Universal health care
“”We cannot protect a man from all sickness and misfortune. But it is our obligation, as a society, to provide assistance when he encounters these difficulties… A rich society must care for the poor.
|—Otto Eduard Leopold von Bismarck.|
| The dismal science|
Universal health care, also spelled universal healthcare, describes any system whereby all residents of a given jurisdiction, often a country, are able to receive medical attention without suffering from financial hardship. The 1948 Constitution of the World Health Organization declares healthcare a fundamental human right. Universal health coverage includes not just the full spectrum of health services, namely the promotion of healthy lifestyles, prevention, treatment, rehabilitation, and palliative care, but also the necessary legislation, financing, infrastructure, and bureaucracy. But it does not mean all possible medical services since no country can afford to do so sustainably. Nor does it prevent people from paying out of their own pockets for supplemental elective services such as private hospital rooms or cosmetic surgeries.
- 1 Basic models
- 2 Advantages
- 3 Disadvantages
- 4 Overview of the status quo
- 5 Select healthcare systems
- 5.1 Australia
- 5.2 Canada
- 5.3 China, the People's Republic of
- 5.4 China (Taiwan), the Republic of
- 5.5 Cuba
- 5.6 France
- 5.7 Germany
- 5.8 Japan
- 5.9 Switzerland
- 5.10 United Kingdom
- 5.11 United States of America
- 6 External links
- 7 Notes
- 8 References
There are four basic healthcare models.
- The Beveridge model. Named after William Beveridge, the architect of the United Kingdom's National Health Service (NHS), this system gives the government the ability to directly provide and finance medical care via taxes, making care available at no further cost to citizens in the same way as providing public roads and hospitals are. Besides its mother country, variations of the Beveridge model are found in Hong Kong, New Zealand, Spain, and most Scandinavian countries.
- The Bismarck model. Prussian Chancellor Otto von Bismarck introduced this in 1883 as part of his welfare programs for the citizens of the newly-unified German Empire. Health insurance plans, or "sickness funds," are jointly financed by the employers and employees, and do not make profits. Unlike the Beveridge Model, this system has multiple payers but is tightly regulated, keeping costs down. In addition to its Fatherland, variants of the Bismarck model has been implemented in Belgium, France, Japan, the Netherlands, and Switzerland.
- The National Health Insurance model. This is a hybrid of the Beveridge and Bismarck models. While healthcare providers are private, the system is funded by taxes. Marketing and profits do not exist, and administrative costs are kept low due to its simplicity. This model also keeps costs low by limiting the types of medical services patients can receive and by making them wait for treatment. While the classic model is in its home and native land, Canada, its modified versions have also been adopted in Taiwan and South Korea.
- The out-of-pocket model. This is practiced in countries that do not have a universal healthcare program for one reason or another, which is to say, most of the countries that exist right now. With a notable exception of Cuba, only industrialized countries have universal healthcare. The absence of a well-organized public health system makes it easy for the gullible to be exploited due to the asymmetry of information—doctors know more about medicine than patients—and by cranks and charlatans.
The first and third models are what people mean when they say "single-payer health insurance." Since each country is unique, each must develop its own approach to making progress in healthcare. For example, it would be counterproductive for a poor or developing country to build a state-of-the-art Western-style hospital because few people could afford to use it. This is an instance of the well-known concept of opportunity costs. There exists no such thing as an ideal one-size-fits-all model. Each existing universal healthcare system is the result of compromises, culture, history, contemporary social trends, and education. Still, there is value in international standardization for easy assessment. Willingness to learn from other countries is a strength.
- Affordable healthcare for all citizens (and foreign residents). No one will have to live with too little or no health insurance. Medical bankruptcy will cease to be. A purely competitive market equilibrium does not exist in healthcare due to the asymmetry of information. Obviously, doctors know more about medicine than patients. With the right government actions, however, market forces can help produce the desired social goals. Furthermore, curing patients may not be a sustainable business model.
- Adverse selection is avoided. This is due to another instance of asymmetric information. People naturally know more about their own health than insurers and have an incentive to hide any serious problems lest they are denied coverage or get charged with a higher premium. Furthermore, high-risk individuals are more likely to purchase insurance, and purchase more insurance than low-risk individuals. With such a risky insurance pool, companies must raise premiums in order to stay solvent. This drives away low-risk individuals. Economist Kenneth Arrow showed that this vicious cycle goes away if a single-payer system is implemented.
- Efficiency of scale. More people covered means distributed risks and lower costs overall.
- Bureaucratic simplicity. Money invested in healthcare is spent only on healthcare and related administration, rather than on profit-making insurance companies, which keeps costs low, because the main goal is to get people healthy and save their lives. Single-payer systems have especially low administrative costs.
- Incentives for governments to keep their people healthy in order to reduce costs. This means prioritizing preventive care. As a matter of fact, preventive care and public health campaigns have saved many more lives than specific treatments while costing much less money and despite not receiving a lot of public attention. However, different systems come to different conclusions on what kind of preventive care should be covered. For example, annual comprehensive health checks are free in Japan, but not in the U.K.
- Coverage continuity. Health insurance is not lost due to employment status changes or age. In single-payer countries such as Canada or the U.K., healthcare is funded by general taxation so there are no premiums to pay. In multi-payer countries such as France, Germany, or Japan, the government picks up the employers' shares of the premiums if a person becomes unemployed.
- Improved life expectancy. Countries with universal healthcare report higher life expectancy than comparable ones without. As a recent example, newly industrialized Taiwan implemented universal healthcare in the 1990s and reported markedly higher recovery rates from major conditions and longer life expectancy overall about a decade after.
- Social equity, inclusion, and cohesion. Healthcare will no longer be a privilege of the wealthy; the poor will not have their futures ruined because of medical bills. Historically, national unity was one of the reasons why a national health insurance program was introduced in Bismarck's Germany, and, shortly afterwards, Meiji Japan. More recently, it was also one of the reasons for the passage of universal health coverage in multilingual Switzerland, in the 1990s.
- Basis for long-term economic development. Good health allows children to concentrate on learning and adults on working. Affordable healthcare helps people escape poverty. Adam Smith himself noted the importance of education and health to labor productivity.
- In a single-payer system, there is no direct health insurance costs for businesses or individuals. This lowers inflation and increases employment by reducing the financial burden on businesses to provide workers' healthcare benefits and its associated costs. In short, it is good for business.
