Tuesday, January 31, 2017

Healthcare in the United States and Europe: A Comparative Analysis

"Stop funding useless wars and healthcare in the United States can be free at the point of consumption. There is no argument against this reality." - Kent Allen Halliburton


What is Healthcare? What is its purpose? Is it something that should be guaranteed? Is it something that is essential to living a long and rewarding life? How should it be delivered? Should healthcare be public or private? Who should be eligible for healthcare? How is it supposed to be paid for? These and many other questions will, hopefully, will receive adequate answers before the end of this article. Healthcare is, basically, in a general sense, the maintenance and improvement of physical and mental health, especially through the provision of medical services. It can easily be assumed that the answer to the second question directly relates to the answer of the first question. It serves well to logically assume that its purpose is to provide for the mental and physical health of people in need of such services. These first two questions are that easy to answer. However, the next set of questions are, most definitely, not that simple to answer. A great many factors need to be considered when attempting to answer these questions, from matters of the form of government in a nation, to the economic philosophy of the nation. These ideas are broad, but they are important, as it will be pointed out that in both Europe and the United States, there are various health systems that were established under both liberal and conservative governments.

The manner in which these systems were implemented, the conditions that created them, and their general purpose are also important things to know. This will be done by exploring, briefly, the origins of healthcare is various nations. It also important to know who is covered and who is not, as it relates to women, males, children, or racial or ethnic minorities, among others. The overall percentage of each population that is covered is also important. This will be done by seeking out the statistics and presenting them here. It is also important to briefly mention the overall health status of the populations in various countries involved in the discussion. This will be done, again, by reviewing the data and the statistics on the topic from various sources.

One should also pay close attention to the scholarship on healthcare. It is varied, and by no means, is there a general consensus on any part of healthcare provision or eligibility. The arguments vary dramatically, going from one side to the other, with very little leeway in between. This will be explored by looking at the literature. The very existence of healthcare will be questioned, and the methods of establishment and maintenance will be scrutinized. This will be done to establish a working typology between the healthcare system in the United States, post Affordable Care Act, and the various healthcare systems in Europe, accounting for similarities and differences. Overall coverage statistics, as well as, satisfaction surveys will also be used. The discussion of the scholarship will begin with, Butler, Stewart M. and Edmund F. Haislmaier, A National Healthcare System for the United States (Washington, D.C.: The Heritage Foundation, 1989), but will also include other research that will not be limited by source or time. An analysis, based on the literature and modern news releases and how the public views their health care, will be next. The future of healthcare in the United States will round up the discussion. The standard tying everything together will be provided in the conclusion, along with some suggestions on what a healthcare system should really look like, along with conjecture as to the true nature of the problem.

The Origins of These National Healthcare Systems

When discussing the origins of national healthcare systems it is imprudent to begin the discussion with the United States. The discussion must begin in Europe. The prospect of covering every single nation in the European Union, though, would bog this study down far more than anything. The study would require much more than is necessary to make this article's point. So, as not bore the reader, and to save time, an effort will be made using only the healthcare systems in Germany and the United Kingdom. These two nations have been chosen because they represent, approximately, national healthcare systems established on opposite sides of the political spectrum. The healthcare system in Germany arose from the conservative style of the Prussian military. The healthcare system in the United Kingdom was born under the liberal guidance of the Labour Party. The United States will then be compared to these nations. The comparison, for this section, will be limited solely to crowning moments leading to the establishment of the systems.

The present Social Health Insurance system in Germany began to take root in the late 18th century and subsequently developed in the three distinct stages towards universal health insurance for all Germans. Three stages of incremental developments prepared for Bismarck’s introduction of SHI as a nationwide and comprehensive system in 1883. First, in the late eighteenth and early nineteenth centuries, laws were passed that set detailed rules on how voluntary sickness funds should be organized. These rules included provisions concerning contributions, the benefit package, entry conditions and fund management. In a second stage, in 1843, another round of laws introduced the notion of compulsory membership. The right was given to local governments to acknowledge existing voluntary funds and even to introduce compulsory membership in those funds (Doring, Andrea and Paul Friedmann, “The German Healthcare System,” EPMA, Vol.  1, No. 4). In 1849, it also became possible to make membership compulsory for specific employment groups. In a third stage, a number of laws simply became applicable at the national level. The first compulsory health insurance law was that of 1854, when health insurance coverage became compulsory for all miners. This was a very significant development for the people of Germany, in that it was the first law that covered the entire German territory for one occupational group, with miners being required to become a member of one of the regional miners’ health insurance funds (Carrin, Guy and Chris James, “Social Health Insurance: Key Factors Affecting the Transition Towards Universal Coverage,” International Social Security Review, Vol. 58, No. 1 (2005), 4-7).

This was followed by an important landmark in 1883 for the German people. When Otto von Bismarck introduced Social Health Insurance (SHI) for a larger number of occupational groups, the process towards universal coverage in Germany began to build steam. Initially, the health insurance law of 1883 covered blue-collar workers in only certain industries, such as craftspeople and other selected professionals. It is has been estimated that this law brought health insurance coverage up from 5 to 10 percent of the total population. After 1883, the incremental approach to coverage continued by systematically bringing different socioprofessional groups into compulsory insurance. By 1910, population coverage had reached 37 per cent, attaining 50 per cent by 1930. In 1950, insurance coverage was 70 per cent of the population. One of the last laws enrolled artists and publicists into the SHI system in 1981. By 2000, 88 per cent of the German population was enrolled in the SHI system. Population coverage by SHI is not 100 percent as, above a certain income level, one can opt out of the SHI system and obtain their health insurance from a private source. This system is considered to be a conservative model because it works with private insurance companies and medical providers to attend to the health coverage needs of its people (Green, David, Benedict Irvine, Emily Clarke, and Elliot Bidgood, “Healthcare Systems: Germany,” Civitas (2013), 2-8).

What, then, of the healthcare system in the United Kingdom? The discussion about a national healthcare system in the United Kingdom began in the early part of the twentieth century. The first person to coin the term ‘National Health Service’ was Dr. Benjamin Moore. In, The Dawn of the Health Age, he discussed a national level plan to provide health services to the general public (Moore, Benjamin, The Dawn of the Health Age (London, UK: BiblioLife, 1910). In an address to the Fiftieth Anniversary Conference of the SMA, Dr. Leslie Hilliard mentioned the prominent role that Dr. Moore played in the formation of the SMA. She also considered the early role he played in the development of a National Health Service. In 1912, he founded the State Medical Service Association, which remained in operation until it merged with the Socialist Medical Association in 1930 (Hilliard, Leslie, MD, “Address to the 50th Anniversary Conference,” Socialist Medical Association (1980). Before the National Health Service was created in 1948, citizens were, generally, required to pay for their health care. They were, however, sometimes able to obtain services for free at Voluntary Hospitals. Local authorities operated hospitals for local taxpayers. They provided these services under the authority given to them by the myriad Poor Laws that had been passed by the British Parliament in previous years. In April of 1930, The London County Council was given jurisdiction over one-hundred and forty hospitals that had been previously run by the old Metropolitan Asylums Board, as well as, the administration of any medical schools in the region and any other medical service related institutions. In 1929, just before this, the Local Government Act 1929 was passed, the law allowed local authorities to run services over and above those authorized by the Poor Law, and in effect to provide medical treatment for everyone. By the onset of World War II, the LCC was running the largest public health service in all of Britain (Jackson, W. Eric, Achievement: A Short History of the London County Council (London, UK: Longmans, 1965), 25-30).

There were also systems of private or semi-private health insurance. Most of the health insurance usually consisted of private schemes, such as friendly societies or welfare societies. With the passage of the National Insurance Act of 1911, introduced by, then, MP David Lloyd George, the British government deducted a small amount of money from the weekly wages of every worker. These contributions by the workers were not made alone; however, contributions to the various funds were also provided by employers and the government. Workers were entitled to adequate medical care, unemployment compensation, and a retirement plan. They did not get prescriptions covered, though. This was the first real medical program in Britain that kept detailed medical records of its patients, which served to greatly improve the quality of care delivered to the public. This program did have its limitations, though. First, it was only available to those individuals who paid for it, and it left the majority of the women and children in Britain without coverage (Dawson, Bertrand Edward, 1st Viscount of Penn, “Interim Report on the Future Provision of Medical and Allied Services,” UK Ministry of Health (May 27, 1920). A good place to review the development of British healthcare is the primary sources of the people creating the legislation. David Lloyd George was intimately involved with this process, and fantastic records have survived (The Cabinet Papers, 1915-1986, National Health Insurance,” British National Archives (2015). In 1932, the Labour Party accepted a resolution moved by MP Somerville Hastings. This resolution called for the establishment of a State Medical Service. In 1934, the Labour Party Conference at Southport, England unanimously accepted an official document outlining the fundamentals of a National Health Service ( Murray, D. Stark, Why a National Health Service? The Part Played by the Socialist Medical Association (London, UK: Pemberton Books, 1971), 35-71).

