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Universal Healthcare and Taxation in the Era of COVID-19

Posted on Dec. 21, 2020

Not long ago, Germany was widely criticized for having hospitals and hospital beds that exceeded demand. The excess capacity wasn’t bad, per se, but the country was having trouble keeping its hospitals fully staffed and stocked. Some experts said the system needed drastic measures to survive, like shutting down at least 60 percent of the hospitals and aggressively consolidating the rest.

Then the COVID-19 pandemic hit. Suddenly, Germany’s hospital beds weren’t excessive. Suddenly, Germany was well poised to handle the onslaught of COVID-19 testing and critical care needed. As its neighbors struggled to adopt widespread testing while running out of hospital beds, Germany had the capacity to conduct upwards of 100,000 COVID-19 tests per day. Germany’s hospitals never ran out of capacity. The country’s COVID-19 response and relatively low death rate during the first wave of the pandemic became a global example.

Several factors play into Germany’s relative success story while so many other countries struggle with their COVID-19 response. Germany was one of the first European nations to implement a strict lockdown. It continues to pay reduced wages to people out of work to facilitate sheltering at home. Germany’s journey hasn’t been perfect — the country is now straining under the weight of a second wave. But a key factor has been Germany’s free universal healthcare system. Its room for excess capacity has been an undeniable factor helping Germany in the first wave of the pandemic.

Time to Reassess

At a time when 90 percent of countries have experienced disruptions in their essential health services because of COVID-19, reassessing healthcare system preparedness is key. Not just for this pandemic, but for other unexpected shocks that may come in the future, according to Laurence Roope, an economist at the University of Oxford and senior researcher at Oxford’s Nuffield Department of Population Health.

“I think what we’ve tended to do in the U.K. and in many health systems, generally, is that we’ve sort of been running things at or beyond full capacity for many years, and there hasn’t been enough resilience in the system,” Roope told Tax Notes.

While responses to the COVID-19 pandemic in various countries have depended on many factors outside healthcare, one consistent development is that it is causing government officials and healthcare experts to reassess the adequacy of their systems. Healthcare design and funding is a deeply complex, and at times political, issue that is evolving around the world, and the COVID-19 pandemic has laid bare existing structural issues that experts say can no longer be ignored.

In some countries, like the United Kingdom and Ireland, the pandemic is accelerating discussions that were already underway but approaching an impasse. In other countries, like the Philippines, the pandemic is offering a rare stress test just as the country launches its universal healthcare system. In the United States, the pandemic is shining a bright light on the country’s inability to deal with a widespread emergency and on taxpayers’ struggle to pay for medical care and emergencies in a system that lacks universal healthcare.

United States

At the time of this writing, COVID-19 has cost at least 300,000 lives in the United States. This is the most of any country by a wide margin. The runner-up, Brazil, is trailing by roughly 100,000 deaths. For Reginald Williams of the Commonwealth Fund, the U.S. experience highlights the uniquely disjointed nature of healthcare in the world’s wealthiest country. Williams, who is vice president of international health policy and practice innovations at the healthcare foundation, has spent his career analyzing health systems around the world and says the United States is at a baseline disadvantage because unlike its peers, healthcare is tied to employment or income. As such, Americans face a dual burden of access and affordability compared to their European counterparts that have universal healthcare. Annually, Americans spend more than $10,000 per person on healthcare, while people in the United Kingdom, France, and Germany spend roughly $4,000 to $6,000, according to Commonwealth’s research.

This means that Americans are more likely to go without healthcare. Pre-COVID-19, roughly one-third skipped things like doctor visits, tests, and prescription drugs, according to the Commonwealth Fund. Williams says the pandemic has exacerbated this.

“Data from our research shows that U.S. adults compared to people in other high-income countries face greater financial consequences from the COVID-19 pandemic, and it is something that is a driving factor in their decision-making ability to address their daily needs as well as their healthcare needs,” Williams told Tax Notes.