“”One of the great mistakes is to judge policies and programs by their intentions rather than their results.
- Possibly higher taxes. This is the case in the single-payer U.K., but not in multi-payer Germany. In single-payer Taiwan, national health insurance premiums are not considered taxes.
- Many nations with universal healthcare have seen shortages in healthcare availability for certain medical services, resulting in long wait times, such as in Canada, Sweden, and the UK. However, this is not the case in Germany or Japan.
- Some countries with universal healthcare do not have enough medical professionals. Canada reports a shortage of doctors and nurses in general. France and Taiwan suffer from insufficient numbers of pediatricians.
- Countries that want it must face the high upfront costs of transitioning to universal healthcare. It was noted above that most countries with universal healthcare are rich and developed economies. One of the reasons why Taiwan successfully implemented universal healthcare in the 1990s is her newfound economic prosperity. However, the economist Amartya Sen has argued that universal healthcare is a dream affordable to even the poorest of countries because of the following reasons. First, low wages mean low prices. Second, many preventable deaths can still be avoided even with a limited system. Third, as noted above, covering a community helps distributes the risks and is therefore more cost-effective. Finally, outbreaks of infectious diseases can be contained with the help of a public health system.
- Universal healthcare is a constant struggle to balance costs, access, and quality. For example, patients in France enjoy excellent care and short wait times, but French insurance funds are all running deficits. It should be noted that France has the greatest healthcare system in the world, according to a 2000 WHO report. The costs of maintaining universal healthcare, or financial limitations in its implementation, have a tendency to increase over time. (See figure.) The link between improved medical possibilities and rising healthcare costs also leads some to believe that universal healthcare has become—or will become—unsustainable. Arguably, it may also lead to increasing ethical and financial dilemmas of the "when do we pull the plug?" kind.
- Easy access to healthcare drives supply-induced demand, creating a moral hazard common to all health insurance schemes and healthcare systems around the world and could lead to a tragedy of the commons, a scenario in which rational individual choices jeopardizes the group. In particular, individuals tend to maximize the amount and quality of healthcare they receive but are disinclined to pay more. On top of that, they behave in risky ways knowing that if something were to happen to them, they would be covered by insurance. Governments must encourage individuals to refrain from misusing, abusing, and overusing the system as a matter of personal responsibility. Making people pay more for health insurance also helps alleviate the problem.
- Medical innovations and their adoptions could be stifled due to a lack of financial incentive and low healthcare spending. This is not to say that the government cannot innovate or that it innovates less effectively than the private sector does. Rather, the argument here is that because the government uses its monosopnic power[note 1] to constrain costs by, among other things, selecting which drugs and treatments it will pay for, it adds risks to an already risky market. It becomes less certain whether or not a potential new drug is worth investing in because it may not be paid for. There is no guarantee that quality in basic research will translate to successful commercial applications. Furthermore, which area of medical research the government prioritizes may well depend on how loud the relevant advocacy group is. In a free market, on the other hand, companies will respond to how large the demand for a certain drug or treatment is, i.e., how many people suffer from a condition and how desperate they are, which translates to how much they are willing to pay.
Overview of the status quo
WHO's 2000 Report
On June 21, 2000, the World Health Organization issued a report analyzing the healthcare systems of 191 countries,[note 2] the first of its kind. WHO's assessment was based on five factors: overall population health, health disparities, overall responsiveness of healthcare systems, distribution of responsiveness within a country, and the distribution of financial burden for medical expenses. It found great variations, even among countries with comparable levels of income.
The United States spent a substantial percentage of GDP on medical care and had one of the most responsive systems ever but ranked only 37th while the United Kingdom spent much less, 6% GDP, but ranked 18th. Only two Asian countries, Japan and Singapore, were in the top ten. In Europe, France, Italy, and Spain had the best performing healthcare systems. France in fact had the greatest healthcare system in the world. Most families in India paid some 80% of medical costs out-of-pocket. Columbia had the fairest system of them all. Meanwhile, the most unfair systems are to be found in Brazil, Cambodia, (mainland) China, Myanmar, Nepal, Peru, Russia, Sierra Leone and Vietnam.
At present, about half of humanity lacks access to basic healthcare and some 800 million people spend at least 10% of their income on medical bills. However, several countries in Asia and Africa—Ghana, Kenya, Mali, Nigeria, Rwanda, India, Indonesia, the Philippines and Vietnam—are making progress towards universal health coverage, with increasing percentages of their populations enrolled in health insurance programs. In particular, Rwanda, ravaged by genocide in 1994, has seen its life expectancy doubled since the mid-1990s. By 2018, more than 90% of Rwandans have health insurance. Rwanda's system is a model for other African countries.
Select healthcare systems
Australia is perhaps unusual in that it developed two universal health care systems in quick succession. In the early 1970s, a newly-elected Labor government implemented a system named Medibank. When Australians decided, less than three years later, that they'd like some more conservative government instead, Medibank was restructured into a government-owned private health insurer — complete with a name change to Medibank Private to ensure there was no misunderstanding — as a first step towards selling it off. Before this could happen, Australians changed their mind again, voted in another Labor government in 1983, which set up a new universal health care scheme, Medicare, and kept Medibank Private as a government-owned business to earn a profit for the government and keep the other, smaller private health insurers in line.
Medicare, is nominally funded by a 2% Medicare Levy on income, but in practice it is funded out of general revenue. Medicare covers 100% of in-hospital costs, 85% of specialist costs and 75% of general practitioners' costs. Depending on how they want to run things, medical organisations may either charge the patient the full cost of their treatment (the patient takes their receipts to Medicare to receive the rebate), bill Medicare directly (a practice known as "bulk billing"), or do something in between. In addition, the Pharmaceutical Benefits Scheme (PBS) subsidises a wide range of prescribed medications, and functions as a sole-purchaser for anyone looking to sell medication in Australia, keeping prices of medication down through volume purchasing.
Visitors from countries with reciprocal relationships with Australia (for instance, New Zealand) have limited access to Medicare (though all patients in Australia have access to free hospital care, regardless of whether they are Australian or not). The Australian health system is generally considered to be among the best in the world, providing reasonably timely treatment at a low cost to the country. Australia spends approximately 9.8% of its GDP on health care.
