switzerland, United Arab Emirates and the U.K.

Changing collective minds can seem impossible. But there is precedent. Once unimaginable large-scale change has happened in our lifetime (e.g. legalization of gay marriage, election of the first black president of the U.S. and the #MeToo movement), and support for universal health care has never been higher (71% in favor, according to a 2019 Hill-HarrisX survey ).

Point: As Chuck Pagano said, "If you don't have your health, you don't have anything."

Counterpoint: If good health is everything, why don't we vote as if our lives depended on it? This pandemic has taught us that it does.

Bottom line: Launching universal health care in the U.S. could be a silver lining in the dark cloud of this pandemic. Rather than pay lip service to what really matters, let's actually do something by putting our votes in service of what we really care about: the long-term physical and economic health of our families, our communities and our country.

Photos: Hospital Heroes

Tags: health insurance , health care , Coronavirus , pandemic , New Normal

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Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Floor?

The United States spends substantially more on health care than most developed countries, yet leaves a greater share of the population uninsured. We suggest that incremental insurance expansions focused on addressing market failures will propagate inefficiencies and are not likely to facilitate active policy decisions that align with societal coverage goals. By instead defining a basic bundle of services that is publicly financed for all, while allowing individuals to purchase additional coverage, policymakers could both expand coverage and maintain incentives for innovation, fostering universal access to innovative care in an affordable system.

Katherine Baicker is dean and Emmett Dedmon Professor, University of Chicago Harris School of Public Policy, Chicago, Illinois. Amitabh Chandra is Ethel Zimmerman Wiener Professor of Public Policy, Harvard Kennedy School, and Henry and Allison McCance Professor of Business Administration, Harvard Business School, Cambridge, Massachusetts. Mark Shepard is Associate Professor, Harvard Kennedy School, Cambridge, Massachusetts. Their email addresses are [email protected], [email protected], and [email protected]. This paper is based on a manuscript prepared for the Journal of Economic Perspectives. The authors thank the editors and Joe Newhouse for helpful feedback and suggestions, and Jason Furman and Matt Fiedler for sharing historical data on US uninsured rates. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

Baicker serves on the boards of Eli Lilly, the Mayo Clinic, the Urban Institute, the Chicago Council on Global Affairs, and NORC. Baicker and Chandra serve on the CBO Panel of Health Advisers.

Amitabh Chandra Disclosures

Congressional Budget Office (Federal Government). Panel of Health Advisors. Unpaid. Leigh Speakers Bureau, Speakers Bureau Washington Speakers Bureau, Speakers Bureau Analysis Group, Academic Affiliate Kyruus, Advisor Health Engine, Advisor SmithRx, Advisor

MARC RIS BibTeΧ

Download Citation Data

Published Versions

Katherine Baicker & Amitabh Chandra & Mark Shepard, 2023. " Achieving Universal Health Insurance Coverage in the United States: Addressing Market Failures or Providing a Social Floor?, " Journal of Economic Perspectives, vol 37(2), pages 99-122.

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Canada's universal health-care system: achieving its potential

Danielle martin.

a Women's College Hospital and Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

b Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

Ashley P Miller

c Division of General Internal Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada

Amélie Quesnel-Vallée

d McGill Observatory on Health and Social Services Reforms, Department of Epidemiology, Biostatistics and Occupational Health, and Department of Sociology, McGill University, Montréal, QC, Canada

Nadine R Caron

e Department of Surgery, Northern Medical Program and Centre for Excellence in Indigenous Health, University of British Columbia, Prince George, BC, Canada

Bilkis Vissandjée

f School of Nursing and Public Health Research Institute, Université de Montréal, SHERPA Research Centre, Montréal, QC, Canada

Gregory P Marchildon

g Johnson-Shoyama Graduate School of Public Policy, University of Regina, Regina, SK, Canada

Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicare's founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity.

This is the first in a Series of two papers about Canada's health system and global health leadership

Introduction

Founded on Indigenous lands and the product of Confederation that united former British colonies in 1867, Canada is a complex project. 36 million people from a rich diversity of ethnocultural backgrounds live on a vast geography bounded by the Arctic, Pacific, and Atlantic Oceans, across six time zones and eight distinct climate regions.

Canada is among the world's most devolved federations, with substantial political power and policy responsibility held by its ten provinces and three territories. The province of Quebec, with its unique French-speaking linguistic and cultural context, often charts a policy path that is independent from the rest of the country. 1 The decentralisation of the Canadian polity is expressed in its health-care system—known as Medicare—which is not a national system per se, but rather a collection of provincial and territorial health insurance plans subject to national standards. 2 , 3 These taxation-based, publicly funded, universal programmes cover core medical and hospital services for all eligible Canadians, and are free at the point of care ( figure 1 ).

Overview of the Canadian health system

Adapted from 2 , 3 .

To Canadians, the notion that access to health care should be based on need, not ability to pay, is a defining national value. This value survives despite a shared border with the USA, which has the most expensive and inequitable health-care system in the developed world. 4

Canadian Medicare is more than a set of public insurance plans: more than 90% of Canadians view it as an important source of collective pride. 5 This pride points to an implicit social contract between governments, health-care providers, and the public—one that demands a shared and ongoing commitment to equity and solidarity. 6 Such a commitment is inevitably challenged in each generation by an array of external shocks and internal problems. Currently, wait times for elective care, inequitable access to health services in both the public and private systems, and the urgent need to address health disparities for Indigenous Canadians threaten this equity and solidarity.

In this first paper of a two-part Series on Canada's health system and global health leadership, 7 we analyse the unique history and features of the Canadian health-care system and consider the key factors challenging domestic policy makers and the system's potential to be a model for the world. We then propose a renewal of the tripartite social contract in service of accessible, affordable, high-quality care for all residents of Canada in the decades to come.

Key messages

• • Canada's universal, publicly funded health-care system—known as Medicare—is a source of national pride, and a model of universal health coverage. It provides relatively equitable access to physician and hospital services through 13 provincial and territorial tax-funded public insurance plans.
• • Like most countries that are members of the Organisation for Economic Co-operation and Development (OECD), Canada faces an ageing population and fiscal constraints in its publicly funded programmes. Services must be provided across vast geography and in the context of high rates of migration and ethnocultural diversity in Canadian cities.
• • In 2017, the 150th anniversary of Canadian Confederation, the three key health policy challenges are long waits for some elective health-care services, inequitable access to services outside the core public basket, and sustained poor health outcomes for Indigenous populations.
• • To address these challenges, a renewal of the tripartite social contract underpinning Medicare is needed. Governments, health-care providers (especially physicians), and the public must recommit to equity, solidarity, and co-stewardship of the system.
• • To fully achieve the potential of Medicare, action on the social determinants of health and reconciliation with Indigenous peoples must occur in parallel with health system reform.
• • Without bold political vision and courage to strengthen and expand the country's health system, the Canadian version of universal health coverage is at risk of becoming outdated.

History: a social democratic foundation

The words health and health care were nowhere to be found in the original Canadian Constitution of 1867. However, provincial governments were given explicit authority over hospitals in the constitutional division of powers between the federal government and the provinces and territories. Over time, these subnational governments became the presumed primary authorities over most health-care services.

In the early 1900s, Thomas Clement “Tommy” Douglas, then a young boy growing up in Winnipeg (MB), nearly lost a limb to osteomyelitis because his family was unable to pay for care. When Douglas later became the Social Democratic Premier of Saskatchewan, he implemented universal public health insurance for the province, making it the first jurisdiction with universal health coverage in North America. 8 This insurance initially covered hospital care in 1947. It was expanded to medical care (mainly defined as physician services) in 1962. Services were resourced by a provincial tax-financed plan. Hospitals and physicians maintained a high degree of autonomy, billing the public plan while designing their own models of care.