The final leg of the journey to universal coverage in the United Kingdom came with the passage of the National Health Service Act of 1946. Passed, only around a year after the defeat of Germany in World War II, the National Health Service, had been building momentum long before World War II. For the UK, the war pressed the issue to the front of the political agenda in Parliament. Developing the idea into firm policy did not prove to be very easy, though. The British Medical Association and the Medical Planning Commission, both routinely changed their positions on the idea, as they battled internally over the effects that the law would have on the medical profession. Health Minister Henry Willink put forth a heroic effort to defend the idea, even going so far as to write up his arguments. In the article, “A National Health Service,” Willink outlined the details of the proposed National Health Service. Among the recommendations were the arguments that medical care should be free at the point of consumption, the program should be funded by public tax dollars, and all people, from anywhere, were to be eligible for the program. The paper recommended a system that was run from the local level, upward (Willink, Henry, “A National Health Service,” UK Ministry of Health (March 26, 1944). His critics in the Labour Party, namely the next person to be Health Minister, Aneurin Bevan, however, were not convinced that a locally run system was sustainable. They felt that local governments would be far too limited in their ability to implement the law because local governments were not usually the richest institutions in Britain (Addison, Paul, The Road to 1945: British Politics and the Second World War (London, UK: Jonathon Cape, 1977), 278-296). The law that was finally implemented in 1948 was a single payer system that was run at the national level ( United Kingdom, National Health Insurance Bill (April 30, 1946)HC Deb 30 April 1946 Vol. 422 CC. 43-142).

Finally, the discussion will turn to the healthcare system in the United States. The first proposal for healthcare at the national level came in the form of a proposed bill in 1845. It was entitled, “Bill for the Benefit of the Indigent Insane.” Offered up by Activist Dorothy Dix, the proposed bill called for the establishment of asylums for the indigent insane, as well as, the blind, and deaf. The land for the bill would have come via federal land grants to the states and payment for the system would be split between the states and the federal government. The law was passed by both the House of Representatives and the Senate. It, however, did not make it to law, as it was vetoed by President Franklin Pierce, and the veto was never challenged by the House (Frances, Tiffany, The Life of Dorothy Lynde Dix, Originally published by Houghton-Mifflin, 1890; Classic Reprint (New York: Forgotten Books, 2012), 175-185). There was then, of course, the health section of the Freedman’s Bureau. The bureau built over forty hospitals across the South, staffed itself with over one-hundred and twenty doctors and nurses, and treated over one million sick or dying former slaves. The only surviving Freedman’s Hospital stayed in operation until it was merged with the Howard University, in the Washington, D.C. area, and their Medical School in the mid 1890s (Downs, Jim, Sick From Freedom: African American Illness and Suffering During the Civil War and Reconstruction (New York: Oxford University Press, 2012), 65-94). Actual physical attempts to establish a real universal health coverage system in the United States began in the Progressive Era. In his bid to retake the White House in 1912, Theodore Roosevelt accepted the nomination for President from the Progressive Party on the platform that workers deserved better benefits, especially when the job they were doing ran the risk of killing them at any given time. He lost resoundingly, but a really public debate had begun (Igel, Lee, “The History of Healthcare as a Campaign Issue,” The Physician Executive (May-June, 208), 13-14).

The next step in the evolution of healthcare at the national level in the United States was taken in the 1930s. At a peak of despair, during the Great Depression in the United States, President Roosevelt pressed for the inclusion of language that would have publicly funded, under the administration of the new Social Security Administration, a healthcare system for people affected adversely by the economic downturn. His proposal was rejected almost immediately, with organizations like the American Medical Association threatening to withdrawal support from the Social Security Act if they insisted upon retaining the healthcare provision. He also received criticism from key politicians, which ultimately forced him to abandon the idea in order to pass the most important parts of the bill (Coombs, Jan, The Rise and Fall of HMOs: An American Healthcare Revolution (Madison, WI: University of Wisconsin Press, 2005), 5-6). The torch then passed to President Harry Truman. In his ‘Fair Deal,’ he called for universal health insurance in the United States. This, however, was met with such heavy resistance that he abandoned that part of his plan. He did, however, get the National Mental Health Act passed in July of 1946. The bill called for the establishment of a National Mental Health Institute, which was born out of a need to address mental illness among soldiers returning from World War II. The Hospital Survey and Construction Act, or the Hill-Burton Act, was also passed. This bill was designed to provide federal grants and guaranteed loans to improve the physical condition of the nation’s hospital system. One of the requirements for a hospital in need of repair or for the construction of a new hospital was that in order to receive national funding, the institution was not allowed to deny services on the basis of race, color, creed, religion, or national origin. They were, however, allowed to operate separate but equal facilities to assuage the South. This was later knocked down by the Supreme Court in 1963 (Poen, Monte M., Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare (Columbia: University of Missouri Press, 1996), pp. 161–168).

In the United States, despite these baby steps, the last sixty years have been the most important in the development of healthcare. In July of 1965, under the leadership of President Lyndon Baines Johnson, Congress created Medicare under Title 18 of the Social Security Act (Folliard, Edward T., “Medicare Bill Signed by Johnson: 33 Congressman Attended Ceremony in Truman Library,” The Washington Post (July 31, 1965), A1). The law provided for the medical needs of everyone over the age of sixty-five. It gave them access to hospitals, pharmacies, and physician services that before the law, the elderly population of the United States could not generally afford. The law also required that in order for hospitals to receive payment on patient claims, they had to desegregate (Vladeck, Bruce C., Paul N. Van de Water, and June Eichner, Eds., “Strengthening Medicare’s Role in Reducing Racial and Ethnic Health Disparities,” Study Panel on Medicare and Disparities, National Academy of Social Insurance (October, 2006), 47-52). There is also, of course, Medicaid. Medicaid was also established in 1965. It was designed to provide health coverage for children, single mothers, and the extremely poor. It was created under Title 9 of the Social Security Act (Starr, Paul, Remedy and Reaction: The Peculiar American Struggle Over Healthcare Reform (New Haven, CT: Yale University Press, 2011, 41-51). The next big effort to establish a national healthcare system in the United States came in 1993 with the 'Clinton Health Plan.' The effort failed because, after a series of setbacks, congressional support for the bill evaporated, and it failed to enter into law.

Had it done so, it would have dramatically changed healthcare in the United States, as it sought to reform nearly every aspect of the US healthcare system (Moffit, Robert E., “A Guide to the Clinton Health Plan,” The Heritage Foundation (November 19, 1993). The next major step was the passage of Medicare Part D, during the George W. Bush, Jr. presidency. It was created under the Medicare Modernization Act of 2003 and was designed to provide coverage for prescription drugs, as many people had had to get private insurance to cover those expenses in the past. The bill went into effect in 2006 (Hoadley, Jack, Juliette Cubanski, Elizabeth Hargrave, Laura Summer, and Tricia Neuman, “Medicare Part D Spotlight: Part D Plan Availability and Key Changes Since 2006,” The Henry J. Kaiser Family Foundation (October 30, 209), 1-2). Of course, the latest step, and the most expansive, was the passage of the Patient Protection and Affordable Care Act during the first term of President Barack Obama. This is the act that was designed to complete the journey towards universal healthcare in the United States. The Affordable Care Act (ACA) was signed into law on March 23, 2010. Its goal is to reduce the number of people in the United States living without health coverage and provide coverage for them that is of the finest quality and as affordable as is possible (Pear, Robert, “Brawling Over Health Care Moves to Rules on Exchanges,” The Washington Post (July 7, 2012). The bill was also projected to reduce costs in both Medicare and Medicaid. The laws success since then has been marred, by the laws opposition to secure its repeal (Elmendorf, Douglas W., “CBO’s Analysis of the Major Healthcare Legislation Enacted in March 2010,” Congressional Budget Office (March 30, 2011), 1-10).

How Do the Modern Systems Look When Compared to One Another?

To maintain organized thought, this section will begin with Germany, as well, followed by the UK and then the United States. In a 2004 study, DiPiero compared Germany’s healthcare system with five other nations, all of which had similar universal systems. He was not able to include the United States at the time because the United States did not have such a system. Whether it does even now, is still up for debate. DiPiero also points out that the United States is the sole remaining post-industrial nation without some form of easily accessible universal and affordable healthcare. In this article, he also provides a side by side comparison of the healthcare systems in the six nations, in which it is made clear that while Germany’s system is a social insurance model, it does provide for the needs of its people, and unlike the UK, they can do it without waiting lists. Citizens also have the option, if their income exceeds the average European salary of 49,500 Euros, to opt out of the social program and seek coverage in the private market. They can also buy supplemental coverage, or travel to other markets, for specific health needs, like dental or psychiatric services, if the specific service they need is only offered on the private market, or is simply not available in Germany for any myriad of reasons (DiPiero, Albert, "Universal Problems and Universal Healthcare: Six Countries, Six Systems," Oregon's Future (Spring, 2004), 27-32).

Germany’s healthcare system is a compulsory contribution based social insurance model. This means that the majority of the expenses in the system are funded by the public sector, which receives the funding in the form of social insurance payments, and covers in particular the costs of state supervision and basic infrastructure such as, administrative bodies and ministries, government institutes and facilities, or public health offices and medical education. The medical profession, whether public or private, which is funded by premiums that are collected by the public and private health and nursing insurance companies, is the place to go for direct healthcare services, such as the payment of service providers, e.g. physicians, nurses, the cost of medicine, therapies and medical aids, as well as, equipment. This program is designed to be open and visible, so that people are aware of the flow of money throughout the system (Barnighausen, Till and Rainer Sauerborn, “One Hundred Years of the German Healthcare System: Are There Any Lessons for Mid- and Low-Income Countries?” Social Science & Medicine Vol. 54 (2002), 1559–1573). As far as the numbers go, eighty-five percent of the German population is covered by the social insurance program.