Conservative distaste for the idea that a national government should have some responsibility for the health and well-being of the citizens who pay its taxes, and some strategic schmoozing by for-profit health care lobbyists, has led to the bizarre situation of even the private health insurance industry in Australia being heavily dependent on government money. Private health insurance premiums are an income tax deduction — an in-effect subsidy, and individuals above a certain income level who do not have private health insurance are subject to a Medicare Levy surcharge. 
It's not the first shot: that was the refusal of the then-Coalition opposition to support the original Medibank bill through the Senate. Or the Fraser Coalition government which undid universal health care less than six months after its introduction, creating a system whereby the better off would not pay into Medibank if they held private health insurance. Or the succession of right and centre right governments since 1990-ish that have introduced the health insurance rebate, the medicare surcharge levy, and the lifetime loading charge, all designed to push more and more people out of universal health care and into private health insurance. This is just the latest volley, and given that too few people (Gen-Y'ers who don't realise how good they had it) value universal health care to sustain it any more, it won't be long until Oz is back to an American-style system.
On the plus side, private health insurers and health care providers remain rather tightly regulated. Any premium increases are subject to government review and oversight, the premiums are generally modest — an individual can expect to have to spend no more than a day's earnings on their monthly health insurance premium, and policies tend not to be riddled with gotchas and exclusion, and they universally include allowances for eyeglasses, orthopedic footwear, dentistry, physiotherapy, and even gym memberships and sporting equipment. The downside is that many questionable health practices with no proven benefits such as homeopathy, chiropractor, chelation therapy, crystal healing, acupuncture, etc. are also offered as an incentive coverage by private health insurers to attract customers. In 2013, Medicare clamped down on remedial massages being offered as a rebate, after it was found brothels were using it as an umbrella subsidy for their sex services. "The Lucky Country" indeed.
“”Canadians don't mind the waiting list so much, so long as the rich Canadian and the poor Canadian have to wait about the same amount of time.
Thomas Clement Douglas was a Scottish immigrant who banged his knee as a child. This painful injury left him limping or on crutches, or so he would remain if it were not for a professor of orthopedics who selected him to be the subject of a surgical demonstration. The surgery proved successful, yet Tommy's luck bothered him. He believed that people should be able to receive the healthcare they need regardless of their ability to pay. He made his dream a reality when he became Premier of Saskatchewan. He introduced a government-run single-payer healthcare system for all of the residents of that province, which entered service on January 1, 1947. So successful was the program that people in the other provinces demanded the same thing. Eventually, the federal government adopted the idea, and in 1964, all Canadians were covered by a single-payer universal health insurance program funded by general taxation, which each province or territory running his own Medicare system. Thus, given Canada's decentralized system of government, it is technically accurate to call Canada's healthcare system a thirteen-payer system.
Today, single-payer universal health coverage is consistently the most popular social program in Canada. It covers all medical and psychiatric care, both in and out of hospital, and is a major source of national pride. Canada has made all medical records digital, thus cutting administrative costs. A 2012 national poll (of 2,207 people) commissioned by the Association for Canadian Studies based on Montreal found that 94% of Canadians think universal healthcare is an important source of collective pride.[note 3] Under the Canadian Constitution, it is a provincial and territorial responsibility. As a result, each province and territory has its own separate healthcare system. Furthermore, coverage varies across the ten provinces and three territories. Some pay 100% of all doctor and hospital bills; others require co-pays and deductibles. Most require people to pay for their own prescription drugs; the poor, the elderly, and the chronically ill who need constant medication are exempt. In any case, Canada's efficient payment system and universal coverage offers a great advantage in price negotiations. The Canada Health Act of 1984 laid out the rules that the provinces and territories must follow in order to receive federal funding for their Medicare programs. However, since none can go without federal funding, the Act is effectively mandatory. The keys points are as follows.
- Each provincial or territorial Medicare program must be a non-profit public entity.
- Each healthcare plan must pay for all "medically necessary" products and services. Quite naturally, the definition of "medically necessary" changes over time.
- All residents of the province or territory must have the same access to medical services.
- The plan for one province or territory must pay for a resident patient anywhere in the country.
- Fee discrimination is forbidden.
Furthermore, in order to prevent a two-tier system from emerging, it is forbidden for insurance plans to reimburse anything covered by Medicare, and for Medicare hospitals and doctors that practice privately to bill patients directly. As a result, very few Canadian doctors work outside of the Medicare system. However, about two out of three working Canadians have private insurance for things not covered by Medicare, such as dental care, private hospital rooms, and more. Since Medicare covers all major medical services, (supplemental) private insurance plans are quite cheap, so much so that many employers offer it as a job benefit. It is important to note, however, that patients who require treatment in another province or territory may be billed for treatment. In particular, since Quebec did not sign on to the inter-provincial billing agreement, out-of-province patients in Quebec and Quebec patients in the other provinces and territories may be asked to pay upfront. They will be reimbursed when they return home.
Canada's National Health Insurance model was more than just a national or federal success. The Asian tigers Taiwan and South Korea implemented modified versions of it as well. When the United States Congress passed a law guaranteeing healthcare to all Americans aged 65 or over in 1965, they did not just adopt the Douglas model, but also the name he gave it, Medicare.
However, the Canadians do not have everything going their way. Canada's current spending levels cannot keep up with the rising cost of healthcare. Nor is there an ample supply of doctors and nurses, as few Canadian students today consider such professions to be desirable. Worse, an official commission in 1991 recommended the reduction of the number of medical and nursing schools. As a consequence, the ratios of doctors to patients have dropped across Canada, especially in rural areas. With insufficient numbers of homegrown doctors, Canada is forced to import from developing countries. Both federal and provincial governments have been either unable or unwilling to provide additional funding for Medicare. But perhaps the most serious problem facing Canadian healthcare today is the infamous queue. If a medical problem was deemed non-urgent, the patient would have to wait. Wait times depend on the province or territory and on the treatment. Orthopedic surgery is one of the most notorious. (This is perhaps ironic, given the story of Tommy Douglas.) People have to wait for up to a year just to get a consultation, and if the orthopedist decides surgery is suitable, the patient will have to wait for several months.