The federal government played a part in the emergence of universal health coverage during that period through its spending power, which it used, and continues to use, to maintain national standards for universal health coverage. Thus, the Saskatchewan approach was adopted in the rest of the country through the encouragement of the federal government, which originally offered 50 cents for every provincial dollar spent on universal health coverage. Panel 1 outlines key events in this complex historical process that culminated in the unanimous adoption of the Canada Health Act 9 in Canada's Parliament in 1984.

An abbreviated history of Canadian Medicare

Led by Premier Tommy Douglas, the Saskatchewan Hospital Services Plan is introduced as the first universal hospital insurance programme in North America

Led by Prime Minister Louis St. Laurent, the Hospital Insurance and Diagnostic Services Act establishes 50:50 cost sharing with provincial hospital insurance plans that meet the criteria of comprehensiveness, universality, accessibility, and portability (user fees are discouraged despite no explicit prohibition)

Implementation of the Hospital Insurance and Diagnostic Services Act, with five provinces participating

Premier Tommy Douglas announces his plan for universal publicly funded medical insurance coverage (Medicare) in Saskatchewan

Organised medicine launches a large-scale campaign against Medicare

All ten provinces now participating in the Hospital Insurance and Diagnostic Services Act

July 1, 1962

The Saskatchewan Medical Care Insurance Act takes effect, establishing universal publicly funded medical insurance for Saskatchewan residents

July 1–23, 1962

Saskatchewan doctors' strike, led by the Keep our Doctors committee

July 23, 1962

Saskatoon Agreement ends the strike, establishing opt-out provisions and protections for the fee-for-service, private practice model

Led by Justice Emmett Hall, the Royal Commission on Health Services recommends comprehensive universal health coverage for all Canadians

Led by Prime Minister Lester Pearson, federal Liberals announce support for 50:50 cost sharing with provincial health plans that meet the criteria of comprehensiveness, portability, universality, and public administration

Dec 8, 1966

The Medical Care Insurance Act is passed in Parliament, legislating federal support of provincial Medicare plans that meet the criteria of comprehensiveness, portability, universality, and public administration

July 1, 1968

The Medical Care Insurance Act comes into effect

All provinces now have established comprehensive medical insurance plans that meet the federal criteria for funding eligibility

Led by Prime Minister Pierre Elliott Trudeau, federal Liberals introduce Established Programs Financing, which provides block funding transfers to provinces and lessens federal involvement in health-care provision

Led by Justice Emmett Hall, the Health Services Review raises concerns about the increase in user fees and extra billing by physicians

The Indian Health Policy is adopted, formalising the federal government's responsibility for health-care provision for Indigenous Canadians as directed by constitutional and statutory provisions, treaties, and customary practice

Prime Minister Pierre Elliott Trudeau and Queen Elizabeth II sign the Constitution Act, establishing Canadian sovereignty through patriation; previously established Constitutional convention remained unchanged, including provincial jurisdiction over health service delivery and financing, and a federal role in pharmaceutical regulation, public health, provincial oversight, and provision of services for those groups under federal Constitutional authority (such as Indigenous peoples, armed forces, veterans, inmates, and refugees)

Under Minister of National Health and Welfare Monique Bégin, the Canada Health Act is passed unanimously by Parliament, explicitly banning extra billing and establishing criteria for transfer payment eligibility (with penalties for violations): public administration, comprehensiveness, universality, portability, and accessibility

The Canada Health Act outlines the terms and conditions to which all provincial and territorial plans must adhere in order to access federal funding for health care: portability, universality, accessibility, comprehensiveness, and public administration ( panel 2 ). Three of these conditions are particularly effective in ensuring some commonality across 13 health systems: portability, universality, and accessibility. Portability allows insured residents to keep their coverage when travelling or moving within Canada. 11 Universality stipulates that access must be on uniform terms and conditions—ie, individuals do not have preferential access based on the ability to pay privately. Accessibility means that no user fees are charged for publicly insured services: when a Canadian visits a doctor or is cared for in any department of a hospital, there is no payment or deductible. Provincial and territorial governments have upheld the principles of the Canada Health Act through various laws and policies to ensure ongoing federal funding; currently, federal transfer payments amount to approximately 20% of provincial health budgets. 12

Overview of the Canada Health Act

The following criteria and conditions must be met for provinces and territories to receive federal contributions under the Canada Health Transfer.

• • Public administration: plans must be administered and operated on a non-profit basis by a public authority
• • Comprehensiveness: plans must cover all insured health services provided by hospitals, physicians, or dentists (for surgical dental procedures that require a hospital setting)
• • Universality: all insured residents must be entitled to the insured health services on uniform terms and conditions
• • Portability: insured residents moving from one province or territory to another, or temporarily absent from their home province or territory or Canada, must continue to be covered for insured health services (within certain conditions)
• • Accessibility: not to impede or preclude, either directly or indirectly, whether by user charges or otherwise, reasonable access to insured health services

Adapted from 9 , 10 .

Financing: deep public coverage of a narrow basket of services

Financing in three layers.

Expenditures on health constitute 10·4% of Canada's gross domestic product (GDP; table ). This figure increased consistently for many years and peaked in 2010, at 11·6%, but decreased steadily in the years following the 2008–09 recession. 14 Although this figure seems to have stabilised, 14 it has not yet recovered to its previous peak.

Canada versus OECD comparators by indicators of the Triple Aim

OECD=Organisation for Economic Co-operation and Development. HAQ=Health Access and Quality. NA=not available. GDP=gross domestic product. PPP=purchasing power parity.

Pundits and think tanks often claim that governments in Canada have a public monopoly on health care, but only 70·9% of total health expenditure is publicly sourced, mainly through general taxation. 15 This percentage represents a considerably lower public share than that of the UK and most other nations in western Europe ( table ). Approximately half of the 30% private expenditure comes from out-of-pocket payments by patients; the other half is covered by private supplemental health insurance plans.

The financing of health services in Canada involves three layers ( figure 1 ). Layer one comprises public services (those that Canadians recognise as Medicare): medically necessary hospital, diagnostic, and physician services. These services are financed through general tax revenues and provided free at the point of service, as required by the Canada Health Act. Coverage is universal in this single-payer system. The most important quality of this layer is relatively equitable access to physician and hospital care. 16 Another benefit is cost containment: within Canadian publicly funded insurance plans, administrative overhead is extremely low—less than 2%—because of the simplicity of the single-payer scheme. 17

Layer two services are financed through a mix of public and private insurance coverage and out-of-pocket payments, and include provision of outpatient prescription drugs, home care, and institutional long-term care. Provinces and territories each have a diverse mix of public programmes in this layer, without any national framework. For example, in some provinces, such as Ontario, all senior citizens older than 65 years have public prescription drug coverage, whereas in others, such as British Columbia, drug coverage is income tested. 18

Layer three s ervices are financed almost entirely privately and include dental care, outpatient physiotherapy, and routine vision care for adults when provided by non-physicians. 3

Approximately 65% of surveyed Canadians have private supplemental health insurance, mostly through their employers. 19 This insurance covers some or all of the costs of layer two and three services, notably outpatient prescription medicines, generally with co-payments or deductibles. 20 An additional 11% of people have access to supplemental services through government-sponsored insurance plans. 19 However, many Canadians do not have supplemental insurance, with provincial estimates ranging from a quarter to a third of the total population. 19 , 21 These individuals have to pay out of pocket for outpatient medicines, counselling services (when provided by non-physicians), and more. Such spending has been steadily increasing, particularly for low-income Canadians. 14 More than CAN$6·5 billion in household funds was spent on pharmaceuticals alone in 2014. 18 The large number of Canadians who do not have access to supplemental insurance has led to concerns about equity, fuelling calls for public coverage of a wider range of services than are currently available in layer one.

The federal government holds special responsibilities for providing health coverage and services to Canadian Forces personnel, inmates of federal prisons, eligible Indigenous people, veterans, and certain groups of refugees. 22 The federal government also has stewardship responsibilities for pharmaceutical regulation, health data collection, and health research funding ( figure 1 ).