The other fifteen percent are split between those that opt out and purchase a private plan and those who receive government funded care related to their work, i.e., soldiers and diplomats, and the like (Matz-Townshend, Cathy J., “Fast Facts: German Health Insurance,” How to Germany (February, 2015). The rates charged for coverage in the Krankenkassen, the institution that administers the social health insurance program, are generally 14.6 percent of the average German citizen’s salary. Both the government and employers contribute to this rate. The client is responsible for the rest in the form of monthly premium payments and copays at the point of consumption (Green and Irvine, 2-4). The table below offers a brief explanation of how funding for the German healthcare system is distributed. These numbers are accurate as of 2007 (Ridic, Goran, Suzanne Gleason, and Ognjen Ridic, "Comparisons of Health Care Systems in the United States, Germany, and Canada" National Institute of Health, Vol. 24, No. 2 (2012), 112-120). Because of formatting issues this table did not come out looking all that well. Assume that all 1995 figures relate to the first of the three numbers given. 2000 goes for each second number given, and 2007 goes for each third number given. (Doring and Paul, Ibid)

Funding of the German healthcare system .


Total expenditure

186 474 mln euros
212 335 mln euros
252 751 mln euros

Public sector


SHI insurance


Private health/nursing insurance


Employer contributions


Private households


Moving onto to the United Kingdom, the people of the UK get their healthcare from the National Health Service, which is run by the Department of Health. Brought into operation in 1948, it is a single payer system that is free at the point of consumption to anyone that is in need of services, from day to day citizens to visitors from across the ocean. Depending on income, people can opt out of the system for private coverage if they are able to pay the higher premiums (Doyle, Yvonne and Adrian Bull, “Education and Debate: Role of the Private Sector in the United Kingdom Healthcare System,” British Medical Journal, Vol. 321, No. 7260 (Sep. 2, 2000), 563). They can also seek supplemental coverage if they are a visitor, if they do not meet the requirements for free treatment, something new as of late, or they are able to pay a reduced rate for services (Guidance on Overseas Visitors Hospital Charging Regulations,” National Health Service (October 1, 2012 – May 29, 2015). This, however, is a complex system to run, and the thus, the National Health Service of the United Kingdom is not unified. Each of the members, England, Whales, Scotland, and Northern Ireland, have their own local version of the system that they operate almost entirely independent of one another. Despite this, they all still do get funding from the central government, though. For the sake of this discussion, the National Health Service will be spoken of as single entity. (Plimmer, Gill, “Private Company in NHS Hospital Takeover,” Financial Times (November 10, 2011). This ‘devolution,’ as it is referred to, was not part of the founding of the system. It is only a recent occurrence. This was implemented in late 2007 to early 2008 to offer each member state a little bit more autonomy in the deliverance of public services. This autonomy was sought after a series of disagreements between officials in England and those in the other member states. For example, Scotland does not means test the elderly before supplying them with health services, whereas, England does, which causes their richer elderly citizens to return to the private market for service, despite many wishing to remain with the NHS (Triggle. Nick, “NHS: Now ‘Four Different Systems,” BBC News (January 2, 2008).

However, recent reforms under the Health and Social Care Act of 2012, which went into effect in April of the following year, have changed the organization of the National Health Service a little bit. First of all, some of the responsibilities for the delivery of services at the local level have been handed over to private interests known as, Clinical Commissioning Groups. The organizations are ran and led by General Practitioners, the very physicians who are delivering those services at the local level (“National Health Service Constitution,” National Health Service (July 27, 2015), 8-15). The part of the National Health Service that gets the most criticism, however, is their waiting lists, which is used to manage flow and ensure that everyone gets the same general quality of services. Waiting times have improved, but people are still waiting extended periods of time for, on some occasions, vital services that could save their lives (Office for National Statistics, “Referral-to-Treatment Waiting Times in England: 2007/2008 – 2012/2013,” Nuffeild Trust (April, 2013). See the link to observe average waiting times in the UK's NHS. What, then, do the numbers look like for the United Kingdom? Looking at spending in the UK healthcare system, one can quickly tell that the system relies a great deal on public spending and funding. One can also see clearly that private insurance plays a much smaller role in the system than do public funds. It has already been stated that the National Health Service is reliant upon public funding and spending (Office for National Statistics, “UK Spending on Public and Private Healthcare: 1997-2012,” Nuffeild Trust (April, 2013). Follow the link to see the sources of funding for the UK's NHS. The program is used by roughly ninety-five percent of population. The other five percent of the population gets their health coverage from the private market. The total number of people using public health services in the United Kingdom has risen to over fifty-eight million people, leaving a little over four million people who choose to purchase private coverage (Chang, Josh, Felix Peysakhovich, Weimin Wang, and Jin Zhu, “The UK Healthcare System,” Columbia University (2010), 1-11.)

In its present condition, the National Health Service provides a fine example of a single -payer versus a multi-payer system, which is the way of doing things in Germany, but what, then, of the United States? To keep from rehashing points made earlier, this section will be limited to the period post, Affordable Care Act (ACA). The healthcare system in the United States is a multi-payer system and a conglomerate of multiple organizations that are theoretically supposed to provide for the medical needs of the entire population, insure them for personal injury or illnesses, and ensure that the cost of these services is reasonable for everyone. This, of course, does not happen in the United States. Despite, passage of the ACA, there are still a great many people in the United States who are living daily without health insurance and little to no access to effective preventive care or treatment. It’s not that the ACA is a failure, in fact, it is actually working quiet well, at least for the additional people that can afford to buy into the system (AP, “CDC: Uninsured Drop by 11M Since Passage Of Obama’s Law,” The New York Times (March 24, 2015). It’s just that even though this new program is slowly but fundamentally altering the US healthcare system, it is not yet able to sufficiently provide for the additional people still uninsured U.S. Burden of Disease Collaborators, “The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors,” The Journal of the American Medical Association, Vol. 310, No. 6 (August, 2013), 593-604). In her article, “Healthcare’s Road to Ruin,” despite it being a little right leaning, Elisabeth Rosenthal outlines all of this, as well. Her opinion is that the ACA is making the situation worse, but the statistics do not support her claims, which raises the question, where are she, and the other people like her, getting their information ( Rosenthal, Elisabeth, “Healthcare’s Road to Ruin,” The New York Times (December 21, 2013).

Of course, if one is to assess the present condition of the US healthcare system, it is absolutely mandatory to begin with the Patient Protection and Affordable Care Act, which was officially passed on March 23, 2010. The ACA makes the possession of health insurance in the US, just like Germany’s program, a compulsory matter, to the point of even levying a tax penalty on those individuals, whose misfortune it is to still lack the ability to afford adequate health coverage (Mosquera, Mary, “SCOTUS Majority Embraces Individual Mandate, ACA,” Government Health It (June 28, 2012). Despite the compulsory nature of the law, it does have certain new benefits like the fact that people can no longer be denied health insurance because of a pre-existing condition, and the like. The program also allows for people to obtain subsidies for the purchase of health insurance on a series of state and federal operated health insurance market exchanges, a testament to American Federalism and the diffusion of power, whether or not one agrees with state’s rights and other arguments made against the exchanges.

The states are supposed to have sole control over the market exchanges, but some states are unable to afford to set one up, while other states, like Texas, have simply refused to set on up (Wilkinson, Emily, “Gov. Perry Says No Thanks on Behalf of Texas to Health Care Reform,” Houston Business Journal (July 9, 2012). The role of the federal exchanges is to help people in states without an exchange to obtain adequate health coverage. People should be able to purchase plans that not only meet their income requirements, but which are also personally tailored to their specific medical needs. Before the passage of the bill, there was a lot of concern about the complex nature of the exchanges, in that it was thought that many people, unfamiliar with insurance language, would find it difficult to navigate the website and would have undue difficulties finding the coverage that is most appropriate to their present needs. There was also great concern that many people would still be left uncovered (Pear, Ibid). The later concern was spot on, as millions of citizens in the United States are still living without needed health services, solely because of the cost. Tavernise, Sabrina, and Robert Gebbeloff, “Millions of Poor are Left Uncovered by Health Law,” The New York Times (October 2, 2013).

While it did, as has been pointed out, reduce the uninsured population in the United States by some eleven million people, the ACA has only narrowed the gap between the insured and uninsured in the general population, rather than closing it as many Democrats and other supporters had hoped it would. Here is what the numbers say about the present condition of the healthcare system in the United States. In 2012, the year of the law’s passage, forty-six percent of the American population was living with little to no health coverage. Cost for healthcare has risen dramatically in the last twenty years, while real wages have failed to keep up. From 2001 to 2005 alone, the cost of healthcare rose thirty percent, while real wages rose only three percent. Overall health costs, on average throughout the United States, annually exceed two trillion dollars. This is despite the fact that the average federal budget is only, on average, a little over three trillion dollars. As of 2012, the uninsured adult population numbered thirty percent of all adults. Further, up to seventy five percent of these adults are presently living below the poverty line. Additionally, for those that can afford a plan on the exchange, the ability to make timely payments is still limited, as other important bills continuously interfere with people’s ability to pay their insurance premiums. Fifty percent of all personal bankruptcies are a result of an inability to pay medical bills, that are subject to inflation and a rise in the general prices for good care. Furthermore, these numbers do not show any sign, at present, of slowing down. Costs are also still on the rise in the United States. This is shown by the fact that twenty-eight percent of people who consider themselves to be middle-class, are still having trouble paying for their medical expenses and for many of the same reasons that the poor list. Most healthcare expenditures in the US are geared towards chronic diseases like diabetes. Some estimates show that as much as fifty percent of all such diseases are caused by preventable ailments, such as high/low blood sugar or obesity (Health Care Statistics,” Health Care Problems (August, 2015).