Such long wait times in an otherwise functional and egalitarian system have given rise to the argument that the ban on private payment is tantamount a ban on the procedure altogether, since access to a waiting list is not the same thing as access to treatment. There are treatments that people are willing and able to pay for, if they were allowed to, but are difficult to obtain under Medicare. This argument came into prominence in the Canadian Supreme Court case Chaoulli v. Quebec. An elderly Quebecker was suffering from a painful condition that, according to Dr. Jacques Chaoulli, necessitated a hip-replacing surgery. But Dr. Chaoulli could give his patient nothing more than a spot on the queue. He decided to go to court on behalf of his patient after nine months and used the aforementioned argument. The Supreme Court agreed and wrote, "The prohibition on obtaining private health insurance, while it might be constitutional in circumstances where health care services are reasonable as to both quality and timeliness, is not constitutional where the public system fails to deliver reasonable services." This astonishing decision led some to predict that a two-tier system was coming to Canada. But that has not happened, at least not yet. Rather, governments have worked to bring in more doctors and to spend more money in order to reduce the waiting lists. Nonetheless, a shortage of doctors and long wait times remain basic features of the Canadian healthcare system.
China, the People's Republic of
Since the dismantling of much of the Communist healthcare system under economic reforms, access to healthcare in China has deteriorated substantially. Citizens found they needed to save substantial sums to cover potential medical bills, depressing consumer spending, with patients in impoverished rural areas often refusing medical treatment for fear of costs.
The Chinese government, apparently not realizing what a success story its healthcare system was, has since reformed the healthcare system with public insurance programs. Now, almost the entire population is covered by insurance, though it only covers about half of healthcare costs in most instances, though it is working on making healthcare affordable to everyone by 2020.
The Special Administrative Region of Hong Kong maintains a British-style healthcare program and refused to give it up when taken over by mainland China in 1997. The Hong Kong Hospital Authority is solely responsible for the delivery and financing of healthcare.
China (Taiwan), the Republic of
“”To find your way in the fog, follow the tracks of the oxcart ahead of you.
“”In the end, the program that they finally set up in 1995 really is like a car that was made of different parts, imported from overseas, but manufactured domestically.
Taiwan emerged in the late twentieth century as one of the twenty-five richest countries in the world, thanks to a period of rapid industrialization and modernization of under two decades. By the 1990s, she has become a leading producer of electronic devices and components. As a result of this process, Taiwan also became a democracy. Thanks to this new political environment, the incumbent Nationalists had to confront the Democratic Progressives, who were making the case for universal health coverage. A commission for healthcare reform was established and diligently studied the healthcare systems of other advanced countries. The Beveridge model was quickly rejected because, unlike the United Kingdom, Taiwan had mostly private hospitals and health insurance plans already in place for civil servants. A system that relied on private insurance to pay the bills was preferred. That meant the Bismarck model, as was already implemented in Germany and Japan, for example. However, the Bismarck model relies on too many insurance funds. Taiwan preferred a single government-run insurance plan. This is of course the national health insurance model from Canada. But the Taiwanese system has a major difference from its Canadian counterpart. While Canada's Medicare is paid for by general taxation, Taiwan's National Health Insurance (NHI) is funded by a monthly premium deducted from people's paychecks. Taiwan does not consider this mandatory premium to be a tax. Those who cannot afford to pay the premium are offered interest-free loans. Taiwan's system is thus a hybrid of the German and Canadian models.
From France, Taiwan picked up the idea of storing medical records digitally on an electronic card. All of the patient's history of treatments, medication, and doctor visits is stored in his smart card, and the information can be accessed by a specialized card reader. Billing information goes straight to the government's health insurance office and is paid automatically. If someone visits the doctor for an unusually high number of times over a short period, they get a visit from the Bureau of National Health Insurance. This helps make Taiwan's system one of the most efficient in the world, with only about 2% of funding going to administrative costs in most years, as efficient as the U.S. Medicare system. As is the case in France and Japan, Taiwan's Bureau of National Health Insurance has the sole power to negotiate prices for medical services and medication. This helps keep prices low. Furthermore, this government agency does respond to public demands and today, Taiwan's National Health Insurance covers physical health, mental health, dental care, vision care, prescription drugs, in-hospital care, out-of-hospital care, organ transplants, acupuncture, long-term care, and traditional Chinese medicine. There are no gatekeepers; Taiwanese patients can visit specialists at will, and wait times are practically nonexistent.
Shortly after Taiwan's universal healthcare system entered service in March 1, 1995, some eleven million people who previously had no health insurance suddenly had access to medical care. Demand for doctors and hospitals skyrocketed and the market responded by a flood of new supply. In fact, hospitals and clinics compete vigorously for patients; those in the large cities stay open for twelve hours a day, seven days a week. Doctors in Taiwan must work long hours in order to make up for the low fees. In the end, though, low spending has posed a threat to universal healthcare in Taiwan, as many clinics and hospitals are running the risk of bankruptcy. In order to keep the system afloat, the Bureau of National Health Insurance must provide more funding, one way or the other. From 2002 to 2013 it opted to borrow money from banks, because politicians shrank away from making their constituents pay co-pays or higher premiums. Except for the first three years of operation, Taiwan's system sustained deficits as expenditures increased at a faster rate than revenue growth. A major healthcare reform, Generation 2 National Health Insurance (G2-NHI), unveiled in 2013, was intended to address this issue by introducing supplemental insurance premiums levied on bonuses, rent, interest, dividends, professional fees, and pay from second jobs. This reform has not only covered current expenditures but also eliminated past deficits. Taiwan's system is now in sound financial shape.
Health policy analyst Tsung-Mei Cheng, who helped bring universal healthcare to Taiwan, explained that Taiwan's successful healthcare reform is due to the following reasons. Universal healthcare was supported by a majority of voters and a major political party decided to take advantage of this to counter a rising opposition party that had openly embraced the concept. Sustained economic growth and prosperity meant the reform was financially realistic. Cheng said the lesson for other countries is that they should exploit these windows of opportunity, which come only so often.
Some 85% of Taiwanese are satisfied with their healthcare system and their life expectancy is about 80 years, on par with countries in the Organization for Economic Cooperation and Development (OECD). In 2013, Taiwan spent less then 7% of its GDP on healthcare, below the OECD average of 9.2% in 2012. Unfortunately, Taiwan's ability to share its success story with the world is restricted by the One China policy. For example, representatives from Taiwan are not invited to attend WHO conferences.
Whether the system itself is really as good as claimed or not, Cuba is a major exporter of highly trained medical talent, with Cuban doctors involved in humanitarian efforts around the world.
Cuba's healthcare system is an extreme form of the Beveridge model, with absolute government control.