A small number of Canadian residents do not have public insurance for layer one services. Most are newcomers experiencing provincially mandated delays in coverage, rejected refugee claimants, and temporary residents with expired work or education permits. 23 In Ontario, a province of 13·6 million people, approximately 250 000 people are non-status residents and might therefore be unable to access health-care coverage. 24 When necessary, these people often attempt to access care through emergency departments, where upfront payment is not required. 25

Decentralisation of delivery: a defining feature of Medicare

Medicare is a single-payer layer of financing that is highly decentralised in terms of service delivery. This split between financing and provision of care evolved very differently from, for example, the more centralised National Health Service in the UK.

Doctors are most commonly independent contractors, billing public insurance plans on a fee-for-service or other basis. 26 Despite the fact that they work within the boundaries of regional or provincial health authorities and in hospitals financed almost entirely publicly, few accountability relationships exist between physicians and health authorities, hospitals, or governments. 27

This structure can again be traced back to Saskatchewan, where physicians responded to the single-payer model with a province-wide strike for 23 days, demanding to preserve their ability to bill patients or private insurance plans rather than the government. 28 The strike ended with the Saskatoon Agreement, a truce whereby doctors would become part of the system as publicly paid but self-employed professionals with minimal engagement in or accountability to system-wide governance. 29

Further fragmentation is inherent in the fact that hospitals, health authorities, and other organisations often have their own independent boards and separate budgets, and thus make decisions about the kinds of services they will provide independently of other parts of the system. 9

The centralised data collection that occurs in single-payer insurance plans has great potential to support quality improvement of the health system. Currently, these data inform the strategic directions of health ministries and support excellent health services research in most provinces. Unfortunately, their use for operational purposes to drive front-line improvements has been scarce. Data are seldom provided in real time to organisations and providers delivering care because of the prioritisation of privacy, data security, and the difficulties involved in provision of just-in-time data from large administrative databases. 30

The ease of innovation scale-up that should in theory characterise a single-payer environment remains under-realised. 31 , 32 In Canada, the rate of adoption of electronic medical records increased from about 23% of health-care practitioners in 2006 to an estimated 73% in 2015. 33 Nonetheless, hospital-based systems and primary care systems are commonly designed in isolation from each other. This separation makes information sharing difficult as patients move through distinct parts of the system that use different electronic tools unlinked to each other, causing further fragmentation of care.

National bodies that could overcome fragmentation of coverage or service delivery have had varying degrees of success. The special Canadian brand of decentralisation is illustrated in the case of health technology assessment, an area in which many countries use arm's length agencies to make nationwide decisions about funding allocation (eg, the National Institute for Health and Care Excellence in the UK). The Canadian version is the Canadian Agency for Drugs and Technologies in Health (CADTH), an intergovernmental body that provides evidence-informed funding recommendations as to which drugs and technologies should be publicly covered. However, unlike most international health technology assessment organisations, CADTH's outputs are advisory only. Although regional health plans made coverage decisions consistent with these recommendations in more than 90% of cases between 2012 and 2013, manufacturers must nonetheless navigate 13 provincial and territorial labyrinthine approval processes even after receiving CADTH sanction. 32 Furthermore, 85% of private plans provide coverage for all prescriptions, including those that CADTH recommends against, with the result that evidence-informed recommendations do not necessarily cross the public–private divide. 34

The context for change

Fiscal constraints.

As Canadian governments, providers, and the public consider how to address the important health policy challenges of the day, their options are defined by several factors. Some of these factors are common across many countries in the Organisation for Economic Co-operation and Development (OECD), such as fiscal constraints, population ageing, and the social determinants of health; other factors have uniquely Canadian elements, such as geography and particular patterns of migration.

Following the recession of 2008–09, economic growth in Canada was slower than it had been throughout much of the post-World War 2 era, with GDP growth averaging just over 2% annually between 2011 and 2016. 35 In the past decade, provincial governments have increasingly focused on reducing the rate of growth in health-care spending, which constitutes 38% of provincial budgets based on the pan-Canadian average. 14

Population ageing

In demographic terms, Canada is still a younger country than many European nations. 36 The fertility rate in Canada, which was 1·6 children per woman in 2015 ( table ; data from World Data Bank Portal), has remained relatively stable over the past decade, largely because of higher rates of childbearing among Indigenous and foreign-born Canadian women than among the general population. 37

Nevertheless, ageing remains an inevitable reality as the baby boom generation enters its senior years. People aged 65 years and older represent Canada's fastest growing age group, and 85% of seniors aged 65–79 years reported having at least one chronic condition in 2012. 38 The financial burden of ageing is not expected to be catastrophic, contributing an estimated less than 1% per year to health-care spending; however, the trend is important for design of health services. 39 The traditional hospital-focused and physician-focused nature of the Canadian system must evolve to meet the growing need for home-based and community-based care, interprofessional team-based care, and institutional long-term care. 40

Social determinants of health

The Lalonde Report of 1974 ( panel 3 ) served as a catalyst for widespread recognition that health is determined more by social, cultural, economic, and gender-based determinants of health than by access to health-care services. 41 In a country where the contribution of health services to health is estimated to be only 25%, the impact of other determinants including poverty is considerable. 42 More than 13% of Canadians were living in a low-income household in 2016. 43 This hardship disproportionately affects vulnerable Canadians from particular ethnocultural backgrounds and some groups of migrants who are more than twice as likely to experience poverty than other Canadians. 44 Thus, as is the case across high-income countries, policies aimed at income redistribution, housing support, and early education and childhood development programmes will continue to be crucial to the health of the population. 45

The history of national commissions and inquiries on health care in Canada

1961–64: Royal Commission on Health Services (Hall Commission)

Led by Justice Emmett Hall, the Commission recommended comprehensive health coverage for all Canadians and development of national policy in health services, health personnel, and health-care financing.

1973–74: A New Perspective on the Health of Canadians (Lalonde Report)

Led by Marc Lalonde, Canadian Minister of National Health and Welfare, this paper introduced the public health imperative and called for the prevention of illness and promotion of good health. It called for the expansion of the health-care system beyond disease-based medical care.

1979–80: Health Services Review

Led by Justice Emmett Hall, this review reported on the progress made since the 1964 commission and sought to determine whether provinces were meeting the criteria of the Medical Care Insurance Act. This inquiry identified widespread extra billing and user fees, and served as a catalyst for the Canada Health Act.

1991–96: Royal Commission on Aboriginal Peoples

The Commission investigated the evolution of the relationship between Aboriginal and non-Aboriginal people and governments in Canada. Major recommendations included the training of 10 000 health professionals over a 10-year period.

1993–97: Commission of Inquiry on the Blood System in Canada (Krever Inquiry )

Led by Justice Horace Krever, the Commission investigated the use of contaminated blood products that infected 2000 transfusion recipients with HIV and 30 000 with hepatitis C between 1980 and 1990. This Commission led to the creation of Canadian Blood Services in 1998.

1994–97: National Forum on Health

Commissioned by Prime Minister Jean Chrétien, this group of experts from across Canada focused on broad determinants of health and the need for enhanced emphasis on evidence-based care.

1999–2002: Standing Senate Committee on Social Affairs, Science and Technology Study on the State of the Health Care System in Canada (Kirby Committee)

Led by Senator Michael Kirby, this committee conducted a comprehensive review of Canadian health care. Recommendations included a call for enhanced federal oversight to ensure effective care and efficient resource use, and highlighted poor health human resource planning as a cause of geographical inequities.

2001–02: Commission on the Future of Health Care in Canada (Romanow Commission)

Led by former Saskatchewan Premier Roy Romanow, the Commission called for a renewed commitment to the values of equity, fairness, and solidarity. The report was the catalyst for the 2003 “Accords” and the establishment of the Health Council of Canada (defunded in 2014) to monitor progress on key objectives.