Having reviewed the past and present conditions of each nation’s healthcare system, it would be prudent to explain, in greater detail, how they happen to relate to one another. First of all, while both Germany and the United Kingdom cover all of their citizens that do not opt out of the publicly funded or subsidized programs, their programs grew in completely different conditions. Germany’s system began forming at the height of the power of the German Empire in the late 19th century, under the guidance of the very conservative Prussian military man, Otto von Bismarck. The National Health Service in the United Kingdom was born out of the liberal political push in Great Britain after World Wars I and II. The Labour Party led the governing coalition at the time, and so the group was responsible for the law’s passing and implementation. They are also funded differently. The German system is funded from multiple sources like taxes or insurance premiums, whereas, the system in Britain is funded almost completely by tax revenues earned from increased taxes levied on the general population. Germany has a multi-payer system; Britain has a single-payer system. Germany’s system is compulsory, whereas in Great Britain’s system, it is not a requirement because in a free care system, the entire burden is placed on the government. At present, both systems have certain programs that are operated independently of one another, but Britain’s private sector does not play as major a role in the distribution of products and services. This is handled almost entirely by the National Health Service, despite recent measures to begin privatization in certain areas (Jones, Roswynne, “How Private Firms Already Run Frontline NHS Services by Stealth,” The Mirror (May 29, 2013).

Comparing the US healthcare system with Germany and the United Kingdom will very quickly reveal which of the systems the United States’ system most resembles. It, of course, most resembles the German healthcare system. Insurance coverage in the US healthcare system is operated under the ACA, and it is compulsory, while the private option still plays a large role in the system; even more so than the system in Germany. It is also multi-payer system. Further, the development of a national healthcare system in the United States, again, shares the most in common with the German system. This is so because, unlike the British system, not everyone was covered by the first round of legislation, whereas, the system in Germany took over one hundred years to fully cover its entire population. It would seem that healthcare in the United States is evolving along a similar path as the German system with universal coverage only a small numbers of years away from being the standard for all Americans. It resembles both systems, in that it allows for people to obtain their health insurance through a private provider if they are able to afford that option. It, however, resembles neither system, in that the provision of health insurance from private companies is the primary means by which a citizens can obtain coverage. It also fails to resemble either system in the realm of the uninsured. There are little to no uninsured persons in Germany or the United Kingdom, whereas, in the United States, there are still tens of millions of people who have no adequate health coverage, whatsoever (Tavernise and Gebbeloff, Ibid).

What are the Main Issues in the Present Healthcare Debate?

To review the debate on healthcare in Germany and Great Britain, a Europe-wide focus will be used. This is so because, as regards the debate over universal health care, Europe is ahead of the United States, in that each nation in the European Union is bound by the European Charter to provide easily accessible universal healthcare to its citizenry. If they fail to or are unwilling to adopt the statute, they run the risk losing membership status or having their application for entry into the union denied (Neergaard, Neela, “EU Health Care Law in a Constitutional Light: Distribution of Competences, Notions of ‘Solidarity, and ‘Social Europe,” in Van de Gronden, Johan Willem, Erika Szyszczak, Ulla Neergaard, and Markus Krajewski, Eds., Health Care and EU Law: Legal Issues of Services of General Interest (The Hague, Netherlands: Asser Press, 2011), 19-58). The United States does not have any such national level guarantee. Here are just a few articles that hit on the central issues of the healthcare debate in Europe. In, “Healthcare Systems in Comparative Perspective: Classification, Convergence, Institutions, Inequalities, and Five Missed Turns,” by Beckfield, Olafsdottir, and Sosnaud, the authors review and evaluate recent comparative social science scholarship on healthcare systems. They focus on what they say are the four strongest themes in this field of research. They are, ‘the development of typologies of healthcare systems,’ ‘assessment of convergence among healthcare systems,’ ‘problematization of convergence among healthcare systems,’ and ‘the relationship between healthcare systems and social inequalities.’ Their goal was to highlight the central debates that animate current scholarship and to identify unresolved questions and new opportunities for research. They also identify what they say are the five main currents of research, or what they call ‘five missed turns,’ in contemporary sociology that they feel have not been as properly integrated into the research on healthcare systems as could possibly have been. The five currents are ‘emphasis on social relations,’ ‘culture,’ ‘postnational theory, ‘institutions,’ and ‘casual mechanisms.’ They conclude by highlighting some of the most significant challenges for comparative research on healthcare systems.

They begin by discussing the classification of healthcare systems, which is their ‘the development of typologies of healthcare systems.’ They identify three distinct models that they have found: the Bismarck model, the Semashko model, and the Beveridge model. The Bismarck model is financed through insurance fees, and the role of the state is limited to overseeing a system of contracts among patients, providers, and insurers. The medical profession has the autonomy to make decisions about the provision of services. Countries like the United States, Canada, and France have such a model. In the Semashko model, universal health care is controlled directly by the state, which owns facilities, finances them through the state budget, and allocates services to the population. Countries like Bulgaria, Poland, and Russia have this model. The Beveridge model secures free access to health care in hospitals but does not require complete state control of all facilities. In addition, the medical profession has higher levels of autonomy, and physicians can opt out of the system. Countries belonging to this system are Italy, New Zealand, Spain, Sweden, and the United Kingdom. They follow with convergence, which is their, ‘assessment of convergence among healthcare systems,’ where they discuss the seeming tendency of healthcare systems to converge into larger units, like the Organization for Economic Co-operation and Development (OECD), or the World Health Organization (WHO). They make comparisons to the business world and organizations like the World Trade Organization (WTO) to show how these new international efforts can work effectively. They then discuss the expanding institutional boundaries of healthcare systems, which is their, ‘problematization of convergence among healthcare systems,’ where they argue that one of the underlying issues in the convergence debate is that although healthcare systems are national, they are also international, and arguably becoming more international over time as global health gains attention and funding and as patients engage in what they call “medical tourism.” They finish the section with Disparities, Inequalities, and Inequities, which is their ‘the relationship between healthcare systems and social inequalities,’ where they argue that the current trend in governmental and nongovernmental organizations is to make efforts towards reducing healthcare disparities and to encourage advocates and researchers that are interested in doing so, to incorporate the most recent research on health inequalities into to their regular research policy.

The authors then identify their ‘five missed turns’ in the comparative research on health care systems. The five missed turns are ‘emphasis on social relations,’ ‘culture,’ ‘postnational theory,’ ‘institutions,’ and ‘casual mechanisms.’ For them, it is surprising that the analyses of specific relational structures have not made more of a mark on the comparative analysis of healthcare systems and their social relations. In their discussion of culture, they have considered how the overarching cultural context of a society, or a smaller unit, affects how individuals respond when confronted with a health problem. They believe that the postnational approach fundamentally reframes the questions of classification, convergence, institutions, and inequalities that motivate so much research on healthcare systems. This is so, they say, because scholars that classify healthcare systems rarely incorporate information on the nation-spanning organizations and policies that shape the healthcare system as an institution. They are ignoring international implications. Research on social stratification, or ‘institutions’ in sociology has taken an institutional turn, in that, the rules of the game, as formalized in law and enforced by the state, have become central to explanations of social inequalities in wages, employment, and poverty. The sociological analysis of mechanisms, or sequences of events that connect causes to effects, has matured to a point that it has a programmatic statement, in that, it promises to be a valuable theoretical development in the comparative research on healthcare systems. They conclude by stating that they feel the availability of data is what is making much of the research difficult to fully integrate into the mainstream scholarship (Beckfield, Jason, Sigrun Olafsdottir, and Benjamin Sosnaud, “Healthcare Systems in Comparative Perspective: Classification, Convergence, Institutions, Inequalities, and Five Missed Turns,” Annual Review of Sociology, Vol. 39 (2013), 127–146).

In, “Role of Private Sector in United Kingdom Healthcare System,” by Doyle and Bull, the authors argue that since 1948, the private sector has viewed itself as complementary to the National Health Service (NHS). Before the NHS was set up in 1948, healthcare was provided by charities and voluntary hospitals, private medical clubs, occupational medical services and works clubs, fee for service insurance, friendly societies, or public medical services, which were funded by subscription and medical fees, paid on an ad hoc basis. The structured health insurance sector initially developed between 1940 and 1947, with the instigation of the London based Hospital Services Plan, now PPP Healthcare, and the amalgamation of several regional schemes into British United Provident Association (BUPA). By the late nineties, a great many millions of people had received some sort of private assistance or bought into a private health insurer. This change has not been sudden; it has progressed slowly over time, to the point that every sector of the British healthcare system has been integrated with the private sector in some form or fashion. Also occurring slowly over time were improvements in financing, modulating case loads, and a switch to evidence based medicine, which is designed to prioritize care in such a way that all people have equal access to a system of finite resources. This includes, of course, the use of waiting lists to regulate flow, cost, and access.