France's national healthcare system started out as an insurance fund covering low-wage workers employed in certain industries in 1928. It then gradually expanded to cover the entire population, thanks to French egalitarianism. Starting in 1998, all French citizens aged 15 or over have their own carte vitale, literally "vital card," which digitally stores their medical records. Doctor consultations, diagnoses, prescriptions, treatments, warnings, and which insurance funds the patient is subscribed to are all included. Children have their medical records stored in their mothers' cards. Lost cards may be dropped into the nearest mailbox. About 80% of these eventually return to their respective owners. To ensure privacy, these cards are encrypted. When a doctor makes a home visit, he brings his own laptop computer and a portable card reader.
French clinics are characteristically austere, but all carefully list their prices and services for their patients to see. Most people do not have to wait long. Exceptions are those who require the attention of pediatricians, who are few in number. Most doctors are members of labor unions, which negotiate service fees on their behalf. French doctors are not exactly rich, but medical education in France is free. When a consultation is finished, the doctor updates the patients' medical record via the carte vitale. Billing information is automatically transmitted to the appropriate insurance fund(s). Doctors receive their payment within a week or so, as required by law. Patients must pay consultation and treatment fees, or co-pay, upfront, but are reimbursed by their insurance at the end of each month. This is to remind them they are receiving a valuable service. However, there is a cap to how much one must pay in a single day. Exceptions include those living below the poverty line, who are subsidized. The poorest of the poor and those certified to be chronically ill pay nothing at all. Nor do women in their final five months of pregnancy and the first four months after childbirth. In these cases, doctors are paid from the government's social security funds.
Which insurance plans one gets is a function of employment and geographic location. People often stick to their insurance plans for life. Premiums are split between the employer and employee. If a person is currently out of a job, the government pays for the employer's share of the premium. Insurance funds are non-profit entities and are tightly regulated. One does not lose insurance due to loss or change of employment. There are no deductibles. All claims must be reimbursed. Denial of coverage due to pre-existing conditions is forbidden. Although people do not have much choice in choosing their public insurance plans, they have a great deal of freedom when choosing doctors, hospitals, and even procedures. Furthermore, they may choose a private insurance plan for additional coverage.
All these features keep costs low while ensuring quality care. However, French insurance funds are making losses and economic growth cannot keep up with the rising costs of the system. As a result, proposals for reforms emerge every once in a while and doctors go on strike every now and then. Whatever changes made to the system, they will be in accordance with the principles of solidarity and equity.
“”A program of applied Christianity.
|—Bismarck on his social welfare policies.|
The Reichstag passed Bismarck's Sickness Insurance Law in 1883, thereby creating the world's first national healthcare system, one that survived in its basic form till this very day regardless of system of government and in spite of all the socioeconomic and political upheavals befell the Fatherland in the twentieth century. Insurance is mandatory and premiums are split between employers and employees. No new taxes are necessary. (Bismarck hated taxes.) People pay as a fraction of their income through payroll deductions; the more one earns, the more one pays. Benefits cover not just regular medical care, but also dental care, vision care, chiropractics, physical therapy, mental health, nursing homes, health club membership fees, and, if recommended by a doctor, spa trips. Doctors and hospitals are numerous and wait times are short. All insurance funds are private entities and most operate as non-profits. Still, they compete vigorously for customers. All insurance plans must accept all applicants and must pay all claims submitted by a certified doctor or hospital. If a person becomes unemployed, the government covers the employer's share of the premium. There are hundreds of insurance funds to choose from, but the exact number changes over the years. The introduction of a digital health card in 2008 significantly reduced administrative costs. Another cost-saving feature is central database detailing which drugs and treatments are covered by which insurance fund will cover.
Most German citizens and foreign guest workers are covered. But the richest of German households are exempt from mandatory health insurance, as it is believed they do not need help. These can subscribe to a profit-seeking insurance plan and some private hospitals do cater to this segment of the population. This exemption has proven to be controversial. Opponents complain that it violates the principle of solidarity while supporters argue that it offers relief to the basic system, which currently operates on a shoestring budget, forcing the government and the funds to introduce cost-saving measures. For example, starting 2006, patients are required to pay a fee for each quarter of a year, but all services covered by insurance remain free after that. Further reforms limited the treatments and drugs doctors can choose and how much money they can earn. In particular, a policy known as "global budgeting" means that the system stops paying for healthcare after a specific amount has been reached. If medical professionals continue to work, they will not be paid. German doctors are not high-earners, but medical school in Germany is free. Nevertheless, these cost-control measures have led to public protests by doctors and medical students.
During the Meiji Era (1867-1912), Japan sent her best and brightest to Europe and the United States to learn what the Western world had to offer and bring home the best ideas they found. Some returned with the concept of a national health insurance program from Bismarck's Germany. They also invited German doctors and economists to come to Japan to teach the nation how to run such a system. As is the case with the Bismarck model in Germany, Japan's system at its core survives till this day. Universal healthcare is considered a fundamental component of the social safety net. Wait times are generally short or nonexistent, and patients rarely bother to book an appointment beforehand. In fact, the Japanese are some of the the biggest consumers of medical services and products in the world.[note 4]
However, unlike Germany, where the richest are exempt from the requirement of subscribing to an insurance fund, everybody in Japan must do so. This "individual mandate" is believed to be a part of personal responsibility. The thousands of insurance funds in Japan generally fall into three categories, depending on how much the government is involved. The most common funds are set up by large corporations and large government agencies, where premiums are split between the employers and employees. People working for small companies also split their premiums with their employers, but the government subsidizes the fees. Finally, retirees and the self-employed split the premiums with the government. The government also pays the premiums for the unemployed and those who are living in poverty. Also unlike the Germans, the Japanese lack the freedom to choose which insurance plans to opt in—their employers or local governments do that for them—but they do have the power to choose doctors and hospitals, which do compete for patients. Japanese insurers cover both traditional Chinese and modern Western medicine, including dental care and mental health. For cultural reasons, the Japanese prefer medication to surgery. Seemingly glaring omissions are pregnancy and childbirth. These must be paid for out of pocket. Nor do they cover contraceptive pills. This is because pregnancy is considered a natural condition for healthy women. However, women receive a grant from the government whenever they become pregnant, and the money is roughly sufficient to pay for maternity care, delivery, and postnatal care. On the other hand, Caesarean sections are covered by insurance.