2003: National Advisory Committee on Severe Acute Respiratory Syndrome (SARS) and Public Health

Led by David Naylor, this committee was established to review the circumstances of the 2003 SARS outbreak. The report identified significant issues with public health in Canada and led to the creation of the Public Health Agency of Canada.

2008–15: Truth and Reconciliation Commission of Canada

Undertaken as part of holistic and comprehensive response to the systemic abuse suffered by Indigenous Canadians under the Indian Residential School system, the commission identified calls to action to advance reconciliation. Although not specifically focused on health care, the report highlighted substantial gaps in health care for Indigenous people and outlined the substantial impact of the trauma on mental and physical health.

2015: Advisory Panel on Healthcare Innovation

Led by David Naylor, the panel's Unleashing Innovation report highlighted the need for enhanced patient engagement, workforce modernisation, technological transformation, and improved scale-up of existing innovations.

The geographical challenges to Canada's health system are enormous. Approximately 18% of Canada's population lives in rural or remote communities dispersed throughout 95% of the area of the second largest country in the world ( table ). North of the densely inhabited Canada–USA border corridor, the need for remote primary care facilities and frequent medical transport to specialised centres renders health-care delivery both challenging and expensive ( figure 2 ). 46 The distribution of health-care providers and resources does not mirror need: only 13·6% of family physicians and less than 3% of specialists live in rural and remote areas of Canada. 47 Similar distributional imbalances exist for nurses and other regulated health-care professionals.

Population density and distribution of hospitals in Canada (and the UK)

The map shows the population density and wide geographical distribution of health-care delivery. For comparison, a map of the distribution of hospitals in the UK is shown inset. Hospital data for Canada are from DMTI Spatial, 2016, and population data for Canada are from Statistics Canada, 2016. UK hospital data are from the National Health Service, 2016, and UK population data are from Eurostat.

These realities have led to the emergence of high-performing regional networks for expensive specialty care, such as trauma services, cancer care, and organ transplantation. Telemedicine—in which local providers or patients receive specialist advice via telecommunication—has facilitated rapid access to emergency subspecialty assessment and follow-up, and is gradually expanding its role in chronic disease management. 48 New curricula and legislation have allowed rural nurses, nurse practitioners, pharmacists, and primary care physicians to broaden their scopes of practice into areas such as oncology or surgery. 49 , 50 Trainees across the regulated health professions are increasingly being trained in rural or remote communities to prepare them for careers outside major cities. 51

Despite these successes, Canadians living in remote areas must often travel long distances to access anything beyond the most basic forms of health care. 52 For example, in Nunavut, a northern and largely Indigenous territory, 58% of patients needing inpatient and outpatient hospital care are transported outside the territory. 53 These geographical complexities might change in the coming decades, as Canada continues to urbanise. Census data from 2016 show that almost 60% of Canadians now live in metropolitan areas, with one in three individuals living in Toronto, Montréal, or Vancouver. 54

Ethnocultural and linguistic diversity and migration

Migration has been and remains an important force shaping Canadian demography and identity ( figure 3 ). At present, more than one in five Canadians are foreign-born. 55 Canada welcomed nearly 325 000 immigrants and refugees in 2015, representing just under 1% of the total population. 56 Most immigrants and refugees settle in one of the country's three biggest cities—Toronto, Montréal, or Vancouver. 57

Map of Canada by country of birth

The map illustrates the population density and the proportion of provincial populations based on country of birth. For comparison, a map of the UK by country of birth is shown inset. Population data for Canada are from Statistics Canada, 2012, and population data for the UK are from the UK Office of National Statistics, 2016.

Despite the Canadian commitment to multiculturalism and a general historical pattern of strong immigrant integration into Canadian society, the health status of many migrant groups often differs from that of Canadian-born patients. 58 , 59 , 60 Newly arrived economic immigrants are typically healthier than the general population, but this so-called healthy immigrant effect declines over time, partly because of the stresses of integration, and it is not found across other classes of migrants. 61

Recent immigrants are twice as likely to have difficulty in accessing care than are Canadian-born women and men, and seek primary care less often than either established immigrants or the Canadian-born population. 62 , 63 However, with longitudinal data controlling for individual propensity to seek care, immigrants are no more likely to be without a regular doctor or report an unmet health-care need than is the Canadian-born population. 64 For refugees, challenges are more prevalent and complex. 65 Language is the most commonly cited reason for difficulty in accessing care among many categories of migrants, whether they are newcomers or established. 55 Availability of interpretation services and adequate use of those services, along with appropriate training for health-care providers and increased health and legal literacy for newcomers to Canada, would pave the way for improved access to context-sensitive care ( panel 4 ). 65 , 66

Health-care experiences of vulnerable groups in Canada

Vanessa: an Indigenous health story

Vanessa is a healthy 28-year-old First Nations woman pregnant with her third child. Her two previous deliveries were uncomplicated and her pregnancy is considered low risk. On her northern First Nations reserve, primary care services are provided by nurses in the community clinic and supported by a family physician who flies in once a month. The nearest community an hour away has a small hospital, but provides no intrapartum services.

Vanessa has access to prenatal care close to home. It is important for her that such care is given within the community, increasing the ease of access and sense of cultural safety. Her medical care and prenatal vitamins are covered through public health insurance plans, as is her transportation to medical appointments outside the reserve. She worries about her partner when she is away, particularly given the deep impact of a cluster of recent suicides in the community that included his teenaged sister. The community is affected by many preventable deaths, including suicides, and trauma, but no births—the circle of life feels incomplete.

At 34 weeks' gestation, Vanessa must travel to the city, where she sits in a motel room and waits to go into labour. Neither the timing of the baby's arrival nor the potential complications that can arise can be predicted, so Vanessa waits alone. As for most women in communities like hers, the birth will occur not with a midwife in her community, but in a hospital hundreds of kilometres away from her partner and children, compromising her much-needed sense of cultural safety. Her access to health-care services free at the point of care is critical, but she wishes her care could be connected to her home, her family, and her culture. If these defects in the system are addressed, perhaps Vanessa's next generation will grow up to expect access to such vital, culturally safe health care.

Mahmoud: a migrant health story

Mahmoud is a 52-year-old Syrian dental surgeon who arrived in Canada with his wife and four children in 2016, as a government-sponsored refugee family. The children started public school while both parents enrolled in the government-funded English-language training for the first months of settlement.

Despite having publicly funded health insurance immediately on arrival, Mahmoud does not access primary care for himself or his family for many reasons, including discomfort with the English language and a lack of knowledge of where to seek care. When he begins to feel unwell, after stalling for a long time, he goes to a local community clinic. An appointment is given for him to return with interpreter services for the following week.

Unfortunately, in the meantime, Mahmoud is admitted to hospital with uncontrolled blood sugars. He is started on oral hypoglycaemics. As a refugee, his medicines are covered, but when he transitions to regular provincial health insurance he will have to pay for his medicines out of pocket.

The process associated with recognition of Mahmoud's dental credentials and skills is complex and lengthy. To take care of his family, he takes up taxi driving. With his unpredictable hours, he finds it hard to comply with his prescribed regimen and starts missing follow-up appointments.

As the Ramadan period approaches, Mahmoud knows he will fast but does not consult with the health team at the local clinic, unsure whether he would be understood as he does not know how to get an interpreter. Despite the fact that there is an increasing sensitivity to the diversity of the Canadian population by the health-care professionals, who are also becoming increasingly diverse, more work is needed to improve communication and personalisation of care, especially at the primary care level.

Policy challenges

Three urgent issues.