The authors also discuss the ever increasing demand for ‘state-of-the-art’ medical services at a pace quicker than that set by government wait lists. They argue that the private sector in Britain has served this complimentary role that it assumed quite well, actually. The private sector has been able to take over operation of less important services like non-emergency travel needs for the elderly, disabled, and post-op patients. Their conclusion points out that as the private sector is further deregulated, the private sector will be more and more involved in the primary delivery of health services at the point of consumption. They contend, however, that continuing to deregulate the private sector is not the answer. The private sector, especially if they are being contracted to provide expected services to the general public on behalf of the government, should be regulated to prevent the development of any inequalities that would damage the universal nature of the healthcare system. They do temper this statement, though. The contend that while they believe that the private sector should be regulated, they argue that it should not be so heavily regulated that innovation and entrepreneurialship are discouraged, which leads to people failing to test new ideas, products, or services in the market, missing countless opportunities to improve the daily lives of the citizenry. This damages the economy, lowering available resources, and decreasing the quality of the limited resources being delivered as more cost control, flow, and access protocols are implemented in order to retain universal access (Doyle and Bull, 563-565).

In, “Seeking Healthcare Elsewhere,’ by Antje and DuBois-Pedain, the authors look into the increasing frequency in the case law of the European Court of Justice (ECJ), of cases supporting European citizens’ right to free travel throughout Europe, in the effort to obtain medical services that may not be reasonably available in their home country, but might be so, in another member state. The main concept of the article is that with increasing frequency, European citizens are seeking healthcare in other member states, when there is an ‘undue delay’ in the receiving of services in their home country. There are potential questions of sovereignty, social solidarity, and quality of services that arise from this, but the ECJ has consistently ruled that in the case of a life altering or preserving medical treatment, if a person is unable to receive the service in their home nation in a reasonable amount of time, ‘without undue delay,’ in relation to their medical status, they have the right to freedom of movement guaranteed by the European Charter. They can use this freedom to travel to another member state that has the service available sooner, without any worries of reprisal from their home country. In fact, the ECJ has also ruled many times that member states, who are largely responsible for the after care of the patients in question, are obligated to provide that service and to reimburse the patient for the costs of the services received in the other member state (“European Charter of Fundamental Rights and the European Union,” European Union, Chapter V, Article 45 (2000), 15-18).

The author’s primary case is that of a Mrs. Watts. At the age of seventy-two, she was in need of a hip replacement. Her present condition was immobilizing her, and the new hip was necessary to ensure comfortable living for the foreseeable future. Her doctors reviewed her case and determined, based on their data that she was in good enough of a condition that she could be put on a one-year waiting list. After that year, she would then be able to get her surgery free of charge at the point of consumption. Her issue was that her medical condition was degenerative. The doctor’s clearly recognized that too much delay could lead to further physical damage and discomfort, with the possibility that surgery would no longer be a possibility. They, however, assessed that the risk of a one-year wait was not that severe. This brought about the controversy. Mrs. Watts was not satisfied with this option, so she petitioned the NHS to allow her to receive the hip replacement in France. Her initial request was denied, but that did not stop her. She appealed the case to the ECJ, where it was ruled that despite potential questions of sovereignty, social solidarity, and quality of services, the National Health Service could not decline a citizen’s application to receive services elsewhere because of the established wait list routine. If there was an ‘undue weighting period,’ a member nation was obligated to approve the application and to reimburse the patient for any costs incurred for the reception of services in the other member state. The NHS’s argument was that this inhibited their ability to deliver affordable health insurance to everyone because such actions force them to raise their prices, reducing the number of people that can afford to purchase their services. Their argument was rejected; however, because the ECJ felt that the waiting list system violated the right to free travel throughout the union for all citizens, arguing that nothing should get in the way of that freedom (DuBois-Pedain, Antje, “Seeking Healthcare Elsewhere,” The Cambridge Law Journal, Vol. 66, No. 1 (March, 2007), 44-47).

In, “Public Healthcare in the European Union: Still a Service of General Interest?” by Adam Cygan, the author examines how recent judgments of the European Court of Justice have interpreted the concept of a service of general interest in Article 86, (2) of the European Charter, as regards the delivery of healthcare services. The article explores how and why the Court has afforded greater latitude to Member States in organizational matters by not applying competition rules. By contrast, the Court has actively promoted patient mobility and has not applied the derogation in the article, where it would restrict the free movement of services. Does the Court's policy of protecting individual rights undermine the ability of Member States to deliver a universal healthcare service within finite resources? This is one of the main questions that the author presents. He begins by defining some terms. He starts with a ‘Service of General Interest,’ or a public service provided by the state to the people for little to no cost. In the case of the National Health Service in Britain, that ‘Service of General Interest’ is healthcare and services are provided for free at the point of consumption. He then differentiates between this and what he calls a “Service of General Economic Interest,’ such as a service provided by an industrial company producing goods for the market with the expectation that remunerations will be forthcoming.

The author then divides the articles into a series of eight specific subject areas, followed by a conclusion. These sections are ‘The State as the Provider of Public Healthcare,’ ‘Organization of Public Healthcare in the Member States: Competition and Free Movement Issues,’ ‘The Boundaries of Community Competition Rules,’ ‘Monopsony Situations and Article 86 EC,’ ‘Deregulation and Healthcare Services,’ ‘Do Free Movement Rights Undermine a Universal Healthcare Service?,’ ‘Is Patient Mobility a Reality?,’ and ‘The Scope of Article 86(2) EC in Healthcare Services.” This article follows up on the previous article in that it reviews cases similar to the Watts case that show how the ECJ has made rulings that might be contradictory. From this, and other sections of the charter, like Articles 49 or 152, they develop a somewhat contradictory case law. They recognize that each member nation has the right to control the production, financing, and delivery of all health related service within their borders. However, at the same time, referencing cases like that of Mrs. Watts, the author makes it clear that the ECJ has ruled that despite this first ruling, no law from any of the member nations can supersede the natural right of each citizen to free movement within the European Union.

The author also discusses the conflicts that these, and similar rulings, have created within the healthcare systems in some of the member nations. He uses Britain as an example. The NHS provides services, free of charge, at the point of consumption. They argue that Britain uses waiting lists, and certain priority protocols for life-threatening conditions, to ensure that everyone gets equal and affordable access to healthcare. They do not believe that they can control the cost and availability of services if fewer people are making use of the system. They are then saddled with the cost of unused services and steep reimbursements to other nation’s healthcare programs. They also argue that this arrangement of their healthcare system should not be subject to Article 86 EC because they do not charge for services at the point of consumption. All services are provided to everyone free of charge, despite sometimes being late in coming. The ECJ would normally consider that argument more legitimate; however, as many healthcare systems have done in Europe recently, Britain has begun to contract out certain services, such as non-emergency transport services, to the private sector. Slowly, the private sector in Britain, as it is all over Europe, is playing a bigger role in the delivery of primary medical services on behalf of the various states that use them. The ECJ has ruled that this places a commercial facet onto some of the dealings of the NHS, which gets them closer to resembling a ‘general economic interest,’ making them subject to the Freedom of Movement laws. They are now obligated to allow people to get services elsewhere in Europe, if the provision of services will be unduly delayed in their home nation. These contradictory rulings make it difficult for a single, coherent, and unified healthcare system to develop in Europe because controversial questions of social solidarity, national sovereignty, and territorial integrity, as is the case is some areas where the only services available in a remote area are those provided from the opposing side of international border, have been left unanswered (Cygan, Adam, “Public Healthcare in the European Union: Still a Service of General Interest?” The International and Comparative Law Quarterly, Vol. 57, No. 3 (July, 2008), 529-560).

Now, what of the healthcare debate in the United States? First, as has already been indirectly noted, the debate over healthcare in the United States is fundamentally different than that of Europe. This is so because most members of the European Union already had a system or at least, the semblance of a system in place by the 1950s. This is also true because European nations are bound by the laws of the European Charter, ratified in the mid 90s, to provide accessible service to all their citizens, if they intend to retain membership in the European Union. In the United States of that era, as was noted earlier, the liberal swing that was sweeping Europe at the time, did not hit the United States as dramatically. Many people, out of pure experience alone, had had enough of Depression era policies. Roosevelt’s attempt to make healthcare a part of the Social Security Act and Truman’s attempt to establish universal healthcare after World War II both failed because of violent backlash from the American right wing. Johnson’s attempt in the sixties only covered the elderly, children, and the extremely poor, and Clinton’s attempt in the early nineties was an abject failure. It was not until the passage of the ACA in 2012 that the US system began to resemble the early stages of a universal healthcare system. What this says is that the debate in Europe assumes that a Universal Healthcare system is already in place and is not going anywhere any time soon. Thus, they argue about funding, access, quality of services, loss of clientele to other economic zones when people seek healthcare elsewhere, availability of quality healthcare professionals, level of privatization, and many other issues, but hardly, if ever, is the idea brought up that a public healthcare system that serves all of the people should not exist at all. Whereas, in the United States, even after the passage of the ACA, the existence of such a system was and is, still a matter of serious debate.

