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United Nations General Assembly 2019

This series decodes deals, political moves, and gossip at the world’s biggest political summit.

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Guess the government agrees
MAYBE CARE FOR ALL

The US just promised to adopt universal health care

Annalisa Merelli
By Annalisa Merelli

Geopolitics reporter

Every single member of the UN doubled-down today on a commitment to provide universal health coverage to their citizens. The fact that the US will be among them is perhaps evidence of how disconnected these declarations can be from actual domestic political agendas.

Yet the issue is important, and it shows just how out of line the US approach to health care coverage is compared to the rest of the world. Only about half the world’s population has access to the kind of affordable health care services that don’t require crippling out-of-pocket costs. Most of those people are in mid- and low-income countries. Or they are in the wealthiest country on Earth: the US.

Bringing universal health care to everyone is one of the “sustainable development goals,” the ambitious to-do list for UN member countries to complete by 2030. For the UN, universal health care means, “financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”

The declaration, drafted through the leadership of Thailand and Georgia, breaks that down further, laying out a detailed 83-step process to provide accessible health coverage to the half of the world that doesn’t have it. The process includes guaranteeing access to sexual and reproductive care, addressing the needs of refugees and migrants, and working to eliminate catastrophic out-of-pocket costs—the kind that contribute to poverty in many developing countries, and that is the leading cause of bankruptcy in the US.

Supporting the declaration is a new report just published by the World Health Organization (WHO), which details its own set of interventions it believes are needed to bring health care access to everyone. For many countries, typically low-income ones, getting to universal health care means finding the resources to build the systems required. Peter Salama, WHO’s executive for universal health care, told Quartz that for rich ones, however, it’s about finding a solution to the fact that health care costs are rising faster than income growth.

That all countries achieve health care coverage for all their citizens is in the global interest, according to the UN, not least because stronger health systems improve the health of citizens and lower the risk of catastrophic pandemics, even in countries that already have strong health care access.

Do it for the money

While in the US, where the debate on universal health coverage is whether or not it should exist, most of the rest of the world has either already implemented it or is discussing how and when. The evidence—be it costs, access to services, or health indicators—show that the best way to get a healthy population is for a country to provide coverage to all its citizens, specifically through public financing.

Countries choose different paths toward universal health care—some funded through taxation, for instance, and some through mandatory insurance—but there is, Salama said, one important strategy in common between countries that are successful in delivering good health care to their citizens: Whether the actual health provider is managed by the government or private, the funding is public. This gives a government the negotiating power to maintain lower costs, while sparing people the financial burden of incurring high out-of -pocket expenses.

Salama said that financial burdens are a sign that a health system isn’t working for its citizens, as is a focus on curative care rather than preventative care. What’s more, these two things are connected. The US, the only rich country that doesn’t provide universal health care, offers a great example of how. The cost of medications for chronic conditions such as diabetes or asthma is several times more expensive in the US—where there isn’t one large public player negotiating the cost of medications—than it is in other rich countries.

This also shows how public financing is key to promoting a preventive system rather than a curative one. If the cost of diabetes medications is so high, and the earnings are made by the private sector, it is in the industry’s interest to cure the condition rather than prevent it. Sickness is a much more lucrative industry than wellness.

A goal within reach

Getting universal health care to half the world’s population by 2030 is an ambitious goal, and an expensive one. The WHO says it would cost about $7.3 trillion. Fortunately the world is already spending almost as much on health care—$7 trillion—so it’s really just 5% short. Universal health care is a more efficient system, however, so once those systems are in place, health care will become more affordable. In the long run, the world will save money.

Once again, the US is a good example: Overall, the US spends about 18% of its GDP, or $3.5 trillion, on health care. About $1.5 trillion of that is fronted by the government, the rest is paid for by its citizens, out of their pockets. This amount is much higher than it needs be because the private market is ineffective in keeping health care costs down. To reduce costs, the system would require drastic change.

Creating publicly-funded health care systems isn’t the only thing needed to get health care for everyone. Another important step, according to the WHO, is focusing on the primary health system. The best way to reduce cost and improve results is to keep the population healthy in the first place. That should be the role of a primary health care doctor, someone who monitors health and prevents the onset of diseases as much as treating them. “We used to think about primary care as poor health for poor countries,” Salama said. “But no one believes that anymore.” In fact, the report urges all countries to invest an extra 1% of their GDP into primary health care in order to improve quality and reduce the cost.

The value of a promise

The WHO and the UN are celebrating the signing of the universal health care resolution as an important achievement. It will be adopted during a high level meeting, which is an exceptional meeting convened by member states during the UN General Assembly in order to discuss an especially urgent topic. High level meetings don’t happen every year, and only six have been dedicated to health issues in the UN’s history. The first was held in 2001 to address the AIDS epidemic.

The WHO report says that the decision to hold a high level meeting shows that countries are taking the issues seriously. And even though the commitment doesn’t come with a binding timeline, it says a lot that governments are willing to put their signature on it.

“This is the first step to making a political commitment to give the half of the world populations that currently doesn’t have access to universal health coverage the right set of health services,” Salama told Quartz.

So, does that mean the US government is signing a promise to give its citizens universal health care coverage by 2030? Essentially, yes. But the declaration doesn’t align in any way with the current government’s plans—from contraceptive coverage, to finding ways to reduce costs, to addressing climate change in order to reduce its impact on public health. It’s hard not to see this as an indicator of just how little the US government cares about the commitments it makes with the international community. Since the UN’s creation, the US has been a chief offender when it comes to not sticking to commitments, for instance in its treatment of refugees.

Although the declaration and report have a strong focus on financial sustainability, WHO director-general Tedros Adhanom Ghebreyesus is reluctant to call out the US for lacking a commitment to reform.

“Whether it’s the US or another country, we don’t prescribe this model or that model,” he told Quartz, “[…] any country based on its situation can select what is appropriate.”

However, he continued, the declaration does require a commitment to ensure access to health care doesn’t cause severe financial hardship.

“But, of course, at the end of the day it becomes a political choice,” he said.

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