Canadians have a life expectancy at birth of 82·14 years ( table ), which is longer than the OECD average. Canada also outperforms the USA, the UK, and Denmark in terms of amenable mortality (ie, deaths that should not occur in the presence of timely and effective health care), as measured through the Health Access and Quality (HAQ) Index. 13 But key observations from international comparisons point to a decades-long struggle with wait times for some elective care and inequitable access to services outside the traditional Medicare strength of hospitals and doctors. 67 Average life expectancy also masks variations in vulnerable groups, most notably Indigenous populations: First Nations people have a projected life expectancy of 73–74 years for men and 78–80 years for women; for the Inuit, living in the far north, life expectancy was 64 years for men and 73 years for women as of 2017. 68

What is most distressing to many observers of the Canadian system is the persistence of its problems over time. 69 Change in Canada is often slow and incremental, by contrast with the major and rapid transformations often observed in reforms of the UK's National Health Service. 70 It is thus most accurately described not as a system in crisis, but a system in stasis. 71 Within that context, and considering the complex needs of many segments of the Canadian population, three crucial problems require action.

Wait times for elective care are too long

Urgent medical and surgical care is generally timely and of high quality in Canada, as indicated by outcomes such as acute myocardial infarction mortality ( table ). However, the timeliness of elective care, such as hip and knee replacements, non-urgent advanced imaging, and outpatient specialty visits, is problematic. 72 The proportion of Canadians waiting more than 2 months for a specialist referral is 30% ( table ), which is far greater than any OECD comparator in the Commonwealth Fund's comparison of 11 countries. 67 Similarly, the proportion of Canadians waiting more than 4 months for elective non-urgent surgery is greatest at 18%.

Governments have experimented with wait-time guarantees, focused programmes, and targeted spending in priority areas such as cancer care, cardiac care, and diagnostic imaging, with varying degrees of success. For example, all provinces achieved wait-time benchmarks in radiation oncology in 2016, but long elective MRI wait times remain largely unchanged over the past decade, despite substantial growth in the number of machines purchased and scans done. 73 , 74

The high degree of physician autonomy in Canada does little to encourage doctors to join organised programmes to reduce wait times. Successful models exist, such as the Alberta Bone and Joint Health Institute in Calgary, which reduced wait times for consultation for hip and knee replacement from 145 days to 21 days through innovations including interprofessional teams and centralised referral. 75 However, physicians have competing responsibilities, and there is no systemic support for their involvement in system change. If a government or regional health authority wants physicians to participate in such an initiative, it must often rely on exhortation or simply pay its doctors more to gain their involvement. Poor federal–provincial–territorial collaboration also hinders the ability to scale up such successful responses to wait times across provincial borders, hence the characterisation of Canada by at least one former Minister of Health as a “country of perpetual pilot projects”. 76 , 77

Canada's reasonable performance on composite quality metrics such as amenable mortality suggests that these wait times for elective care do not necessarily translate to worse health outcomes. 78 However, for the Canadian public, long wait times for elective care are a lightning rod issue and threaten to undermine support for Medicare. Some groups have turned to the courts as a means of challenging the public–private payment divide. Relying on the constitutional Charter of Rights and Freedoms, major lawsuits in Quebec and British Columbia have argued that various provisions of provincial laws, including those that prevent privately financed care, are at the root of public wait times and threaten the right to security of the person. 79 , 80 , 81 , 82

Little more than a decade ago, the Quebec government responded to the Supreme Court of Canada's Chaoulli decision by allowing private insurance for a few types of surgical procedures, but this outcome did not create a viable private market for a health insurance duplicative of Medicare. 83 A more ambitious lawsuit impugning provincial Medicare laws was launched in British Columbia in 2016. 84 Unlike the Quebec trial, which sought only to overturn limits on private duplicative insurance, the plaintiffs in the Cambie Surgeries Corporation case in British Columbia seek to also overturn restrictions on user fees and on physician dual practice. 85

In the past decade, Canadian courts have made important judgments on several other major questions of health-care delivery, including the legalisation of safe injection sites, reinstatement of insurance coverage for refugee claimants, and legalisation of medical assistance in dying. 86 , 87 , 88 These decisions have generally increased access to care for vulnerable people. However, should the court in the Cambie Surgeries Corporation case establish a legal right for Canadians of means who wish to jump the public queue, this case could fundamentally reshape Medicare laws across the country and could threaten equitable access to care. If Canadians are unable to find ways to change the system from within through clinical and political leadership, there is a risk that changes will be forced by the courts, which are a blunt instrument for making policy change.

Services outside the Medicare basket are often inaccessible

Up to a third of working Canadians do not have access to employer-based supplemental private insurance for prescription medicines, outpatient mental health services provided by professionals such as social workers or psychologists, and dental care. 21 These individuals are more likely to be women, youths, and low-income individuals. Public coverage of those services varies between provinces, but generally focuses on seniors and unemployed people receiving social assistance, leaving the working poor most vulnerable. 89 Thus, inequities in health outcomes driven by the social determinants of health are at risk of being compounded by the narrow but deep basket of publicly funded services.

Notably, Canada is the only developed country with universal health coverage that does not include prescription medications, and 57% of prescription drug spending is financed through private means. 18 , 90 Nearly one in four Canadian households reports that someone in that household is not taking their medications because of inability to pay. 91

Beyond prescription drugs, inequitable access to home-based care and institutional long-term care is pressing. In 2012, nearly 461 000 Canadians aged 15 years or older reported that they had not received help at home for a chronic health condition even though they needed it. 92 Because such layer two services receive inadequate public financing, Canadians aged 65 years or older have cited inability to pay as the main barrier to accessing the home and community care support they needed. 92 Some combination of inspired leadership, public financing, engaged governance, robust regulation, and intergovernmental cooperation seems to be needed to protect the public interest and address inequities of access to layer two services.

Indigenous health disparities are unacceptable

As in other settler societies such as Australia, New Zealand, and the USA, Indigenous populations in Canada were colonised and marginalised. In the Canadian case, marginalisation took the forms of Indian Residential Schools, government-enforced relocation, and historically segregated Indian hospitals, to name a few. 93 , 94 Three distinct and constitutionally recognised groups—First Nations, Inuit, and Métis—constitute 4·3% of the Canadian population and experience persistent health disparities relative to the non-Indigenous population, including higher rates of chronic disease, trauma, interpersonal and domestic violence, and suicide, as well as lower life expectancy and higher infant mortality rates. 95 , 96 , 97 For example, Canada's infant mortality rate dropped by 80% from more than 27 deaths per 1000 livebirths in 1960, to five per 1000 livebirths on average in 2013. 98 However, the estimated rate in Nunavut (the northern territory in which approximately 85% of the population is Inuit) was more than three times the national rate at 18 deaths per 1000 livebirths in 2013. 98

Other far-reaching inequities exist in the social determinants of health that even the best health-care systems cannot redress. Indigenous Canadians face substantial wage gaps of up to 50% compared with non-Indigenous groups, after adjustment for education and age. 99 Persistent racism and social exclusion permeate not only the health-care but also the education and justice systems, with subsequent disparities in high school education rates, incarceration rates, and other factors often driving egregious health statistics. 100

These challenges are not evenly distributed: figure 3 illustrates the proportion of the population that is Indigenous by province and territory. Due in part to higher fertility rates in the Indigenous population than in the general population, by 2036, a projected one in five people will be an Indigenous person in the western provinces of Saskatchewan and Manitoba. 101

A dizzying array of services in the health-care system, including federal programmes, provincially provided services, and highly bureaucratised add-ons, together continue to fail to meet the needs and constitutional rights of Indigenous people. 102 Indigenous people are covered by provincial Medicare plans, but some on-reserve health-care services fall under federal jurisdiction, and many Indigenous people receive supplemental insurance through the federal government.

Canada is actively grappling with its colonial history. An unprecedented Truth and Reconciliation Commission (TRC) released a report 94 in 2015 that shared the stories of Indian Residential School survivors who lost connection to family, land, culture, and language through a process intended to assimilate them into western society. Seven of the 94 calls to action in the report refer directly to steps required to address the inequities in health. From recognising and valuing traditional Indigenous healing practices to training Indigenous doctors and nurses and setting measurable goals to close gaps in access to health-care services, the TRC calls to action address crucial themes, many of which are rooted in self-governance. The newly established First Nations Health Authority in British Columbia, which is self-governed and community-driven, is an example of the type of emerging model intended to address the demand for self-governance in the administration and delivery of culturally safe and responsive services for Indigenous people in Canada. 103 The remaining TRC calls to action, should they be implemented, would help to reduce disparities in the social determinants of health, leading to better health-care outcomes.

