Today, Explained - Where Medicare-for-all is real

Episode Date: February 19, 2020

The Democratic presidential candidates keep having the same argument over Medicare-for-all at the televised debates. To spice up the conversation, Vox’s Dylan Scott takes Sean on a journey to Taiwan to explore how the idea works in practice. (Transcript here.) Learn more about your ad choices. Visit podcastchoices.com/adchoices

Get groceries delivered across the GTA from Real Canadian Superstore with PC Express. Shop online for super prices and super savings. Try it today and get up to $75 in PC Optimum Points. Visit Superstore.ca to get started. All right, so talk to me about Taipei. Do I have to? It's hot. It's bustling for sure. Wait, Dylan, why are we in Taipei again? So, my colleague Bird Pinkerton and I went to Taiwan

for this series of stories on international health systems. I think this is the hospital. And we had this appointment with a college professor, but we needed to kill some time beforehand. And his office just so happened to be right next to the National Taiwan University Hospital

in downtown Taipei. We've got an hour and a half. We see as much as we can. So what did you see when you went inside? It was really crowded inside. Teaming with people. Like there was the opening registration lobby, which was just a big kind of open room, and there were like buzzers pinging all the time. Press a button, take a number.

People getting their numbers called. Like, there seemed to be a lot of patients at this hospital looking to get treated. Taiwanese want their health care. But there was one exception. The one place that seems kind of empty and very slow is the cashier's desk. They did have a cashier's desk. It's basically empty. You could have seen a tumbleweed blowing through.

Why were there no people at the cashier line, Dylan? So Taiwan has a national health insurance plan, one public program that covers everybody. And under that public program that covers everybody, when people go to the doctor or people go to the hospital, they have to pay either nothing at all or very little of their own money to get the medical care that they need. So you're not going to see people, you know, standing at the cashier's desk, haggling with some poor hospital assistant trying to figure out what they pay, because Taiwan has come up with this system where everybody's covered and the actual cost of medical care at the point of service is very low.

Dylan Scott reports on health care at Vox, and he's been working on a series called Everybody Covered. It's a look at what the United States can learn from other countries' health care systems. You will surely be hearing more about Medicare for All from the Democratic candidates at tonight's debate. But today on the show, we're going to take you to two other countries to find out how their universal coverage works. Taiwan's fully public system and the Netherlands' fully private system. We're going to start with Taiwan. If you're a Taiwanese citizen or if you live in Taiwan, you get a health insurance card from the government and it covers your benefits for almost all of the medical needs that you would have. You know, going to the primary care doctor, seeing specialists, going to the hospitals, medications and prescriptions.

It's really only certain things like cosmetic surgery or more elective things that aren't covered by the National Health Insurance Plan. Everything that you would really think of as medical care that you would need is covered by this single government plan. Everything that you would really think of as medical care that you would need is covered by this single government plan. Okay, but Dylan, whenever you see the democratic debates, all the candidates are going back and forth about how you're going to pay for Medicare for all this multi trillion dollar hole 3.4 trillion a year, it turns out costs are going to go up. I don't know, my parents always told me that nothing in life is free. How much are the Taiwanese people paying for this privilege of this fully funded healthcare system? So like, compared to what we have this, you know, Frankenstein system we have in the US, what Taiwan's doing is actually quite cheap and more

efficient. And so Taiwan spends about 6% of their GDP on healthcare and the United States spends over 17 percent. And should I assume that like everyone in Taiwan loves this system? It is really popular, at least according to the surveys that some government officials showed us while we were there. Once people got insurance and once they started using their benefits, its popularity rapidly increased and it stayed high over time. These days, it hovers somewhere around 80%. And I think that's a number that sticks out even compared to sort of other developed economies

and certainly compared to the United States. But you did say that hospital was really busy, the one you went to, right? Are they all like that or was it just the one? The big hospitals, they're always crowded. We actually talked to a researcher named Xuxia Chang, who has studied this, and he told us that there's so many people waiting, want to see the doctor. That's the situation in Taiwan. It's a big problem for Taiwanese healthcare everywhere, that patients use a lot of healthcare,

and that tends to mean that hospitals are crowded and doctors feel overworked. My Canadian family says the same thing about their system. Oh, it takes forever to get something done. There's such a wait. There's such a wait. Right. And this is sort of, you know, if you think about healthcare from an economic point of view, this is one of the concerns. Like, if you give everybody insurance, if you tell them you don't really have to pay any money when you go to the hospital or go to the doctor, then they're going to go to the hospital and go to the doctor. And then it becomes harder for the providers, the people on the supply side, to meet that demand.