To establish the frame work of the American debate on healthcare, a review of the text, Critical Issues: A National Health System for America, will begin this section. It is necessary to admit that this book was published in 1989. Using a text this old is not always smart when forming a discussion, especially when a lot of dramatic changes have taken place since then; however, it still serves a more than adequate role in framing the healthcare debate in this country. Edited by Stuart M. Butler and Edward F. Haislmaier, the text begins with their introduction, where they argue, briefly that the American healthcare system in dire jeopardy. In this short chapter, they use convincing data to show that the American people are not satisfied with their services and that millions of people are without coverage every day, including children, the disabled, and even veterans. This disturbs them because it forces millions of people to play, as they put it, ‘Russian Roulette,” with their health. This leads to passing on doctor appointments in order to afford rent or food, not being able to afford coverage because of a lack of available work, or even passing on healthcare all together because a disability has left them immobilized, unable to pay for services, or worse, they are out of range of available services and are unable to travel to the services because a transportation service that they can afford is not available or does not go out to where they live. This, of course, often leads to chronic conditions or even premature death from a condition that could have been treated sooner, and prevented death, if only the circumstances had been more favorable for the patient. They also argue that the system is fundamentally broken and in extreme need of proper reform. Each chapter outlines a different aspect of this argument, ending with what they believe is a plan that will help the system to improve itself and recover from the public opinion hit that it had been suffering from throughout the 1980s (Butler and Haislmaier, v-viii).

In Chapter 1, “Why America’s Healthcare System is in Trouble,” Haislmaier argues that healthcare in the United States did not arise as a response to any consumer demand movement, but rather that it evolved out of the marketing and professional objectives of the people supplying the care. They argue that this has created enormous gaps in coverage along class lines and that it has also created a system with costs that are rising out of control. He also argues that many of the attempts to repair the system, like cost controls or industry taxes, have tended to be much more destructive than they were ever helpful. He says that this is due to the fact that they ignore the structural flaws of the present system and simply add to the already over burden system, each time they create new legislation to patch a new round of legal or financial issues. One can see, presently that this attitude has not changed at all, just to make a quick note. It’s either that or they recommend such a radical overhaul of the existing system that they overwhelm consumers, who are then more likely to reject such drastic changes than support them, as rapid change tends to make people uncomfortable, especially when it challenges the stability of their own livelihood (Haislmaier, Edmund, “Why America’s Healthcare System is in Trouble,” in Butler and Haislmaier, 1-42).

In Chapter 2, “A Framework for Reform,” Butler argues that a key to the inability to reform the present system effectively is the conservative tendency to do little more than criticize any liberal proposal that hits the floor, regardless of the details or possible merits of the proposed legislation. He also argues that this has blocked the American public from seeing the true benefits of a properly functioning market based national insurance system. He also begins to build the framework for a reform that he argues would guarantee coverage to a majority of Americans that is of high quality and fairly priced. He begins with the argument that the tax incentives that suppliers and consumers are receiving for healthcare expenses are perverse in nature, in that they favor the relatively wealthy and leave the poor, disabled, and elderly at a distinct disadvantage, even when it comes to the consumption of basic life saving services (Butler, “A Framework for Reform,” in Butler and Haislmaier, 43-54).

In Chapter 3, “Healthcare for Workers and Their Families,” Haislmaier picks back up. In this chapter, he argues that the needed key to fix to the present broken system is to take what is already what he calls a ‘quasi-market’ system, and turn it into a complete market style system. He further argues that in order for the new system to work, the government has to commit to attending to the needs of those individuals or families who are genuinely unable to provide for their healthcare, despite available public programs. He also argues that the people would have an obligation by this commitment, as well. They have to agree to obtain at least a minimum of amount of compulsory health coverage. In the next three chapters, they and contributing writers go on to outline the specific reforms in their strategy to reform the American healthcare system. First, they argue that Medicare should, essentially, be completely privatized and made into a voucher and tax-free savings account program. Next, they argue that the state level of government is the best place to implement these reforms, where they say that some of the greatest innovations have already taken place. They finish off by concluding that only a broad market based reform package, such as they have begun to outline in this text, will create a sustainable universal healthcare system in the United States. The other two contributing authors, to avoid not giving credit where credit is due, are Peter J. Ferrara, who wrote Chapter 4, “Healthcare and the Elderly,” and Teree P. Wasley, who wrote Chapter 5, “Healthcare for the Poor, Unemployed, and High Risk.”

Negative! It may just be the quibbling foolery of a madman betrayed by the market, but this is the absolute worse way to go, if healthcare is to be properly reformed. One must admit, though that is truly flabbergasting that US conservatives have embraced such a system with open arms because in a market capitalism haven such as the United States, the plan would probably not only be accepted by industry, but also embraced as a cure all by the general public. It gives people the basics from the government, and does it without making them feel like they have betrayed capitalism. Furthermore, the person that introduced such a policy would either become a national hero or the worst thing that this country has ever seen. History has proven time and time again that relying on the market to repair society’s ills is sketchy at best. A company out for profit alone has very little incentive to worry about consumers at the point of sell or low tier employees of their company; for that matter, their sole goal is the expansion of their market share and increased wealth. The health and well being of 300 people at a plant, in a small town, down an old dirt road means nothing to them when ten zeros follow the one on their finance reports, under wages, next to their name. The primary criticism in this article is that such a healthcare system is not just commoditizing the products and services provided by the healthcare system, but also the very people that are integral to the continued operation of the system. One might think that this argument may refer to just the people receiving services.

No, no, no. It also refers to the people who are providing the services. Such a system turns patients into numbers. For, the more patients a physician sees and treats, the more money they make, the more money the insurance company makes, and the more money the pharmaceutical companies make. It’s a supply chain driven by the needs of the super wealthy at the top that ultimately ignores those who cannot afford to buy into their little club. The service personnel, then, are seeking not to cure and prevent modern health problems, but to get into those medical specializations that will make them more marketable to higher paying hospitals or private practices (Weisz, George,  Divide and Conquer: A Comparative History of Medical Specialization (New York: Oxford University Press, 2006), 63-85). They become nothing more than tools. Such a system would rob both patients and providers of their basic intrinsic human value. Worse though, is what will happen to the economic status of highly trained medical professionals. As more and more medical professionals specialize, the market will begin to become overloaded with such specialists, and too few general practice physicians, which would cause the price of specialized medical services to tank below, what would be for them, unsustainable levels. It would also raise the price for basic services, like cold medicine, so high that cold epidemics could spread all over again. Now, while this may be beneficial for the poor, unemployed, and high risk, it will not be good for their providers. They will have been, essentially, proletarianized. Their real wages will drop dramatically, they will be in massive debt because of the still ridiculous price of their education, and they will no longer be dedicated to providing the finest service available. Rather, they will resemble the fast food worker who drops a burger on the floor and doesn’t think twice about still serving it to the customer.

This is about the finest example of a workable conservative healthcare system that one will ever find, in that with certain guaranteed social restraints in place, the system could avoid the ill effects of economic downturns or corruption, but this article has already made its argument against that very clearly, and hopefully, convincingly enough. Now, notice, this argument is not about reforming an already existing universal healthcare system. What it is really arguing is that market capitalism is the best and most sound economic philosophy on which to build a truly universal healthcare system. What exists today is a hybrid of this philosophy, and the philosophy of the opposing side of the argument. What is the opposing side of this argument? In a brief entry in the British Medical Journal, Dr. Peter Hall points out that Great Britain has provided precedent for labeling basic healthcare services a matter of basic human rights. In 1984, the BMA withdrew from the World Medical Association in protest to their support of a South African healthcare system that was built and operated on the principles of Apartheid (Hall, Peter, “Highest Attainable Standard of Health is a Human Right,” British Medical Journal, Vol. 334, No. 7600 (May 5, 2007), 917). Interestingly enough, as has already been pointed out, the European Charter makes the very same claim. However, they are not the only ones. The United Nations has also established that healthcare is, in fact, a basic human right. In a General Resolution, ratified on December 6, 2012, the United Nations declared that:

Every human being has the right] to the enjoyment of the highest attainable standard of physical and mental health, without distinction as to race, religion, political belief, economic or social condition, and the right of everyone to a standard of living adequate for the health and well-being of oneself and one’s family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond one’s control. - (United Nations General Resolution A/67/L.36, “Global Health and Foreign Policy,” United Nations General Assembly (December 6, 2012)

Now, to be sure, there are politicians in the United States that in the not so distant past, suggested that such a philosophy was the best basis upon which to develop a national healthcare policy. In 1980, Edward Kennedy challenged sitting President, Jimmy Carter, for the Democratic Party’s nomination for the Presidency of the United States. One of his primary social programs was the establishment of a single payer universal healthcare system that would have been free at the point of consumption and would have been paid for by slightly higher income tax rates, slightly higher employer tax rates, and government subsidies. One must admit, though that he had a very difficult time getting his appoint across when asked to outline the policy. His aides were more likely to provide an accurate description of his ‘stance’ than he was. The weakness of his campaign guaranteed that his run would be short lived, and Jimmy Carter retained the nomination (Stanley, Timothy Randolph, “’Sailing Against the Wind’: A Reappraisal of Edward Kennedy’s Campaign for the 1980 Democratic Party Presidential Nomination,” Journal of American Studies, Vol. 43, No. 2 (August, 2009), 239-246). Subsequently, Jimmy Carter was defeated by Ronald Reagan in the general election in November in what can only be declared a resounding landslide. Not long after, Reaganomics happened to the country and helped to ensure that the debate over federal health care policy would avoid the existence of universal care as a topic and that healthcare, the people that provide it, and the people that receive it would continue to be commoditized (Smith, Hedrick, “Reagan Easily Beats Carter; Republicans Gain in Congress,” The New York Times (November 5, 1980).