An opportunity to renew the social contract

The role of governments: federal, provincial, and indigenous.

As Canadians observe the 150th anniversary of Confederation in the face of these three important challenges, a renewed vision of the roles of governments, providers, and the public will be required to overcome the stasis of the present and achieve the potential of single-payer Medicare. Rather than continue the Canadian tradition of slow, steady, and incremental change, governments must step forward boldly and with proactive commitment to ensure a vital and sustainable system for all Canadians.

The predominant administrative and delivery responsibilities for health care in Canada will always lie with provincial and territorial governments. The work of reorganising resources, building infrastructure, and delivering programmes for an ageing population under fiscal constraints is theirs to lead. For wait times in particular, a focus on provincial implementation of successful projects using the available financial and policy levers is long overdue.

However, provincial and territorial governments cannot succeed alone. At a few key times in Canadian history, the federal government has overcome decentralisation and fragmentation by setting a national vision for health care and investing politically and financially in that vision. In an era in which Canada is reasserting its commitment to progressive values on the international stage, 7 health care represents a key domestic opportunity to recommit to the core Canadian values of equity and solidarity. 104

The movement to expand the scope of the public basket of services is at the heart of this approach, and we support mounting calls for universal prescription drug coverage 105 as well as expanded home care, 106 long-term care, 106 and mental health services 107 to be included in layer one of the financing system. Royal Commissions as far back as the 1964 Hall Commission 108 and as recent as the 2002 Romanow Commission 109 have clearly articulated the need for this expansion. In particular, debates about a so-called Pharmacare system are gaining needed momentum, as multiple economic evaluations have suggested that improved access through an expansion of public coverage is possible at lower overall costs. 110 As the Quebec experience illustrates, it is difficult for any one province to begin alone as Tommy Douglas did in Saskatchewan—federal cost sharing and stewardship will be required at an early stage to achieve the savings as well as the coverage and quality goals of Pharmacare. 111

With respect to wait times, solutions will continue to be based in local innovations, but the infrastructure for national spread and scale-up requires active federal involvement. One possible approach, recommended by a federally commissioned panel on health innovation, would be a Healthcare Innovation Fund intended to accelerate the spread and scale-up of promising innovations. 32

A constructive partnership between the federal government and Indigenous peoples could overcome one of Canada's most difficult challenges—the very poor health outcomes of Indigenous peoples. Newly established principles guiding the relationship between the Government of Canada and Indigenous peoples, as well as the launch of a new federal Ministry of Indigenous Services established in August, 2017, could set the tone for renewed terms of engagement. 112 This commitment to self-determination will mean supporting new models of self-governance within and beyond the health-care sphere, with a particular focus on healing from intergenerational trauma and a strengths-based, wellness-focused approach to enhancing the social determinants of health. Canada's considerable experience with decentralised models of health-care delivery should allow for such innovation, and the opportunity must be seized with more urgency.

The TRC's calls to action must move from suggestions based on the courageous voices of survivors of the Indian Residential School system to non-negotiable tasks for all levels of government, all professional organisations, and all citizens. These tasks include: first, measurement and frank evaluations of health-care systems and programmes; second, creation of cultural safety and humility within a health-care system that needs to rebuild trust; and third, true representation of Indigenous Canadians within the ranks of providers and leaders of the health-care system. Mutual accountability here is essential.

The role of providers

Canadian hospital-based nurses, nurse practitioners, pharmacists, physiotherapists, and other health professionals are employed by health service delivery organisations and regional health authorities. As employees, these regulated health professionals have accountability for quality improvement and system reform, and their influence and importance in the system have been increasing steadily for decades. 113 The scope and availability of interprofessional and nurse-led care models continue to grow, as evidenced by policy outcomes such as the rapid increase in nurse practitioners in Quebec as part of that province's approach to primary care reform. 114 Given the importance of interprofessional teams in improvement of access to high-quality primary and specialty care, such teams must be accelerated to reduce wait times, work on disparities associated with social determinants of health, and improve care for vulnerable groups.

By contrast, Canadian physicians remain primarily self-employed, independent professionals. 115 Ongoing conflicts are fuelled by mounting pressure to alter this arrangement and increase professional accountability for and to the system. 116 Productive partnerships between physicians and governments at times exist, but co-stewardship of finite resources is not built into the structure of the system. The need for physician engagement, both at the individual and collective level, is crucial as Canada moves to address long wait times for elective care, because solutions so often involve the reorganisation of traditional referral models and the introduction of team-based care. Furthermore, expanded public coverage of prescription medications will necessitate a drive towards more evidence-informed and value-based prescribing. Canadian physicians are well situated to constructively contribute to such efforts to define value and help to shift behaviour. As founders of evidence-based medicine and important contributors to global medical research, Canadian physicians must help to lead the necessary research and debates on change within the health-care system. 117 They are critical partners in ensuring quality, consistency, and availability of services. 27 Medical associations in at least two provinces have recognised the importance of system stewardship in the practice of professionalism and have committed to health system reform in collaboration with governments. 118 , 119 The Canadian Medical Association's renewed strategic plan places patients at the core of its mission. 120 And leaders in medical education have embraced a social accountability mandate and are actively working to train the “right mix, distribution, and number of physicians to meet societal needs”. 121 This approach is a model with potential broad international application.

The role of the public: patients, taxpayers, and citizens

It is not yet clear what mechanisms will emerge to alter patient behaviours as the system evolves. An early example of patients being encouraged to engage directly in system stewardship is Choosing Wisely Canada. This clinician-led campaign to address overuse of tests and treatments is part of the international movement to reduce low-value care. 122 The campaign offers four questions that patients can ask to start a conversation with their health-care provider about whether a test, treatment, or procedure is necessary. 123 Users of services will also need to be willing to participate in new models of care delivery that have been shown to successfully reduce waits for specialty care. These models will include those that are more team focused than physician focused, and models centred in comprehensive primary care with expanded scopes of practice.

Public engagement and participation in health-care policy require engagement with people as taxpayers, who want value for money, and as citizens, who continue to believe in the principle of equitable access to services. At times, governments have assessed public support for various reform options through the public consultations of independent Royal Commissions or external advisory panels, many of which are listed in panel 3 . National Royal Commissions are independent inquiries, invited through the power of the Crown to investigate matters of national importance and characterised by extensive consultations with the public. 124 , 125

Such commissions produce reports that are often accused of gathering dust, but at times they can be transformative in terms of public views and judgment, eventually having a profound effect on government policy. Some commissions even produce immediate change. Despite admirable efforts by health-care providers on the ground in Ontario and British Columbia to contain the outbreak of severe acute respiratory syndrome (SARS) in 2003, a subsequent review highlighted long-ignored flaws plaguing the system that were unmasked by the outbreak and led to formation of the Public Health Agency of Canada 1 year later. 126 , 127

As in the rest of the world, other models of citizen engagement in public policy are being explored, but the value of such initiatives is not yet known. 128 Citizens' panels are becoming more common, such as one on national Pharmacare in 2016. 129 Public support for and participation in values-based, evidence-informed decision making will be crucial to ensure financial sustainability and to mitigate the risks of overprescribing in the area of pharmaceutical policy.

Public engagement in health research—as seen, for example, in the Canadian Institutes of Health Research-funded Canada's Strategy for Patient-Oriented Research— incentivises each province and territory to identify research priorities in collaboration with patients, and must continue. 130 Public input of this kind should be nurtured, since it can help policy makers to balance the need for health system investment against other social priorities.