If the patients are too satisfied and the doctors are very unsatisfied, they're unhappy, how can you expect the system to be sustainable? And so what we've heard from Xuxial Chang and from others is that, like, that is one of the fundamental problems that the Taiwanese system has always struggled with, is how to make sure that there are enough doctors, enough hospitals available to treat everybody who needs it. We actually met with two doctors in a coffee shop in Taipei, and they were members of this medical labor union that was formed a little less than a decade ago,

I think in response to some of these concerns in the medical profession about how national health insurance was affecting their quality of work. My name is Max. I'm Dr. Jin. One of them was named Max, and he was dressed in this, like, dapper newsboy cap. And he told us that, like, he thought of himself as a political lefty, but he was also, like, clearly overwhelmed as a doctor working in the National Health Insurance Program. So Max actually works in an emergency room, and he would tell us that people would just come in

all the time for every little thing. Some people abuse the emergency, abuse the health care. Taipei, you know, very densely packed urban city. You know, there's a lot of herds of scooters and people just zooming down the street. And so you can imagine at a like major trauma center in a city like that, like you're dealing with accidents and broken bones

and all kinds of sort of serious medical trauma all the time. And yet at the same time, because patients had so little sort of incentive to like be thoughtful about how they use healthcare, somebody would also just like walk into the emergency room because, like, my wrist hurts or something that's not necessarily actually that serious. But under the Taiwanese system, it doesn't really make that difference to that patient, whether they go to the ER or whether they go to their primary care doctor.

How could we differentiate really medical need or just some people want? So it's hard to determine what kind of medical care people actually need versus what they... Yeah, yeah. You read my heart. One really vivid picture that Max painted for us was he told us... In Taiwan, the doctor in hell and the patient in heaven. In Taiwan, the patients are in heaven and the doctors are in hell. And that was how he saw it as a doctor practicing in Taiwan. And, you know, every health system comes with tradeoffs,

and I think that speaks to the ones that Taiwan has settled on. We want it to be really easy for the patients, but that means we're going to put a strain on our providers too. Okay, so while the system is immensely popular, it's imperfect, really easy for the patients, but that means we're going to put a strain on our providers too. Okay, so while the system is immensely popular, it's imperfect, are there any alternatives? There are. There are countries like the Netherlands that instead of having public insurance for everybody, they've got private insurance for everybody. Can we go there too? Let's.

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Today. Today Explained. It's Today Explained. So Dylan Scott, healthcare reporter here at Vox, champion of the Everybody Covered series. Here we are standing in the Netherlands. Look at that. Some people are biking by.

Oh, oh, and a canal. Look, a rowboat going through the canal. Shall we go eat some frites? We can, I guess. You know, I have to say that the only thing I was disappointed in in my trip to the Netherlands was the food. But did you notice the healthcare they've got over there?

So yes, the Dutch have a universal health care system that in some ways is the polar opposite of the system in Taiwan. So instead of universal public health insurance where everybody gets an insurance plan from the government, which is what the Taiwanese have, the Netherlands has private health insurance for everybody. So everybody gets coverage, but you buy it from a private health insurer instead of the government. Explain to the folks at home and me, because I don't know, how a fully private but fully funded universal health care works. So. I might get into the details. I hope you don't mind. The Dutch system actually shares some important characteristics with Obamacare that

a lot of people are probably familiar with. You've heard a lot about it since I signed it in the law. So they have bans on pre-existing conditions. We're not going to go back to a time when people's coverage was dropped when they got sick. They have an individual mandate. so if you don't sign up for insurance they'll fine you twice and then they'll just automatically enroll you in an insurance plan and start garnishing your wages to pay for it. Thanks Obama. And they have a lot of government assistance. So you could shop for a plan that fits your needs and then we would give you tax credits to help you buy it. Like the government provides a lot of funding to help keep premiums affordable for people.

That means it's less than your cell phone bill, because I know you guys are tweeting a lot. And texting and selfies. Now the Dutch system goes beyond Obamacare in a couple of important ways. So let's start with a basic fact. The majority of Americans do not, let me repeat, do not get health care through the Affordable Care Act. This is like Obamacare for everybody, not just for, you know, the 10 million or so people who buy insurance on the individual market here in the United States. Everybody in the Netherlands gets their health insurance through this private market. And the government

plays a much more active role than even the U.S. does through Obamacare. So in Taiwan, you had the system where everyone goes to the ER because they don't have to pay for it. Do people in the Netherlands not go to the ER because they have to pay for it? Yes. So the Dutch have actually tried to design their system so that people are a little more rational about how they use their healthcare. So for Dutch patients, if you go see your primary care doctor, it's free. You don't have to pay anything. You just show up, you walk out without a bill. But if you go to the emergency room, you have to pay towards your annual deductible, which is capped at about 385 euros a year.