Japan has taken a number of steps to keep the costs of its healthcare system low. Every two years, the Ministry of Health and Welfare negotiates prices and fees directly with doctors and hospitals and subsequently publishes a "Fee Schedule" that applies everywhere in the Japanese home islands, from downtown Tokyo to a remote island off the coast of a rural prefecture. Also biennially, the Japanese Medical Association negotiates with the Ministry how much doctors and hospitals get paid by insurers. While doctors and insurance plans are mostly private, the Ministry determines what insurance will pay for, and how much. For this reason, Japan's multi-payer system operates almost like a single-payer system and Japan's healthcare market operates competitively under the iron hands of government oversight. Interestingly, tight regulation has a cascading effect on the costs of medical care. Since doctors can only earn so much, they demand cheaper but still reliable medical equipment, albeit with fewer functionalities. This incentivizes innovation from the industry. Preventive care is prioritized, and annual comprehensive physical examinations are free.
Rigorous price controls come at a cost, though. Many Japanese hospitals and clinics are direly underfunded, as can be seen from their spartan looks. Breaking even is often a daily struggle. However, hospitals operated and maintained by large corporations are generally in good shape, and these are open to everyone, regardless of employers. But their number is small and they cluster around the large cities. Most medical innovations in Japan originate from the few hospitals operated by the nation's medical schools.
There are a number of ways Japanese doctors can earn more money. They can charge unusually high parking fees or install vendor machines for snacks and drinks in their clinics. The normally stingy Fee Schedule pays doctors rather generously for making home visits. Patients present their doctors with gifts, ranging from some material products, such as golf balls or sake, to cash, on a more or less voluntary basis. And there are envelopes designed specifically for this purpose. In the olden days, Japanese doctors were supposed to treat patients without ever demanding payment, in accordance with Confucian principles, and patients tended to offer gifts of gratitude. This tradition persists today, despite being officially frowned upon. One reason for this is the prestige Japanese society attributes to the medical profession.
In all, Japan's healthcare system is exceedingly efficient, offering excellent services at unusually low costs. While other advanced countries, such as France and Germany, have seen their medical spending on a steady upward trajectory over the years, this is less of a problem in Japan. However, given the states of many hospitals and clinics, its long term viability is in doubt.
“”We opposed reform. But in fact, our insurance industry has thrived with it. Of course, we are Swiss. So we are pleased that everyone in Switzerland now has access to the same package of care.
Historically, Switzerland had had many mutual funds, or health insurance plans, from which workers can purchase via employment. Switzerland is in fact home to some of the world's largest insurance firms. In the 1980s, Swiss insurance firms learned that they could make handsome profits by carefully selecting applicants and diligently denying claims. The big insurance firms bought up the old and small mutual funds. Consequently, the Swiss healthcare system became more and more expensive while leaving an increasing number of citizens without coverage. By 1993, some 5% of the Swiss had no insurance. A government task force was established to examine this national problem and to study the healthcare systems of other European countries.
The Beveridge model was quickly dismissed as incompatible with Swiss capitalist values. But the Bismarck model was a much better fit. A new legislative proposal was drafted. The Swiss Federal Law on Compulsory Health Care, known as LAMaL after its French name, which is a pun from the French word for illness, separates health insurance from employment and establishes a basic coverage package. Firms are not allowed to actively seek profits from the basic package; any surpluses made in one year must be used to reduce premiums the following year. All applicants must be accepted and no claims from a certified doctor or hospital may be denied. As the Law's name suggests, it requires all citizens to have an insurance plan. Anyone who fails to do so is automatically assigned to one of the existing plans and premiums are deducted from paychecks. Under this Law, everyone can afford healthcare and the risk pool is wide enough to keep the insurance funds solvent.
Switzerland is a direct democracy and every major policy change must be approved directly by voters. In the end, solidarity, a fundamental principle of Swiss culture, prevailed, and voters approved the new law, albeit with a narrow majority. LAMaL went into effect January 1, 1996. Today, universal health coverage has become a basic part of daily life in Switzerland that few people question it anymore.
Although Swiss insurance firms may not make profits from the basic coverage package mandated by the government, they may do so with additional benefits, namely coverage of things like cosmetic surgery and private hospital rooms. Indeed, the absence of profits from basic coverage has not prevented Swiss insurance firms from vigorously competing for customers with perks such as user-friendliness, or speed of reimbursement. They typically use the non-profit basic package as a loss leader, drawing customers to lines of business from which they may make profits, such as supplemental health insurance, life insurance, or fire insurance. In fact, the insurance industry reports their profits have been higher after the passage of LAMaL.
Switzerland is a big spender on medicine. As a result, the desire for further healthcare reforms persists. In particular, some would like to see a government-run national health insurance plan, like the one introduced in Taiwan. However, attempts to realize this have so far been defeated. A 2007 referendum saw a clear majority of Swiss voters rejecting this proposal.
“”In Britain today, the NHS is the closest thing we have to a religion.
Lord William Beveridge is an aristocratic social reformer who had a good look at "the mystery of poverty" in his youth. In 1942, while working as a senior official in the coalition government of Winston Churchill, Beveridge published a document titled Social Insurance and Allied Services, more popularly known as the Beveridge Report, and it became an immediate success. In it, he laid out his vision for a welfare state, and, in particular, the Beveridge model of universal healthcare, which is the roadmap for the National Health Service (NHS). The key principle behind the Beveridge model is that no one should ever have to pay out of pocket for medical bills, which are to be funded by the government via taxes.[note 5] Under the NHS, there are no insurance premiums, no co-pays, and no deductibles. However, Lord Beveridge lacked the political skills needed to realize his goals. That job fell to Aneurin "Nye" Bevan, a coal miner and union organizer who became a politician. Bevan decided to nationalize all hospitals and to make their medical professionals government employees. But he made a number of concessions. Doctors could still see patients on their own time and charge fees, but, as Bevan correctly predicted, this parallel private system is negligible in size compared to the NHS. General practitioners could still operate private clinics, but would receive payments directly from the NHS. The private insurance industry could still market plans to anyone not interested in using the NHS.
