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Are you ready for the understatement of the century? Health care is complicated. Across the 200 or so countries on Earth, there are a lot of different ways people receive health care. In this episode of Crash Course Public Health, we’re going to break down the building blocks that are used to create a health care system and take a look at four of the most common models.

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Transcript: https://docs.google.com/document/d/1H5J4HgGDbFyXLr9BVy5dcp6l0ro1HNzDz9nQHXpXpCM/edit

Sources: https://docs.google.com/document/d/1OHJiQ1njj5jWJC1YLDBzQgKC1QfnVgqJbbpK6qs7ekA/edit?usp=sharing

Chapters:
Introduction to Health Care Systems 00:00
Six Building Blocks 2:03
Beveridge Model 5:18
Bismarck Model 6:37
National Health Insurance Model 7:09
Out-of-Pocket Model 7:35
Goals of Healthcare 10:45
Review & Credits 11:44

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 (00:00) to (02:00)



 Introduction to Healthcare Systems (0:00)



For a lot of us, the phrase "healthcare system" can feel like a labyrinth full of paperwork, long lines, and strange-smelling waiting rooms, and navigating this labyrinth can be stressful and overwhelming. In fact, just figuring out how to start your healthcare journey can feel heard enough, not to mention doing the actual, you know, caring for your health.

But this isn't a 21st-century problem. People have spent 100s of years imagining different ways to help people navigate the labyrinth, and they've come up with a bunch of different paths, each with their own benefits and pitfalls. In a lot of places, we've combined these approaches. Like, the U.S. has kind of taken approaches to healthcare from pretty much everywhere, which sounds promising but has turned out to be, well, you'll see what I mean.

Hi, I'm Vanessa Hill, and this is Crash Course: Public Health.

(theme music)

It feels weird to say, but our health isn't just something that we have. It's also something that is cared for and provided to us by others. These people are our healthcare providers, and sure, they include doctors and surgeons who treat us when we need immediate care, but also people who provide ongoing preventative treatments, like therapists, dentists, and nursing home workers.

And while we typically receive care directly from these people, there's an entire world behind the scenes that makes this relationship between patients and providers possible: the healthcare system. The healthcare system is probably best known for generating a lot of opinions and news stories. We see attention-grabbing headlines like "Why America's Healthcare System is Broken" or "This Man Waiter 10 Hours in Emergency Room After Skydiving Incident."

And while these headlines are good at getting clicks, they're not good at explaining

 (02:00) to (04:00)


what a healthcare system does. The World Health Organization defines a healthcare system as "all the institutions, people, and resources whose primary purpose it is to promote, restore, and maintain health." In general, the World Health Organization identifies six building blocks that make up a strong healthcare system. Let's break them down a bit in the Thought Bubble.


 Six Building Blocks (2:24)



Meet Nate. He is having an asthma attack for the first time. The first building block that Nate needs to successfully diagnose and treat his asthma attack is Service Delivery. Basically, there needs to be enough healthcare facilities so that Nate can easily access them. 

Once Nate is at his chosen healthcare facility, he needs his care provider to have Essential Medicines like albuterol, also known as salbutamol outside of the U.S., which helps to open airways in the lungs. And the facility may have essential supplies like a stethoscope for listening to Nate's breathing. Also, Nate probably wants there to be a trained professional at the facility, so another obvious building block for Nate's treatment is a Health Care Workforce that can help him diagnose his symptoms and then treat them.

One building block that Nate might not be thinking about is Health Information Systems. These are systems that help collect and securely store data, and not just about Nate's health - about everyone's health. This could allow patients to have better access to their own health data and also help health care professionals around the world make more informed decisions and diagnose health patterns in a population.

So if a population across the world is experiencing similar symptoms to Nate's, doctors can work together to find common factors that could explain the illness. This means that, while Nate's asthma is being treated by one provider, an entire community of experts could use information about his condition and the medication he receives to help others.

 (04:00) to (06:00)


So the doctor diagnoses Nate with asthma and treats him with medicine, thank goodness. But someone needs to pay the doctor for their time, and the medicine manufacturer for providing the medicine, so Nate wants to be part of a healthcare system that is good at Financing, which means it has structured ways costs are covered.

And to make sure that all these building blocks are working together, we need Governance, or a system to oversee public policy, medicine regulation, healthcare costs, and anything else Nate needs to stay healthy. Thanks, Thought Bubble.

So, yeah, we can probably see why a media outlet wouldn't run a headline like "Man Waits 10 Hours in Emergency Room Due to Lack of Investment in Health Care Workforce, Supplies, Information System, and Assorted Other Institutional Challenges." It just doesn't have the same "click here" ring to it.

There are around 200 countries in the world, each with its own health challenges and solutions for tackling those problems, but this is Crash Course: Public Health, not Encyclopedia: Public Health, so rather than doing an Amazing Race-style speed run of every healthcare system in the world, we're going to put them into four general groups. Each of these systems basically has its own take on how to finance and provide healthcare service.


 Beveridge Model (5:18)



The first kind of healthcare system we'll look at is the Beveridge Model, not the Beverage Model - it wasn't invented by the guy who created Coca Cola. In 1948, the model was developed by Sir William Beveridge, the former director of the London School of Economics and Political Science.