In April the foundation conducted a survey and found that nearly two-thirds of respondents said out-of-pocket healthcare costs would be either very important or somewhat important in their decision to get medical care if they developed coronavirus symptoms.

About 29.6 million Americans (9 percent) were uninsured in 2019, a number that has increased for three years in a row, according to the U.S. Census Bureau. The 2020 figures are likely to be higher because this year U.S. unemployment reached its highest levels since the Great Depression. Compared with other countries, the number of uninsured in the United States is particularly high. For example, Canada, which offers a universal healthcare system, has about 200,000 to 500,000 uninsured, according to researchers at Canada’s Wellesley Institute. Although the United States lacks universal healthcare, the government pays for most of the country’s healthcare spending, according to some researchers.

In 2013 the U.S. government paid for 64.3 percent of national health expenditures, and that number is expected to hit 67.1 percent in 2024, according to medical researchers David Himmelstein and Steffie Woolhandler. It’s nearly as high as Canada’s 70 percent healthcare spending figure. In a 2016 paper, “The Current and Projected Taxpayer Shares of US Health Costs,” Himmelstein and Woolhandler found that the totality of the government’s healthcare funding is partially obscured by its fragmentation into funding streams for the poor, elderly, public sector workers, family planning, and other categories.

Visible or not, Republican and Democratic lawmakers alike agree that healthcare reform is needed. In October the Congressional Budget Office looked at four different ways the United States can attain about 99 percent coverage for U.S. citizens and legal residents. All four would provide default coverage to varying degrees, and the options provide different mixes of full or partial subsidies.

Broad-based tax revenues would fund these plans either fully or in part. Some plans, however, would levy premium-equivalent taxes on middle and higher-income individuals receiving default coverage. But taxing those default recipients would be challenging, to say the least, and would potentially impose financial strains, according to the CBO.

So far, the most ambitious or transformative plans have come from several Democratic lawmakers calling for a single-payer system: Medicare for All.

But President-elect Joe Biden is not a Medicare for All supporter. He plans to pick up where the Obama administration left off by expanding the Affordable Care Act — which extended healthcare coverage by expanding Medicaid, allowing individuals and families to buy potentially subsidized health coverage through marketplaces — and expanding small business coverage.

While the ACA expanded universal coverage, there is still room to grow, as those ineligible for Medicaid and subsidized healthcare have essentially fallen through the cracks. Biden wants to provide a new public option, increase subsidies, and expand Medicaid coverage. But a looming question is how this expansion will be funded.

Congress enacted a suite of general revenue raisers alongside the ACA — tax increases on the wealthy, new excise taxes, and health coverage penalty taxes. A portion of that revenue helps pay for the ACA. Ten years later, some of these revenue raisers have remained, and some have been whittled away by lawmakers. Over the past few years, lawmakers fully repealed the individual mandate and the “Cadillac” tax — the former a penalty tax on individuals with insufficient health coverage and the latter a 40 percent excise tax on expensive health plans. Lawmakers also rolled back a 2.3 percent excise tax on medical devices. And a tax on health insurance providers is scheduled to end in 2021.

Could some of those taxes come back? Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities, does not expect that the Biden administration will resurrect the medical device tax.

“It was clear the industry has done a heavy lobbying campaign, and that tax is not likely to come back,” Van de Water told Tax Notes. As for the Cadillac tax, he pointed out that the underlying issue the tax sought to correct — excessive-cost health plans — is a huge challenge that still hasn’t been solved and is still being discussed by experts.

But ACA-related taxes on high-income taxpayers remain, and they have been the most lucrative provisions: an extra 0.9 percent Medicare tax on earnings and a 3.8 percent tax on net investment income. They apply to individuals earning more than $200,000 annually and couples earning more than $250,000. The NII tax brought in $31 billion and the Medicare tax brought in $10 billion in 2019, according to the Urban-Brookings Tax Policy Center.