How Does the General Public View the Healthcare System?

For one more necessary comparison between these three healthcare systems, it would be prudent to determine how the people receiving health services feel about the various aspects of their healthcare experiences. In Germany, people are generally: very satisfied with the cost, availability, and quality of service, relieved to not be overtaxed, and more than willing to pay the required premiums for services. They are also perfectly happy with providing for the poor, elderly, and disabled. Even more interesting, though, is the fact that most Germans do not object to the compulsory nature of the program because they feel that they are receiving a fair return on their investment (Knox, Richard, “Most Patients Happy with German Health Care,” National Public Radio (July 3, 2008). [67] In the United Kingdom, people using the services are not nearly as dissatisfied with the system as critics in the United Sates have made them out to be. First of all, it definitely has something to do with the fact that in most health ratings, despite stories of ‘horrifying’ waiting lists, the quality, availability, and especially the cost of services in the United Kingdom are more favorable than the United States. People in the United Kingdom are also not locked in the system. They have the ability and the right to purchase private insurance at any time they like, and if they like, this coverage can be for supplemental services not directly provided by the National Health Service. Furthermore, they also have the right under European Law, as has already been reviewed, to seek services in other economic zones if they or their doctor feel that the waiting period for the service in their home country is unreasonable (Harrell, Eben, “Is Britain’s Health-Care System Really that Bad?” Time Magazine (August 18, 2009).

As for the United States, the story is just quite a bit more complicated. In a CBS/New York Times Poll done in February of 2007, it was determined that fifty-four percent of the population felt that the healthcare system in the United States was in need of a fundamental overhaul. It also found that sixty-four percent of the population felt that it was appropriate for the government to guarantee health care for everyone. Similarly, sixty-five percent of the population felt that providing health care for everyone was more important than controlling costs. Eighty-four percent of the population agrees that children should receive expanded coverage. An even more interesting tidbit is that sixty-two percent of the population felt that it was the Democratic Party that would bring about successful reform (Roberts, Joel, “Poll: The Politics of Health Care,” CBS News (March 1, 2007). On an episode of ‘Talk of the Nation’ on National Public Radio in August of 2009, in an interview with Andrew Kohut, of the Pew Research Center, and Drew Altman, of the Kaiser Family Foundation, it was said that the biggest concern is that people worry that the federal government will have too much power over their medical care. They also feel that their choices will be unduly restricted or that some of their procedures or medicines will not be covered. Their ultimate problem was that they were really just plagued with a general worry over change that they felt was moving too fast. They felt that slower more closely managed change is what is necessary for what they believe is a system that is already generally of good quality. It is also said that despite this fear, most people are still hopeful (Wertheimer, Linda, Andrew Kohut , Drew Altman, “Talk of the Nation - How Do Americans Really Feel About Health Care?” National Public Radio (August 18, 2009).

This is interesting, of course, because just over a year later, in another poll conducted by Business News Daily this time, it was found that despite the recent passage of the “Affordable Care Act,” a great many people were till dissatisfied with the quality, availability, and cost of health care in the United States, with over fifty percent of the population rating the system as ‘very poor’ or ‘less than fair.’ (Smith, Ned, “Americans Still Unhappy with Health-Care System,” Business News Daily (September 17, 2010). With this mixture of results, it is understandable that a more recent Kaiser Foundation poll shows that the public’s opinion of the US health care system is still split, with forty-three percent of the population in favor of the system and forty-two percent of the population unhappy with the system. The remaining people were undecided. Follow the link below to a graph that shows that this trend has actually been the norm for just about the past five years ( DiJulio, Bianca, Jamie Firth, and Mollyann Brodie, “Kaiser Health Tracking Poll: April 2015,” Kaiser Family Foundation (April 21, 2015).

What Does the Future Hold for American Health Care?

Even more briefly, what does this all mean for the future of the American health care system? These mixed responses mean that as regards the quality, availability, and cost of health care services in the United States, the general public remains divided. This divided result should, to some, trigger a few more questions about what is going to happen in the near future. If people are still unhappy with their health care, is the Affordable Care Act really doing what it was meant to do? If it has not yet achieved its full potential, in the present economic and political climate, will it be able to? One might imagine that if a Democratic candidate gets elected in 2016, the ACA will simply be expanded or modified to account for system flaws. What happens, though, if a Republican candidate is elected? Worse, what if it is someone like Donald Trump or any one of the many other candidates who have regularly criticized what they have labeled ‘Obamacare,’ gets elected? The Affordable Care Act could find itself on the chopping block. One might hope that such a candidate might not want to risk political capital on challenging a program that people have become accustomed to, but from the well known fierceness of some Republican critics, it should also come to one’s mind that they may not care. (Make note, the rough draft of this article was written before the latest repeal of the ACA and subsequent action taken by Donald Trump to ax the program.)

There are some, as of late, who feel that the American people’s best friend in the world on health care is Bernie Sanders. He has recently come out for a single payer universal health care system that would be free to everyone at the point of consumption. His system would be paid for in a similar manner to that of the United Kingdom’s National Health Service. Though many oppose the idea, he may just fool around and change the nature of the debate. This conclusion is supported by yet another conflicting poll which states that people were not necessarily upset with the ACA for going too far. It surprisingly says that they were actually more upset because they felt that the new law did not go far enough (Budowski, Brent, “Sanders Calls for Single-Payer Health Care,” The Hill (June 29, 2015). The question with Bernie Sanders, though, is not whether or not he is the country’s best friend in the world on healthcare. The real question is what happens if he does get elected? His campaign platform is packed with programs that excite the left, and are starting to make sense to people that count themselves as independents, to the point so that some on the right may be genuinely afraid of Bernie Sanders. Blogger, Charles Topher, certainly believes that this is the case, and he offers his own top ten reasons why this is so. Despite his rather creative use of language, he points out a few things that tend to make some fairly good sense. Among his reasons are: a reasonable stance on gun control, a responsible approach to immigration reform, a radical view on education, and to many Republicans, Topher argues, a tool that is far more fearful than any of his of his political stances. The Republican’s greatest fear is that Sanders will force Hillary Clinton to take stances further to the left, which would then require them to do so if they intend to remain relevant (Topher, Charles, “Ten Reasons Why Underdog Bernie Sanders Scares the Crap Out of Republican Koch Suckers,” If You Only News (May 30, 2015). This could, then, also cause a major split on the right, making it easier for a leftist candidate that would not normally have a chance in this country, to effectively steal an election. This would, logically, lead to a health insurance system that covers all Americans; however, it would not be structured with their funders, health insurance and pharmaceutical companies, in mind. (Make note again, the rough draft of this article was written before the election of Donald Trump).

Conclusions and Analysis

So, what does all of this leave the reader with? To sum up, the article essentially began with a brief definition of health care, “Healthcare is the maintenance and improvement of physical and mental health, especially through the provision of medical services.” This was followed by a review of the origins of the national healthcare systems, or lack thereof, in the United States, Germany, and Great Britain. Germany’s, Social Health Insurance program, began in the late nineteenth century with the passage of regulations government the establishment of sickness funds. Great Britain’s, National Health Service, began to receive political life during World War I. It, however, was not officially founded until after the destruction caused by and loss of life witnessed during World War II. In the United States, one must admit that the discussion for a national style program began early, and in the 1960s, nearly came to fruition, but ultimately, it did not cover anywhere near the amount of people that it should have. In 2012, the country got the Affordable Care Act, ‘lovingly referred to as, ‘Obamacare.” This law greatly reduced the number of uninsured persons in the United States, but it has not completed the job. So, historically, which system does the fragmented US health care system resemble? With its long periods of sometimes uneventful development, its compulsory nature, and the prominence of private interests, the US health care system most resembles that of Germany’s Social Health Insurance program.

The discussion then moved on to the nature of the health care debates in these countries. To understand the debate in Germany and Britain, it was necessary to view their debates from a Supra-nationalist perspective, in that by the authority of the European Charter, in order for either country to retain their membership in the European Union, they are required to maintain a system that grants all of their citizens equal and affordable access to health care. Chapter IV, Article 35 of the charter states,

Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities (“European Charter,” Chapter IV, Article 35, 15-18.“European Charter of Fundamental Rights and the European Union,” European Union, Chapter IV, Article 35 (2000), 15-18).

This is further supported by Chapter V, Article 43, which states,

Any citizen of the Union and any natural or legal person residing or having its registered office in a Member State has the right to refer to the Ombudsman of the Union cases of maladministration in the activities of the Community institutions or bodies, with the exception of the Court of Justice and the Court of First Instance acting in their judicial role (Ibid, Chapter V, Article 43, 18-19).

This requirement frames the debate in Europe in a critical way, in that scholars and administrators are not debating over the very existence of the program, but rather, they are spending more time on issues such as cost, availability, and quality of services provided. In the United States, however, the very existence of a National Healthcare System, is what is what is on the debating table. Granted, a big part of the debate is whether or not the system should be public or private, but the ACA, the closest thing in the United States to such a system, still finds that its future is hanging in the balance. It was Republicans, or the Super PACs that support them that brought the Supreme Court case against the program, and it is Republicans that are still threatening the very existence of the program. Furthermore, if their responses to the Supreme Court’s ruling on the existence of the bill, in late 2012, have any value to them, then the future of the Affordable Care Act is still in question. For a litany of by the minute responses to the ruling, read Hayward, John, “Republican Reactions to the Supreme Court’s Obamacare Decision,” Human Events (June 28, 2012).