One of the foundations of the Beveridge Model is that good health is a human right, which might not sound like a hot take to you, but until then, there were no models for healthcare systems built on that idea. Beveridge recognized that one of the biggest barriers between people and healthcare was cost, so he proposed the establishment of a government-run national health service,

 (06:00) to (08:00)


which would be paid for publicly by taxes, and that could provide care to everyone.

This was one of the first organized instances of universal health care. When we say universal health care now, we mean any geographical region where everyone has access to health coverage, no matter which health care model is being used. When people refer to socialized medicine, they're talking about the Beveridge Model. In socialized medicine, the government pays for and delivers health care. This is the system that we see in places like Great Britain and New Zealand.


 Bismarck Model (6:38)



Another type of health care system emerged from Germany back in the late 19th century known as the Bismarck Model, named after its founder, Otto, Prince of Bismarck, Count of Bismarck-Schönhausen, Duke of Lauenburg, which is basically a long-winded and very badly pronounced way of saying "very fancy German diplomat with a long Wikipedia page. In modern Bismarckian systems, private organizations pay for and deliver the care, but everything is tightly regulated by the government.


 National Health Insurance Model (7:10)



Then, somewhere between the Beveridge Model and the Bismarck Model we have the National Health Insurance Model. The National Health Insurance Model is similar to the Beveridge Model in that the government is the one paying for medical care. However, like the Bismarck Model, private organizations deliver it. We've seen this model used primarily in Canada, Taiwan, and South Korea.

 Out-of-Pocket Model (7:35)


Our fourth model is the Out-of-Pocket Model, which probably wins the award for most helpfully-named model yet. Unfortunately, it also wins the award for the potentially least effective model, because it's basically the lack of a health care model.

It means that people pay for 100% of the treatment they receive themselves. Basically, people get the treatment that they pay for without assistance from the government


 (08:00) to (10:00)


or an insurance company. We see this model in India, the United States, and some low- and middle-income countries in Africa and South America.

It's important to remember that we're using our four health care models to speak very broadly about things that can be pretty gnarly to unpack in practice. Many countries' health care systems incorporate elements of multiple models, and maybe none more so than the United States.

The U.S. is unique, because it's the only wealthy, industrialized country without universal health insurance coverage. Also, the U.S. spends way more money on health care than other wealthy countries. Like, so much money that, in 2018, its spending made up 42% of all global spending on health care, despite making up just 4.29% of the world's total population.

But despite all that spending, the quality of U.S. health care actually falls behind those other wealthy nations that don't spend all that money. In one 2021 study comparing U.S. healthcare results to those in 11 countries with similar levels of wealth, the U.S. ranked last in healthcare access and quality and had the highest rate of premature deaths.

The U.S. healthcare system combines pretty much every healthcare model we've discussed so far. Like, the U.S. Veterans Health Administration resembles something like the Beveridge Model or socialized medicine to take care of veterans' health pretty much free of charge.

But then the U.S. also uses the Bismarck Model, which can be seen in the insurance exchanges introduced by the Affordable Care Act. In these exchanges, private organizations pay for and deliver care, but everything is tightly regulated by the government. People 65 years or older are covered by Medicare, which is like Canada's system in that it's paid for by the government but delivered by private organizations.

 (10:00) to (12:00)


And then, as of 2020, there were around 8.6%, or 28 million Americans, who weren't insured who pretty much used the Out-of-Pocket Model.

So, it's natural to wonder: which of these models is best? This is what public health experts call a terrible, horrible, no good, pretty much impossible to answer question. Ranking healthcare systems is a bit like giving a definitive ranking of the Spice Girls. It's going to come down to what criteria we're using to build our ranking. Scary or Sporty? Posh or Ginger? Wait, why does everyone forget about Baby?

Instead, we can think in terms of goals by asking what a good healthcare system should accomplish.


 Goals of Healthcare (10:46)



One pretty obvious goal of a healthcare system is to improve health, and there's a bunch of different ways to do this. One metric we hear about often is life expectancy, with the general scientific consensus being that healthier people live longer on average. In this category, some of the top-performing countries as of 2020 are Japan and Singapore. But another useful measurement of health might be the number of children who live past the age of five, where San Merino and Estonia have some of the best outcomes as of 2020.

We also want a healthcare system that is responsive. Like, when we need an appointment with a specialist, we don't wanna have to wait months to get treated. And we also want our healthcare system to be equitable. We don't want a healthcare system that's only good at caring for the health of some people. Health is a human right, regardless of where we are or who we are.


 Review and Credits (11:43)



We ask a lot of our healthcare systems: affordability, timeliness, innovation, equitable access. These aren't boxes that we can just check off easily or permanently. In the grand scheme of human history, organized healthcare systems are pretty new,

 (12:00) to (12:45)


and we have a lot of work left to do.

Thanks for watching this episode of Crash Course: Public Health, which was produced by Complexly in partnership with the American Public Health Association. If you want to learn even more about public health, head over to APHA's YouTube channel to watch That's Public Health, a series by APHA and Complexly.

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