The Biden team is generally eyeing tax hikes on the rich and on corporations. Biden wants to increase the corporate tax rate from 21 percent to 28 percent and bring the top individual income tax rate on individuals earning $400,000 or more back up to 39.6 percent. The TCJA lowered the latter to 37 percent.

Biden also wants to eliminate the carried interest loophole so that taxpayers earning at least $1 million would pay the same tax rates on their investment income as applies to wages instead of applying the 20 percent long-term capital gains rate.

Beyond that, Biden is thinking about doubling the global intangible low-taxed income tax rate from 10.5 percent to 21 percent. He also wants to eliminate the step-up in basis rule that increases the value of an inherited asset to its fair market value at the time of the decedent’s death, thereby removing capital gains liability for the recipient.

But Van de Water believes that confronting and improving the IRS enforcement gap is an important part of the conversation. The nation’s tax gap is tremendously high and has soared in recent years because of underfunding at the IRS. Recent research from Lawrence H. Summers, Natasha Sarin, and Charles O. Rossotti, economists at Harvard University and the University of Pennsylvania, respectively, estimates the federal government will lose $600 billion this year in unpaid taxes.

“A lot of the budget pressures in recent years have been reflected in efforts to cut down on annual appropriations — so-called discretionary spending. Including, particularly, the IRS. And the enforcement budget has been cut down, audits have gone down, and estimates of the so-called tax gap are extremely high,” Van de Water said.

“Beefing up the IRS enforcement budget to get people to pay taxes which they already owe, rather than having to actually raise taxes on people to pay what they’re supposed to . . . that would be an attractive approach,” Van de Water said.

Strengthening the healthcare system will have ripple effects beyond pure health outcomes, experts told Tax Notes. Garrett Watson, senior policy analyst at the Tax Foundation, pointed out that there’s renewed interest in onshoring or strengthening U.S. manufacturing of personal protective equipment and other equipment that directly affects healthcare in the United States, and providing tax incentives to do so.

Senator Lindsey Graham [R-S.C.] and Senator Tim Scott [R-S.C.] and Republicans are interested in bills to this effect, and President-elect Biden has also expressed interest in finding ways to incentivize firms and critical supply chains, including personal protective equipment, to come back to the U.S.,” Watson noted. “I imagine that will be another area of interest moving into next year.”

Strengthening the healthcare sector could also generate broader economic recovery, Williams said. “Expanding coverage during the Great Recession, and the time in which the Affordable Care Act came to fruition actually provided some kind of economic stimulus. So the idea of health insurance coverage being critical to economic recovery has already been demonstrated,” he said.

Williams pointed to data indicating the ACA partially acted as an economic stimulus that helped free up public and private resources for investments in jobs and production capacity.

“We saw the U.S. economy gain about 14 million private sector jobs in the five years after,” Williams said. “So you can see the potential for there to be aid to economic recovery by focusing on getting people the healthcare coverage they need.”

United Kingdom

Meanwhile, a different sort of debate is playing out in the United Kingdom. The country is trying to figure out how to raise more money for its chronically underfunded and understaffed National Health Service. At the end of November, the United Kingdom said it would pour an emergency £3 billion into part of the NHS, which offers free universal healthcare. But it may not be enough with the service already struggling to serve the demands of a rising and aging population; and this was before COVID-19 hit.

The NHS, established in 1948, is the one of the world’s oldest universal healthcare systems. In the post-World War II era, lawmakers were eager to implement deep social reforms. But they also saw an opportunity to reshape U.K. society and provide a basic level of social support so that no one would be left behind in the area of healthcare. Today this means all residents in U.K. countries — England, Scotland, Northern Ireland, and Wales — are entitled to free healthcare. Each country operates its own NHS and has its own block of funding. Undocumented immigrants can get free treatment at the emergency room.

The NHS is funded about 80 percent through general taxation. The other 20 percent comes from National Insurance, which is a payroll tax split by employers and employees. There’s also a private system that relieves some strain on the NHS; people who want faster healthcare or to choose their own specialists can purchase private insurance. About 11 percent of U.K. residents have selected this option.