From the day when it first opened, July 5, 1948, till today, the NHS operates on a shoestring budget. Whenever a product or service is readily available at low or no costs, demand for it will be high. In order to alleviate budget issues, treasury officials decided to charge patients a nominal fees on prescription drugs. Children and the elderly (aged 60 or more), pregnant women, and the chronically ill are exempt. Many have to pay for some vision and dental care. However, when the British Medical Association proposed a standard co-pay per doctor visited to be shared between doctors and the NHS, the proposal was flatly rejected by the public. In April 2011, Scotland abolished prescription charges for everyone.
The NHS has taken some steps to keep its operating costs low and is in fact recognized by international experts as one of the most cost-effective healthcare system ever designed. Bureaucracy is minimal, keeping administrative costs low, because there are very few bills and no insurance claims to process. Consultations are limited to about ten minutes. While this may sound draconian, it has been found to be the average amount of time taken by a single doctor visit. General practitioners, or GPs, act as gatekeepers who decide whether or not a patient needs to see a specialist. All patients must register with a GP, who receives a fee from the NHS for each patient registered with her practice. Prevention is prioritized; GP clinics are full of posters informing people what to watch out for and how to take better care of themselves. Furthermore, flu shots are free. The NHS limits the types of medications, tests and treatments it pays for. In other words, care is rationed. The National Institute for Health and Clinical Excellence (NICE) is responsible for deciding what is covered and what is not. NICE often has to make difficult decisions, but maintains strong public support because everyone has a stake in healthcare. The money saved from not treating one person can be used to on another. But perhaps the biggest price-control tool is the dreaded waiting list. A patient must wail weeks to months to see a medical specialist if the patient receives a recommendation from his GP, more specifically a maximum of 18 weeks for non-urgent treatment and four weeks for cancer care.
In order to keep the system afloat, Prime Minister Tony Blair and his successor, Gordon Brown, poured huge sums of money in the NHS. Additional funding made an immediate impact; waiting lists were substantially reduced. The queue for non-emergency care remains long, however. However, the government of David Cameron attempted to introduce privatisation in various guises. This effort is fiercely opposed by the majority of the British populace, and 9 out of 10 doctors oppose the government's "Health and Social Care Bill" that will abolish Primary Care Trusts and place 80% of responsibility for finance on general practitioners, which is expected to lead to the hiring of outside private groups to manage hospital's financial matters. It was also opposed by the British Medical Journal, The Lancet, the British Medical Association, Royal College of Radiologists, Royal College of Paediatrics and Child Health, Royal College of Nursing, Royal College of GPs, the Faculty of Public Health, and the Royal College of Midwives — basically most doctors, specialists and hospital workers. Despite the almost complete opposition from experts, the bill was passed by the Conservatives in 2012.
There is even a Twitter page of real British people expressing support for the NHS. This led to Twitter crashing when millions of Britons turned up to defend the NHS. The NHS supporters included Stephen Hawking, who said, "I wouldn't be here today if it were not for the NHS." This was in response to an especially unresearched article claiming that Hawking, who has suffered from ALS for many years, would have been euthanised under the NHS. Indeed, the NHS is a huge part of modern British popular culture, being featured in films, novels, television series, and of course, the daily news.
Doctors working for the NHS enjoy some important benefits. While they have to pay for malpractice insurance, any doctor who can show he was following NICE guidelines is immune from malpractice lawsuits. They graduate with low or no debts, because medical schools are subsidized.
England suffers from a shortage of general practitioners, about 6,000, according to the Royal College of GPs. Furthermore, access to GPs is highly variable across different parts of the nation. A recent plan by NHS England to reduce the workload of general practitioners and therefore NHS spending is the recruitment of "link workers," whose job is to prescribe physical exercises and art classes to patients who do not need pills and to monitor their progress. Another plan is the recruitment of more than 20,000 physiotherapists, pharmacists, and paramedics to work alongside overburdened GPs.
United States of America
“”Only a crisis—actual or perceived—produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around. That, I believe, is our basic function: to develop alternatives to existing policies, to keep them alive and available until the politically impossible becomes the politically inevitable.
Due to a decision during WWII, health insurance became an untaxed benefit that employers could use as an incentive to get around wage freezes. Immediately after this decision pretty much all companies began offering health insurance, which continued even after the end of the war, and this coincided with an increase in quality and relevance of health insurance. Thus, when Presidents Harry Truman and Dwight D. Eisenhower considered starting up a single-payer system, the strongest opposition came from the labor unions, who considered this a massive threat to their interests. With a single-payer system, the unions would have one fewer incentive for workers to join them. They were successful in killing it, thereby setting it on the course that got it to the present day.
The current American healthcare system is an amalgam of all four basic models listed above. It uses the Beveridge Model for military veterans (Veterans Affairs), the Bismarck model for those with employment-based insurance, the National Health Insurance model for the elderly (Medicare), and the out-of-pocket model for everyone else, or 15% of the population in 2008. Such a system is neither efficient nor cost-effective. At least 18,000 people die unnecessarily every year in the United States simply because they're uninsured. In fact, the main problems are with mortality among younger Americans. Total health spending is 17.6% of GDP compared to a developed country average of 9.6%, and most of it goes to profit margins for private insurance companies. For-profit health care encourages the use of expensive procedures, drugs and medical equipment to treat relatively minor issues while the root of the problem is ignored. In other words, Americans spend far more for worse care ($947 per person on average compared to $487 per person in developed nations overall) while subsidizing healthcare costs for other countries, including those in Europe. More specifically, most of the world's leading pharmaceutical and biomedical engineering companies are American, and most of their research and development are done in the U.S., which is also where most of their profits come from. This makes it easy for the governments of countries with universal healthcare to negotiate costs down. This is not necessarily uncommon knowledge. Shortly before the 2018 midterm elections, President Donald Trump said,
“”We are taking aim at the global freeloading that forces American consumers to subsidize lower prices in foreign countries through higher prices in our country.
In January 2019, Senator Bernie Sanders and like-minded Congressional representatives introduced a legislative proposal to cut prescription drug prices in the United States by (1) encouraging competition between generic drugs and brand-name drugs, (2) allowing Medicare to negotiate prices directly with pharmaceutical companies, and (3) enabling patients to import drugs from Canada, where prices are lower. Prices are deemed "excessive" if they are higher than the median in Canada, the United Kingdom, Germany, France and Japan. They urged President Trump to support the legislation. However, there was no immediate response from the White House.