The next part of the discussion attended to the matter of the general public’s perception of their respective their national health care systems. This section was able to get back down to the reactions of the public in each nation. For both Germany and Great Britain, the overall consensus was that despite some minor irritants such as waiting lists, upfront fees, or monthly premiums, which many people felt were socially justified, both nation’s were generally satisfied with their services. It was the American public’s perception of health care that was really difficult to pin down. Multiple polls gave multiple answers. The most recent poll shows that the American people are still divided on how they feel about the US health care system, with a generally even split between those that rate it as satisfactory and those that rate it as unsatisfactory, with a gap of about fifteen percent, who either do not care or chose not to respond. So, as the next election season rapidly approaches, one can reasonably assume that the very existence of such a system will still play prominently in political debates.

The final section was a discussion of the future of American health care. Using the data just referred to, it was determined that the future of health care in the United States was not certain. It was also determined that the next election could be instrumental to its survival or destruction. However, realistically, one must admit that the evidence does not necessarily suggest that American healthcare, namely the ACA, is going to die. However, the evidence also does not necessarily suggest that it will necessarily survive. There are any number of very well known and extremely creative ways to murder social programs that have been employed in the United States throughout its history. Going into them is outside the scope of this study, but let it be sufficient to say definitively that, “The future of health care in the United States is still, without a doubt, uncertain.” Hopefully, if enough get signed up for the ACA, it will eventually evolve into a truly universal system like the German system did. Even better, in pristine conditions, the right to health care has the potential to be declared a natural constitutional right in the United States. The realization of such an outcome is not, in most opinions, even remotely possible. To finish off, having never mentioned the myriad problems in Veterans hospitals throughout the United States, or the social nature of the program, some might criticize that this study is not complete. However, with all of the corruption and injustice that has been uncovered in the Department of Veterans Affairs lately, it was decided that attempting to dive into that at the moment, would severely bog down an already fairly lengthy research project (Brown, Desiar, “Timeline: The Story Behind the VA Scandal,” USA Today (May 22, 2014). Additionally, the VA Scandal was already addressed in another recent piece on the Refuse To Cooperate Blog.

Additional “Theoretical” Analysis

Before reading this section, understand that this section is purely speculative and based solely on the knowledge, experience, and education of the author. To the logically sound mind that takes an interest in broad social questions, a very pervading question should enter the mind very quickly. What if a singular political issue is not the problem? What if it is more all of the problems in this country constituting a greater struggle for survival? This should smell oddly of 1861. This is so because it is starting to seem that the ultimate argument is not about a singular issue, but rather, about an, admittedly, very broad, ‘way of life.’ It’s not necessarily even a race, religion, or gender preference issue, specifically. It is embedded beneath all of this and more. This problem regards the very nature of how people live their daily lives in this country, and it is a problem that has existed since the foundation of this country. It is also hard wired into the nation’s constitution. This nation was not founded on the democratic values of life, liberty, and the pursuit of happiness for all. It was not founded on the principles of equal access to government services, especially when, for most of its history, there was no real effort to ever actually create such a thing to begin with. It was founded on three key principle crimes that have since been made precedent: Real Estate Fraud, Tax Evasion, and Treason.

The land that the ‘Founding Fathers’ settled, in what is now the United States, was not fairly purchased or traded for, but rather, it was taken by force and barbarism. The motivation for separating from England was because of overbearing and stifling taxes, that all of the King’s colonies were equally subject too, in the effort to support the defense of their holdings with local money. It was for the tax relief of a few wealthy elites, who did not want to share their wealth with the appropriate authorities. The war was not fought for the life, liberty, and pursuit of happiness for all. It was fought for and founded by a group of men taking advantage of a three thousand mile gap between them and the King. It was founded by a handful of traitors guilty of High Treason against the British Empire.

It was founded, additionally, on the values of profit, social manipulation, and the rule of the many by the ‘privileged’ few. It was a system draped in freedom’s calling, with room for expansion only as social conditions allowed, which was designed to ensure their ability to retain control of the nation in perpetuity. Currency and how much of it one can stock pile are the sole determinants for eligibility in what has become a, now, highly secretive, and almost, untouchable, ruling elite. Race at that economic level, is irrelevant. To this ‘Invisible Hand,” to use a term a term only mentioned by Adam Smith, himself, three times in his professional writings, and only once in his most recognized work, The Wealth of Nations, human beings are now nothing more than economic units with a maximum efficiency rating and a monetary value attached to them that determines their worth to the system. What kind of system is this? It is definitely not a Communist system, and even if it was, it would still have problems because of the system that Communism was born out of. It is Capitalism, a system that is best run by an, in this case, ‘elite’ few, that is most efficient when labor is cheap and compliant, and that is geared towards one ultimate goal, the accumulation of wealth. This system was designed to commoditize people and to eliminate the population’s natural urge to worry more about the basic intrinsic human value of each individual and replace it with an unquenchable thirst to consume.

Here’s the problem then. Humans have naturally evolved as a communal species. People need human contact to survive infancy, let alone to remain sane for the whole of their natural lives. It goes against our very nature do nothing but take from people. If people do not give back some of the things that they have gained, or at the least, share it with others, they are unable to remain settled about what they have. Just consider how many private charities that exist which are run by stars that have way more money in their possession than they know what do with. This, of course, brought to the present day, also lends to societies setting up services to serve the general population’s health, security, and living needs. Humans, unmolested by propaganda, cannot sit back and watch other people suffer. It goes against everything that has been bred into their genome for the past four million years. They feel compelled to help those that are in trouble even when doing so may place their own well being second to the person they are helping.

However, as can been seen daily in the streets of this country, this is precisely what has been happening. People are sitting idly by while the homeless go untreated, the poor stay poor, and people’s physical liberty is constantly under threat of elimination. This usually is not a sustainable condition, however. Eventually, a point is reached where people are no longer able to stomach watching an injustice continue. In 1861, with all of the political divisions that existed and the threats of session that were hurled about on the regular, a tense situation got worse, and the Civil War broke out. A man was elected that though he was not fully open about it in policy debates, was politically bound to challenge slavery, as many of his biggest supporters were abolitionists. This system had been the way of life in the US South since before the signing of the Declaration of Independence, it was all these people knew, and white men all over the South gave their lives for their ‘way of life.’ This is, of course, ignoring the fact that to them, all slaves really were was an economic commodity to be bought and sold.

Almost exactly one hundred years later, they were at it again. Even to the point that another President got assassinated. If President Johnson had not ensured the passage of the major Civil Rights legislation of the 1960s, the 1970s and the 1980s would have been extremely different. White men, all over the US South, were defending their rights to operate their states under the system of laws most commonly referred to as ‘Jim Crow Laws,’ and many put their lives on the line to help preserve their new status quo. Given all of this, if one pays particularly close attention to the politics surrounding health care and other hot button issues, they will notice that it is happening all over again. This time, however, it is going to turn out much worse than anything our society has yet encountered; and more than likely, it will make the carnage of the Civil War seem trivial by comparison. This ‘white’ ruling elite, ignoring their ‘tokens,’ is slowly losing their grip on American society, and they are pulling out every stop they can think of to hold on to their power, from massive public spectacles (Sports Teams), to sex and drugs, in the hope that people will be less resistant to bad policies, to the construction of a massive propaganda machine that has come to rival any such program that has ever invented anywhere in the world (World Wide Web).

What is the solution, then? What would all of this look like if that solution was already in place? Another capitalist regime is not the answer, and neither is anything born of capitalism, like communism, as anything born of corruption, is by its very definition, corrupt in and of itself. These are not easy questions to answer, and frankly, a well thought out, coherent, reasonably sound, widely popular, and fair solution is not necessarily the most important thing to think about right now. An entirely different way of thinking is required, one that is more in tune with human being’s natural tendencies. Perhaps, the establishment of a resource based economic model would be more appropriate. However, to make such a thing work, a great many people would be required to completely abandon everything that they have ever believed in, and that could cause severe backlash. The changes need to be gradual, as there is no such thing as an insta-fix. There is one thing, however, that can be and should be made as widely known as possible. It is something that the people can easily understand and that does not necessarily have to surrender results immediately. It must happen soon, though, as the repercussions in the next election, and the next political phase of this country for that matter, will not be to the liking of the faint hearted. Further, the coming events will take years of healing and tons of finite resources to recover from, if nothing is done.

This is so because the ruling elite of this country are not just facing challenges from within any more. They are facing criticism from the international community. This, of course, is bringing their credibility into question on the world stage, and they are failing to control the flow of information into the country, so everyone knows that the rest of the world sees them as a joke, sees them as a sore loser, and more than anything, they see American prestige dropping as more and more nations prove quite clearly that they are no longer solely dependent, if they are at all, upon the money and resources of the United States. Here is the thing that always gets hairy for people. The only way that effective change will be realized, is if the people of the United States take matters into their own hands. Now, to be sure, this is not a call to arms because as many people throughout history have shown, there are safer and much more effective models available to make the voice of the people is heard and obeyed. Hopefully, this effort does not fall upon the crippling scourge of biologically functioning, but socially defective ears. People of the United States unite! Push for the creation of a Universal Health Care System in the United States. The only thing you have to lose is your fear…..