At its launch the NHS was revolutionary. No other western society provided free healthcare to everyone, irrespective of ability to pay. One of its enduring hallmarks is its somewhat malleable nature. As the times have changed, so has the NHS. Over its 72-year history the service has been reformed and reshaped numerous times, from funding reforms, to a consolidation of primary care providers, to the creation of an internal market and reforms addressing inequality and care for the elderly.

Future of the NHS England

The NHS is now sitting at an important crossroads, particularly the NHS England. The government keeps infusing it with cash. Over the past few years, NHS England funding has risen by tens of billions of pounds. But there’s almost always a budgetary shortfall that translates to longer wait times, more scrutiny of NHS finances, and government-mandated cost cutting. The question right now is will the NHS England continue to provide quality, timely healthcare? What will it look like in the future?

Over the years, it has become apparent that the level of funding isn’t enough. Annual NHS England deficits have exceeded £500 million over the past few years, and some healthcare researchers estimate that deficits are even higher when cost-cutting and cash infusions are taken out of the equation. According to research from the Nuffield Trust, the true underlying deficit was £4.3 billion in 2015-2016 and £3.7 billion one year later. The government’s answer in 2015 was to create a one-time £1.8 billion sustainability fund. But the government again had to push another £1.8 billion into the system in 2019.

Meanwhile, strict cost-cutting has been the name of the game. This has translated into a higher reliance on generic drugs, cutting administration costs where feasible, and putting a freeze on pay increases.

Pre-pandemic, inpatient admissions grew 7 percent between 2009-2010 and 2016-2017. They are expected to grow substantially over the next decade as the country gets older. Estimates forecast that the country’s population age 85 and over will grow 67 percent, while younger people, age 15-64, are expected to grow a paltry 1.5 percent, according to a joint 2018 report from The Health Foundation, Institute for Fiscal Studies, The King’s Fund, and the Nuffield Trust.

The ripple effects of the COVID-19 pandemic are worrisome. Because of COVID-19, treatment of new cancer patients is down by 20 percent, and about 300,000 fewer people visited a cancer specialist between April and September compared to the same period in 2019, according to the BBC.

The BBC also reported that the number of NHS patients waiting more than a year for hospital care jumped nearly a hundredfold — from 1,600 in February to 140,000 in September. Ideally, waits should not exceed 4.5 months.

“There’s a certain amount of value in having access to a public good — like healthcare — even when there’s uncertainty about whether or not you’re going to use it,” Roope said. “I think one of the big lessons from COVID is that while there might be a certain degree of efficiency in the short term by just having the capacity that you need and no more, it is a short-sighted strategy. The fatal weakness is that it can leave health systems highly constrained when dealing with unexpected, but ultimately inevitable, shocks,” he said.

Despite these issues, the NHS consistently ranks among the world’s best healthcare systems. But there is wide acknowledgement that there is room to improve, and some changes have already begun. The government is planning to build 40 new hospitals and is pledging an extra £1.8 billion on capital spending projects, including infrastructure projects and hospital upgrades.

Some added relief is also on the way. Days before the United Kingdom went on lockdown in March, new NHS funding legislation giving the service an extra £33.9 billion per year for the next five years received royal assent. The law will give the NHS the largest cash settlement ever, according to Health and Social Care Secretary Matt Hancock.

Yet the extra funding does not cover NHS budget gaps. The Health Foundation and Institute for Fiscal Studies have found that NHS funding will need to increase by at least 3.3 percent annually through 2033-2034 to maintain its level of service. If the United Kingdom wants to improve and expand services and investments in areas like general practice, cancer, and mental health, funding will need to hit an extra 4 percent annually. The NHS funding bill comes close — the government said the budget will grow 3.4 percent on average — but still falls short, especially because the amount is not adjusted for inflation.