Canadian lessons for a global world

Canada's most important accomplishment by far has been the establishment of universal health coverage, which is free at the point of care, for medical and hospital services. The preservation and enhancement of Medicare are due largely to Canadians' pride in caring for one another—an expression of equity and solidarity that runs core to Canadian values. Hinging on a social consensus of equitable access to health care, the simplicity of the system—no variable coverage, no means testing, and no co-payments—is easy for Canadians to understand and support.

But universal health coverage is an aspiration, not a destination. All countries must continuously consider the depth and scope of coverage that is politically achievable and fiscally feasible. In Canada, that necessary work has not been done for more than 40 years. The Canadian experience thus offers a cautionary tale on incrementalism. In the absence of bold political vision and courage, coverage expansion can be very difficult to achieve, with the result that the Canadian version of universal health coverage is at risk of becoming outdated.

A powerful mechanism such as a single-payer insurance system is only as good as the willingness of system leaders to use it for reform. In turn, reform requires a willingness on the part of governments to pursue change, rather than simply managing the status quo. Clear mechanisms are lacking to consistently realign resources to meet population needs, promote evidence-based care, reduce variation, and contain costs. Health care is ultimately a local affair, and no patient or provider wants the payer in the examination room. However, much of the potential benefit of a single-payer structure is lost when institutions are independent, with little accountability. The potential of the system is further limited by the fact that physicians function alongside but outside the system, rather than as accountable participants through employment or other contractual means. Co-stewardship and accountability should be recognised as integral parts of payment systems rather than avoided or grafted on afterwards.

When Tommy Douglas first established public health insurance in Saskatchewan in the late 1940s, his goal was to begin by creating insurance models that would eliminate the financial barriers to care. He intended to follow that with a second reform of health service delivery that would focus on population health needs, with an emphasis on the reform of delivery models and on the social determinants of health. 131 His government, and subsequent governments, provincially and federally, managed to overcome fragmented institutional structures and decentralisation of power to make the first stage of his vision a reality, but not yet the second. To achieve that second stage in the 21st century, determined action on the social determinants of health and a joint effort by governments, health-care providers, and the public in achieving health system reform will be needed. With bold political vision and courage, this ambitious goal is within reach. 132

Acknowledgments

We acknowledge funding from the McGill Observatory on Health and Social Services Reforms and from the Canada Research Chair in Policies and Health Inequalities (AQ-V) for maps developed by Tim Elrick and Ruilan Shi at the McGill Geographic Information Centre, Montréal, QC, Canada. We thank Ian McMillan and Leah Kelley for assistance with references, formatting, and submission; Karen Palmer for assistance with copy edits, critical review of the manuscript, and expertise regarding the British Columbia court case; and Meb Rashid for his expertise regarding migrant and refugee health issues.

Contributors

All authors contributed to the formulation of the ideas in the manuscript and the writing of initial drafts. All authors contributed to the literature search and editing of the manuscript. APM, DM, and AQ-V contributed to the figures. All authors reviewed and approved the final manuscript before submission.

Declaration of interests

DM is currently an external adviser to the Government of Canada on a review of pan-Canadian health organisations. NRC is a consultant for the cancer strategy of British Columbia's First Nations Health Authority and co-director of the Centre for Excellence in Indigenous Health, University of British Columbia (Vancouver, BC, Canada). GPM was executive director of the Romanow Commission. We declare no other competing interests.

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• Taiwan’s path to...

Taiwan’s path to universal health coverage—an essay by William C Hsiao

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• William C Hsiao , K T Li professor of economics , emeritus
• Harvard T H Chan School of Public Health, Boston, USA
• hsiao{at}hsph.harvard.edu

Who could pass up a chance to redesign a society’s healthcare system, no matter how challenging it may be? William C Hsiao describes how he responded

I was teaching economics at the Harvard School of Public Health when, in 1988, I received a surprising telephone call from the deputy chairman of the Taiwanese government’s planning commission. Could I come to Taiwan and lead a taskforce that was developing plans to provide access to affordable healthcare for the whole population? The task was daunting. Success would require a major revamping of Taiwan’s healthcare system, and the high level taskforce had been suffering from a lack of leadership.

Taiwan was then an emerging economy with 20 million people. Only 40% of its citizens were covered by social health insurance—civil servants and their families and employed workers but not their families. Private health insurance was almost non-existent. The social health insurance plans were run inefficiently by bureaucrats; providers were filing costly fraudulent claims; paying for care was a real challenge for most of the uninsured; and health costs were rising much faster than Taiwan’s high economic growth rate. The government didn’t have much tax revenue available or the technical expertise to overhaul its health system.

Nevertheless, I could see that Taiwan had already created some favourable conditions for universal health coverage (UHC). It was moving from an authoritarian state to a democracy, and the emerging grassroots opposition party was pushing for UHC. The government had asked the taskforce to plan a healthcare system with three clear goals: universal coverage with equal access to quality care, efficient use of health resources, and controlling the rise in health expenditure.

Taiwan had a strong central government with a powerful political elite that could make difficult decisions, and a fast growing economy that created larger economic capacity. Organised vested interest groups were weak because the previous authoritarian regime of the Kuomintang (KMT) Party discouraged them. And Taiwan’s tiny private health insurance industry was not a political force.

But I could see some severe challenges as well. Though most Taiwanese citizens perceived UHC as a benefit for them, they did not grasp that they would have to pay higher taxes or social insurance premiums. Meanwhile, most businesses opposed UHC because they feared the costs. The conservative wing of the ruling KMT party was opposing UHC for ideological reasons, and the governmental ministries and bureaucrats managing the existing plans that covered civil servants and employed workers strongly opposed UHC because they saw it as a threat to their power and influence. Physicians, hospitals, and pharmacies were worried that their incomes and profits would be reduced. Taiwan’s primary care largely consisted of private clinics that pursued profits by overprescribing and overtreating. How could UHC nudge these private physicians to alter their practice?

I took heart that the planning commission overseeing the planning of UHC included all the cabinet ministers that handled domestic affairs. The commission therefore had broad views and was not hindered by the narrow views of the Ministry of Health. Three weeks after the phone call, I arrived in Taiwan to become the chief adviser and chair of the taskforce.

Planning like a doctor

I initiated a planning approach that was based on the systematic process that physicians take with patients. We first diagnosed the causes of Taiwan’s major health problems with solid evidence, then we gathered the global knowledge and experience to treat these problems effectively, in a way that would work for the patient in front of us: Taiwan.

The diagnostic process required the taskforce to collect and analyse Taiwanese health and socioeconomic data as well as examine the historical development of Taiwan’s health system. Around 20 professionals collected and analysed the data and created a cost projection and financing model.

Taiwan had defaulted its financing and delivery of healthcare to the free market. As a result, it had a patchwork healthcare system. The quality of healthcare was highly varied. Some of the physicians and nurses were unqualified, and there was little quality assurance. Privately practising physicians charged high prices and made handsome profits from overprescribing. There was no effective constraint on health expenditure and no government regulations or market forces to encourage efficiency. Delivery of healthcare was fragmented, with separation of prevention, primary, and tertiary care. Government was responsible for prevention, and private clinics provided primary care. Inpatient hospital services and specialist services were a mixture of public, non-profit, and for-profit.

In 1989, we organised a three day international conference that commissioned papers and brought the top academic experts from the UK, US, Canada, Germany, and Japan to share the successes and failures of their health financing and delivery approaches with the taskforce and Taiwan’s top policy makers. Taskforce members also visited several countries to get a more in-depth understanding.

The taskforce had to tackle a broad question: the role of government versus private markets. Ideologies were debated and argued—sometimes heatedly. We organised several meetings with academics and politicians to debate this issue. Eventually, evidence convinced most people that the private market would not be able to achieve universal coverage or finance it, and that the sales and administrative expenses of private health insurance would be huge. Delivery of healthcare could be a mixture of government and private.

At the international conference, the tremendous advantages of a single payer system were brought out by Canadian and US experts. This information convinced the taskforce and leading policy makers to adopt a single payer approach.