Something like 420 US dollars. That's 420, Dylan. Basically, if you're somebody who's like sitting there, you've got something that feels kind of wrong, but you're not sure. You have a choice between either going to the ER, which will cost you like 400 bucks, or you could go to your GP and you can get treated for free. But does that mean that people who like accidentally chop off their left forearm are like going to their GP to be like, help? I can't answer that hypothetical, vivid though it is, specifically. But I will say doctors in the Netherlands are more likely to say that their patients have a higher cost burden.

Like it's harder for them to afford their medications or pay for medical care if they do need to pay for it than people in other countries. How long have they had this system? So they overhauled their system in 2006. Have they figured out any ways to sort of work out the kinks in it? Maybe people avoiding going to the ER, people overburdening their GPs. Yes. So one place where this all kind of comes to a head is like, what if somebody needs medical care outside of normal business hours? What do they do?

I think in the United States, a lot of people are just like, well, I'm going to go to the ER. But like the Dutch are trying to avoid that. So what Dutch doctors have done is set up these cooperatives where a bunch of Dutch primary care doctors will team up basically. And they'll pool all their patients together, and they'll give them a number and say like, if you have a problem after hours, you can call this number and there will be a doctor who can handle your question over the phone. And you know, if you're like chronically ill or you have like a disability or you're elderly, it's hard for you to get out of the house. They'll even have a doctor who's out in an SUV

roaming around the countryside ready to make home visits for patients who need it. Tell me you went for a ride in that Dutch SUV, Dylan. Oh, yeah. We were out on the road for like four hours. So this doctor, Elise, it was her job that night to go out on home visits. So she and her driver, Henry, checked to make sure they had everything they needed. And then they hopped in and me and our photographer for the Dutch story got in the back and we were off.

And so the first place that we stopped, I think, is a nice example of how this after-hours care program is really supposed to work. We were going to see this guy who had called because he was feeling a lot of pain. And we parked kind of down an alley a little bit, like away from the main road, along this block of row houses. Elise got out to see this patient, this older man who was experiencing a lot of pain.

But after she did her exam, her checks on him, she was like, you know, this really isn't serious enough for you to go to the emergency room. So she told him that there were some diagnostic tests that he should get done and that he should call his regular primary care doctor, one of Elise's colleagues in the co-op, the next day. And so, like, this guy who'd been in pain had, like, gotten to see a doctor. He'd gotten some fresh medical advice and, like, a writ to follow up with his regular doctor the next day. But he didn't have to leave his house.

He didn't have to drag himself to the emergency room. And the care that he got provided was free to him. So this co-op idea, for me, was sort of a perfect example of the Dutch way of thinking about healthcare. Well, how do the people like this system? It's still relatively new. So I think on the whole,

like the Dutch are proud of their system. It was abundantly clear from all the people that I was visiting with that they're really proud of how they've managed to organize a healthcare system that often kind of depends on individuals or private actors. But that, you know, having a health system built on those foundations is also going to come with some downsides. Okay, so we've heard about two systems. We heard that they both have flaws and they're both well-liked by some of the citizens who use them. What do you

think works best? I mean, at the end of the day, you're just like, you know, that American system is actually looking pretty good right now. So that would never be my conclusion. The American system did not look better in any respect. But the way I think of it is more every system is going to have its trade-offs. So in Taiwan, it's really easy for the patient for the most part, right? Like costs are really low. You can go to the doctor for free. But the trade-off for that is that the doctors feel really overwhelmed and stressed. And the Netherlands, on the other hand, like they've done a pretty good job of managing how people use healthcare and like imposing this cost sharing to try to encourage

people to be more rational about how they use their healthcare. But that makes it harder on the patients because if you make the mistake of going to the ER when you shouldn't, suddenly you're out 400 bucks when if you had gone to your GP, it would have been free. And so I think it's up to every country to try to decide which of those kinds of trade-offs are more acceptable to us. What distinguishes the United States is we have not reached sort of the collective understanding that both Taiwan and the Netherlands have, that everybody should have healthcare in the first place. And so I think that's where we fall short. But once you've decided to build a universal health system,

it's about figuring out which of those trade-offs are more acceptable based on what patients want, what doctors want, and balancing the interests of the two. Well, maybe we'll get there one day, Dylan. Yeah, maybe. Dylan Scott, he's a reporter at Vox who covers healthcare. You can find his Everybody Covered series at Vox.com. He and producer Bird Pinkerton also made a version of this story for the Impact podcast.

You can find that wherever you're listening to this. I'm Sean Ramos-Firm. It's Today Explained.