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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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For a lot of us, the phrase “health care 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 health care journey can feel hard enough–not to mention doing the  actual, you know, caring for your health.

But this isn’t a 21st-century  problem. People have spent hundreds 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 health care 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! [INTRO] 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 health care providers.

And sure, they include doctors and surgeons who treat us  when we need immediate care, but also people who provide ongoing, preventive 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 health care system. The health care 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 Waited 10 Hours in Emergency Room After Sky Diving Incident.” And while  these headlines are good at getting clicks, they’re not as good at explaining  what a health care system does. The World Health Organization defines a health  care 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 health care system. Let’s break  them down a bit in the Thought Bubble. 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 health care 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 healthcare  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. 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 health care 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 with 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 that same “click here!” ring to it. There are around 200 countries in the world, each with its own unique 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  health care 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 health care service.

The first kind of health care 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 Beveridg​​e, 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  health care systems built on that idea. Beveridge recognized that one of the biggest  barriers between people and health care was cost. So, he proposed the establishment of  a government-run national health service, 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 healthcare. This is the system that we see  in places like Great Britain and New Zealand. 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.

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 see this model used primarily  in Canada, Taiwan, and South Korea. 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 is basically the lack of a healthcare  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 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 country’s 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. healthcare 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 health care 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.

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 health care 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 health  care system should accomplish. One pretty obvious goal of a health care  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 Marino and Estonia  have some of the best outcomes as of 2020.

We also want a health care system that is  responsive. Like, when we need an appointment with a specialist, we don’t want to  have to wait months to get treated. And we also want our health care system to be  equitable.

We don’t want a health care 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. We ask a lot of our health care 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 health care systems are pretty  new–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. Crash Course was filmed in the Castle  Geraghty studio in Indianapolis, IN, and made with the help of all these wombat lovers. If you'd like to help keep Crash Course free for everyone forever please consider  joining our community of supporters on Patreon.