As previously mentioned, a 2000 World Health Organisation report noted that the USA ranked 37th out of 191 countries for the overall quality of health care available to its citizens. France, Spain, and Italy topped the list, though given the aforementioned subsidies, they probably partly owed their status to the U.S. There is fundamentally no reason why Americans cannot benefit from both world-class and affordable healthcare.
On top of this, Roman Catholics have been buying up American hospitals and sometimes own the only hospital in an area. This leads to them imposing their ethical system. No abortions, no contraception, no sterilization and a ban on many fertility treatments.
The best aspect of the current U.S. healthcare system is cancer treatment, only topped by Japan in providing high-tech screening. However, its effectiveness is held back due to a lack of access.
Patient Protection and Affordable Care Act
On March 23, 2010, the Patient Projection and Affordable Care Act, also known as the Affordable Care Act or Obamacare for short, became law, having both massive support and criticism. A key aspect of this law is the "individual mandate," which requires individuals to have insurance or be fined. This proved unpopular. It also bans insurance companies from denying coverage to those with pre-existing conditions, allows young people to stay on their parents' plans till age 26, and requires business owners with more than 50 employees to offer health insurance. These provisions drew great support. The U.S. Supreme Court upheld most of the law as constitutional in a 5-4 decision in 2012; only the requirement that states expand their Medicaid insurance program for the poor was struck down. However, it is not a true universal health care system. Supporters hoped and critics feared that it would evolve into a true government-run system.
In mid-2016, President Barack Obama wrote an article for the Journal of the American Medical Association (JAMA) urging Congress to do more to curb the rising costs of healthcare. He noted that the lack of competition among regional health insurance plans warrants the "public option," or a government-run insurance policy that competes with existing private insurance. He pointed out that the number of uninsured Americans has dropped from 49 million in 2010 to 29 million in 2015[note 6] and that the rate of growth in healthcare spending has slowed thanks to the ACA. This article draws from a comprehensive review of Obamacare the President requested from his staff in 2015.[note 7] A random survey conducted in 2009 by the Mount Sinai School of Medicine in New York found that 63% of doctors support giving patients a choice between public and private insurance, 10% favor the public option only, and 27% private insurance only. Therefore, almost three quarters of medical practitioners support the public option. Given that American public support for it ranges from 50% to 70%, medical professionals are even more supportive of government-run insurance than the laymen. American doctors already have experience with government-run healthcare, that is, Medicare, and they generally like it.
Healthcare reforms in various states
Various states have attempted to implement healthcare reforms over the years, with an eye towards a single-payer universal healthcare system. Vermont did so in 2011, calling its plan Green Mountain Care, intended to the vanguard for healthcare reforms in the U.S. However, it was not a true single-payer system, because it exempted businesses operating in multiple states, thereby exacerbating, rather than simplifying, administrative complexity. This made the plan financially unsound. Nor was the economy of Vermont particularly strong at the time.
Hawaii attempted in implement a universal healthcare system in 2009, with the legislature overriding the governor's veto. However, this effort faltered when the new governor prioritized the Affordable Care Act. California and New York tried year after year to create their own single-payer systems, but have so far not succeeded. Illinois, Washington, Massachusetts, Ohio, Oregon and Pennsylvania all introduced similar bills, but with similar results.
Medicare Extra for All
In addition to the "public option" suggested by President Obama, another way of going beyond Obamacare was proposed by the Center for American Progress known as Medicare Extra for All. It is the midway between Obamacare and the much more ambitious Medicare-for-All proposal, which would implement a single-payer system. (More below.) Under Medicare Extra for All, all U.S. citizens and legal residents would be eligible for coverage, which includes preventive care, vision care, dental care, hearing care, long-term care, and generic prescription drugs. Low-income individuals would be exempt from co-pays and deductibles. Employers may maintain their own insurance plans and employees may choose between government insurance or what their employers provide. Employer-provided health insurance would largely be tax-free. The government would have the power to negotiate the prices of prescription drugs, and medical equipment. However, how much this plan will cost is not known, though proponents admit that substantial tax increases will be necessary.
Medicare for All
Senator Bernie Sanders considers the lack of affordable healthcare in the United States a moral issue and proposed "Medicare for All" to address it. As its name suggests, this legislation seeks to expand Medicare to cover what it currently does not (completely) cover, including vision and dental care. It even goes above and beyond what some private insurance plans currently cover. While private insurance is presently part of Medicare, that would no longer the case under Medicare for All; nor would there be co-pays and deductibles. Medicare for All is a single-payer universal healthcare system. In order to fund his generous welfare program, Sanders proposed a payroll tax on employers and various new taxes on wealthy Americans and corporations.
Support for Medicare for All appears to be growing. A poll conducted by the Kaiser Family Foundation, a nonpartisan think tank, in March 2018 reveals that a majority of Americans support major reforms to the American healthcare system. Specifically, 59% support Sanders' Medicare-for-all proposal and 75% favor a public option or expansion of Medicare. Another conducted by Reuters in June and July 2018 shows that a vast majority of Americans, 70%, now support single-payer healthcare. However, support or disapproval depends sensitively on the way the question is asked, a poll conducted in January 2019 by the Kaiser Family Foundation reveals. While 71% of Americans agree that healthcare should be a human right, support for Medicare for All drops to 37% if it means higher taxes and 26% if it leads to longer wait times. One sees that political discourse on this proposal remains in its infancy; public opinion is not yet stable. Estimates for the cost of the plan varies from $25 trillion to $35 trillion over a ten year period, according to various independent studies.
Medical service providers are also warming to the idea. Even though their payments may fall in the long-run, administrative costs and the amounts of paperwork will also decrease. What really matters to them is not reimbursement rates but net income. Healthcare spending could drop to Canadian levels. Sanders wants to phase Medicare for All in over a period of four years.
By 2019, Medicare for All has become a major political issue for political leaders in Congress, as well as in state and local governments. Many try to control costs and expand coverage, including for illegal immigrants.
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- A monosopny is a market structure in which there is only one buyer but many sellers. The buyer in this case effectively controls the market.
- Among the entities not counted are the Republic of China (Taiwan) and the Special Administrative Region of Hong Kong, despite having different healthcare systems from mainland China.
- By contrast, the Monarchy received a chilly 39% and bilingualism 36%.
- As one learns in economics class, supply induces its own demand.
- Taxes are relatively high in the U.K., and they contribute to the high cost of living.
- That's a drop from 15% to 9%.
- This is apparently the first article by a sitting President that gets published by a prestigious medical journal.
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