Why Universal Health Coverage alone is not enough

A message from Canada


The United States of America has much to be proud of and ashamed of when it comes to its healthcare system.

If you have money, it is the best system in the world; if you don’t, it is arguably the worst. This is the price you pay when you — as a system — prioritize profits and innovation over equity and accessibility.

But to think that the introduction of a single-payer system or a pronounced focus on progressing Universal Health Coverage (UHC) will be the cure for all its flaws is a laughable oversimplification.

Trust me, I’m a Canadian.

I am proud of being a Canadian. I have the privilege of living in one of the most safe, diverse, and beautiful countries in the world. And we also have a generally well-regarded UHC system. But our healthcare system is far from perfect; we consistently score at or near the bottom when it comes to wait times, innovation, and even some of our outcome indicators. And yet, Canadians remain violently defensive of our healthcare system.

As Jeffrey Simpson said in his 2012 book Chronic Condition, “Medicare is the third rail of Canadian politics — touch it and you die.”

So why with universal access and no out-of-pocket payments for medically necessary services does Canada have such a seemingly underwhelming healthcare system?

One word: cohesion.

How many policies does it take to make a great health system?

The history of Canada’s UHC journey is one centred on hospital care and physician services. But this was only meant to be the first step in Tommy Douglas’s vision. He saw Saskatchewan’s — and Canada’s — Medicare program as evolving over time to include an increasing number of services; eventually shifting to a system focused on prevention, and even more progressively, the social determinants of health.

Over 60 years later, we are still hospital-centric and haven’t altered the healthcare paradigm from treatment to prevention. We haven’t accomplished health policy cohesion.

Mini meta-analysis on contributors to health outcomes

Canada is not alone in this. UHC policy anywhere in the world is still largely developed and rolled out in a silo; isolated from so many other areas that arguably play a larger role in our health than the healthcare system itself.

Health In All policy is a concept that represents a whole-of-society response to optimizing UHC and health system efforts. From creating better parks, to promoting healthier foods, to building stronger schools and communities, this comprehensive approach is meant to simultaneously strengthen society and the health system.

But putting this mindset into practice is much easier said than done. It has already been proven to be hard enough to communicate across different parts of the health system, but when you need to collaborate across government more broadly as well, it becomes next to impossible. However, that doesn’t mean it isn’t worth trying.

As the single-payer and UHC discussion continues to stay heated in the United States, it is important not to lose sight of the big picture:

UHC is not the end of the journey, but the beginning.

A different health financing mechanism alone may make healthcare more affordable for some people, but at what cost?

Would Americans accept having to wait months to see a specialist for free? Maybe.

Would Americans accept the concept of a flat health system where everyone (at least notionally) has access to the same good-but-not-great care regardless of income? Maybe.

Would Americans still support a single-payer system when their health outcomes don’t change and population health continues to decline? Maybe.

The point I’m getting at is that you don’t want Canada 2.0. You don’t want a piecemeal universal system that for every incremental improvement comes an incremental inefficiency.

If you are going to go single-payer, which isn’t even necessarily the right approach, you need to learn from the mistakes of Canada and others. You need to reframe the issue to ensure that the great parts of American healthcare don’t become casualties in the single-payer pursuit.

Mike Townsend put forward great ideas in his recent article on what single-payer could mean in a capitalist economy, but I propose that there is also a need to think outside the preconceived confines of health policy.

Unless there is a concerted macro-level effort to make some form of Health In All policy a reality, the impact of any UHC investment in an advanced economy in the 21st century — and by extension, the impact of any health system investment — will almost always be suboptimal.

And with a health system that is already so expensive and a population that is already so unhealthy, suboptimal is not enough.

To make transformational impact, you need transformational effort. In an America that seems set on building walls, why not focus on knocking some down and putting the health of the nation at the forefront of any and all policy discussions?

Just like single-payer, a Health In All approach in America will have to be extremely tailored; but also just like single-payer, that doesn’t mean it isn’t worth exploring.

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