Designing the benefit package was the greatest challenge. We knew we couldn’t reduce what some people already had. There were fundamental decisions about what should be covered—Prevention? Primary care? Long term care? Rehabilitation? Three areas were particularly controversial: dental care, eye care, and Chinese medicine. So we examined the cost and effectiveness of various services.

Meanwhile, many economists argued that health insurance created “moral hazard”—insurance providing free or reduced priced services and drugs induces some patients to demand more than they need medically. There was worldwide evidence for that. The economists therefore suggested co-payments, but some on the taskforce worried that co-payments, co-insurance, and deductibles would deter patients from seeking necessary preventive and medical services.

The taskforce also grappled with incentive systems to pay providers (that is, physicians and hospitals) to enhance efficiency and quality of healthcare. We were mindful that the existing fee-for-service payment method promotes increased expenditure. Better methods have been adopted by many advanced nations. There were some good options: capitation, salaried physicians, hospital global budget, bundled payment, and diagnosis related group payment for inpatient hospital services.

The taskforce developed a model to estimate the costs of different options in benefit coverage and payment methods. Next, we explored various methods of financing them and presented the options to the policy makers. Ultimately, what determined coverage were the costs and the estimated amount of financing required to sustain a plan over 10 years.

In 1989, once we had determined the causes of Taiwan’s major health problems, President Teng-hui Lee asked me to brief him every month. I also met regularly with several other leaders, including K T Li, a political leader from the moderate wing of the KMT. The business community was concerned about the cost of UHC and what it must pay. (It was eventually convinced by the argument that it would maintain the loyalty of workers in a tight labour market by offering health insurance that included family members.)

The planning commission organised public meetings for the taskforce to present our preliminary recommendations and obtain public feedback in 1990. We also presented a proposed plan to various legislative committees. We revised our recommendations based on the feedback, including adding Chinese traditional medicine to the benefit package.

We issued the final plan in 1990, called the national health insurance (NHI) plan. A new team was appointed in the Ministry of Health to flesh out the details of the plan, and the president began strongly pushing the Taiwanese legislature to pass the plan in 1993. As a result, the legislature made only modest revisions and passed it in 1994.

Taiwan’s NHI plan covers all citizens with a comprehensive set of services, including secondary prevention; all physician, inpatient, and rehabilitation services; Chinese traditional medicine; eye and hearing care; most dental care; and visiting nurses. But it doesn’t cover long term care in institutions. Patients must make modest co-payments for clinic visits and drugs, but the total amount any family must pay is capped each year. Employers, workers, and government each pay one third of the cost of employed workers’ insurance. The government pays the premiums for poor people and veterans as well as subsidies for workers in the informal sector. People can buy private insurance for services not covered by the plan such as cosmetic surgery, private hospital rooms, private nursing, and uncovered new expensive but less effective drugs.

A fundamental principle in controlling expenditure was established by Premier Chan Lien when he reviewed the taskforce’s report. The amount of NHI revenue determines the payment rates and amounts paid to healthcare providers. However, subsequent governments have been reluctant to raise the taxes or premiums, which put pressure on lowering the payment to providers. The NHI Administration, a quasi-government agency set up to oversee the plan, also established mechanisms to control the use of new expensive medical technology and drugs to moderate the pressure for expenditure increases.

The taskforce recommended that Taiwan reform its payment system to healthcare providers by introducing bundled payments and diagnosis related group payment methods as well as capitation. Moving away from a fee-for-service system would also reduce the incentive for increased usage induced by physicians. President Lee assured me he’d fight for the payment reforms, but in the end strong opposition from physicians stopped them. Taiwan continued to pay providers on a fee-for-service basis but with a point system to cap the total amount that would be paid out each year. This point system remains today.

The taskforce also recommended prioritisation of quality improvement. This included periodic recertification of hospitals, continuing education of physicians, and, most importantly, monitoring the quality of medical services and discipline the poor performers. However, the progress is slow.

At the recommendation of the taskforce, the government set up a board of directors for NHI which included representatives of payers and payees. Members negotiate what changes in benefits and payments the two sides can agree on, with “neutral” members, including academics, breaking any tied votes. This approach takes the government out of the middle.

Did it work?

Taiwan was fortunate to appoint a capable official to implement the plan, Dr Ching-chuan Yeh. He did a superb job. Since the plan came into effect in 1995 no major revisions have been made, except for financing. In 2012, the legislature added a new source of revenue: an earmarked tax on unearned income.

Now, the plan covers 99% of Taiwan’s citizens with comprehensive benefits; the remaining 1% reside overseas and did not enrol. 1 The health status of Taiwanese people continues to improve. Infant mortality is 4.3/1000 live births and life expectancy 81 years, 1 which is comparable with the UK and better than the US. Impoverishment caused by medical expenditure is minuscule. (That said, personal expenditure on long term care is substantial.) Patients have free choice of providers, with no gatekeeper. Almost all patients can access physician services within 24 hours. There are no long waits for specialty services, imaging, or laboratory tests. Health expenditure is well controlled, with the annual rate of increase in line with growth in gross domestic product (GDP). In 2016, Taiwan spent 6.3% of its GDP on health compared with the UK’s 9.7% or US’s 17.1%. 2

According to the government’s monthly poll, more than 70% of people are very satisfied or satisfied with Taiwan’s health system. 3 Nevertheless, there are media reports of some Taiwanese patients and physicians complaining that Taiwan is too slow in using the latest expensive medical technology and drugs. A comprehensive evaluation of NHI by the government found some specialists believe they are overworked and underpaid, which resulted in a shortage of physicians in these specialties. 4

Although there is no pressing political demand to improve Taiwan’s health system, there are latent problems. The plan is slightly underfunded because the government and the public are reluctant to impose higher tax or premium rates. Consequently, some provider complaints about inadequate revenues are legitimate. I would like to see the clinical quality of healthcare improved in Taiwan—a real challenge given that quality data are controlled by medical specialty societies that are mostly concerned about physicians’ earnings rather than assuring quality of care. Taiwan’s capped fee-for-service payment method impairs the prevention of non-communicable diseases. At the same time, it encourages providers to increase the number of services they provide, increasing health expenditure. Meanwhile, the organisation of Taiwan’s health system remains fragmented with the separation of primary care, specialist, and hospital care. As a result, Taiwan lacks continuity and integration of healthcare.

Taiwan’s experience in establishing and sustaining UHC shows the need for political determination, leadership, technical expertise, and data and that technical design must consider the political realities. 5 International knowledge, experience, and evidence played a major role in informing the design. Taiwan found it was easier to establish a new funding mechanism for UHC than to reform the payment and healthcare delivery system, which requires wide support from the captains of the medical ship: physicians, hospital directors, and nurses.

William C Hsiao has worked on health system design and reform in many developed and developing nations, most recently Malaysia, China, and South Africa. He received his PhD in economics from Harvard University and is a professor at the Harvard T H Chan School of Public Health. He has published more than 180 papers and several books and has advised international organisations, including the World Bank, World Health Organization, and the International Monetary Fund.

Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned; not externally peer reviewed.

• ↵ Taiwan Ministry of Health and Welfare. 2018 Taiwan health and welfare report. 2019. https://www.mohw.gov.tw/cp-137-47558-2.html
• ↵ WHO. Global health expenditure database. http://apps.who.int/nha/database
• ↵ Central Health Insurance Agency, Ministry of Health and Welfare. Public opinion surveys. https://www.nhi.gov.tw/Content_List.aspx?n=B25D8946F7648C14&topn=CDA985A80C0DE710
• Huang-hsiung H ,

Winner of the 2023 Wakley Prize Essay: the importance of universal health coverage

Affiliations.

• 1 The Lancet, London EC2Y 5AS, UK. Electronic address: [email protected].
• 2 The Lancet, London EC2Y 5AS, UK.
• PMID: 38142121
• DOI: 10.1016/S0140-6736(23)02804-0
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