But talk is cheap, and solutions are expensive and potentially unwieldy. The largest question is whether there is room for a tax increase. Compared with countries like France and Germany, the United Kingdom raises less of its national income in tax, suggesting there’s room for tax increases. Certainly, there’s room to stop tax cuts. In November 2019 Prime Minister Boris Johnson froze the country’s planned corporate tax cut that would have gone into effect in April 2020. The money is to be used on services, including the NHS.

Several recent polls suggest U.K. residents are fine with tax increases to fund the NHS. One poll commissioned by the Health Foundation found that 79 percent of respondents felt the NHS is underfunded, and a majority thought funding increases should come through taxation. But there are some major caveats.

The Health Foundation said it’s unclear whether taxpayers would support the level of tax increases needed. Also, there is no clearly favored kind of tax increase. Twenty-four percent said a hike on income taxes would work; 22 percent said a new, earmarked tax for NHS funding would be best; and 16 percent preferred an increase in National Insurance. Importantly, those polls were conducted before the COVID-19 pandemic. Tax increases in this weakened economic environment are likely to be challenging.

The reality is that NHS funding through shifting around the U.K. budget and cutting spending on other services likely won’t be sufficient to meet future demand. There’s been debate over the past few years as to whether an NHS-earmarked tax — a hypothecated tax — could work. But critics say it could make the system more complex and that tying NHS funding to a specific tax could cause underfunding in the event of a recession — a concern playing out in countries that use this kind of funding, like the Philippines.

Excise taxation — specifically an increase on alcohol duties — is another option. While excise taxes are generally seen as regressive, a February study on whether alcohol duties should be used to fund the NHS found the opposite. The Institute of Alcohol Studies found that the lowest-income U.K. households would benefit on net because the benefits of expanded health spending would outweigh the costs of increased alcohol prices.

Overall, the Health Foundation believes the only way to satisfactorily fund the NHS is by raising taxes when the economy starts to rebound, although the organization acknowledges it won’t be an easy decision.

“The timing of tax decisions will depend on the recovery of the economy, but without raising taxes, there is a risk of permanent underfunding. This would leave services destined only to respond to acute needs, unable to prevent ill-health or enable healthier lives,” the Health Foundation said in an overview of this year’s spending review.

“Without [raising taxes], the NHS cannot address waiting times, deliver the ambitions in the long-term plan or innovate to accelerate productivity,” the organization added.

In the meantime, HM Treasury is considering tax increases, according to The Guardian, which obtained a leaked Treasury document laying out some options to shrink the U.K. budget deficit. Politically, this will be difficult for the Conservative government, which vowed not to raise income taxes, VAT, or National Insurance. But increasing the income tax rate 1 percentage point to 21 percent would generate £5 billion annually, according to The Guardian. Another alternative is austerity. For example, freezing public sector pay for two years could free up some £6.5 billion for the economy, according to the report.

There’s also a flashier and highly controversial option: wealth taxation. Wealth taxes are generally considered a long shot, particularly across Europe, which has seen governments experiment with them and then abandon them over the past few decades. But COVID-19 has brought wealth taxation back into public debate. A couple of former government officials, including former Shadow Chancellor John McDonnell and Sir Gus O’Donnell, a longtime cabinet secretary under three prime ministers, think the Johnson government should seriously consider a wealth tax. An oft-cited YouGov poll conducted this summer found that 61 percent of respondents would support an annual wealth tax on U.K. taxpayers with more than £750,000 in assets, not including the value of their main home and their pensions.

The debate became more serious this spring when a group of economists from the London School of Economics and the University of Warwick formed an independent wealth tax commission to evaluate U.K. options.

They estimate the country could raise £260 billion over the next five years if it taxes individual wealth over £500,000 at a 1 percent rate. If the country taxes wealth over £2 million it would raise £80 billion, according to a final report released December 9.

But healthcare funding transcends traditional healthcare, Roope noted. It’s also important for the future of biomedical sciences and research and fighting future pandemics, Roope said. “I think another lessons from the pandemic is that we need a greater appreciation of the value of biomedical research infrastructure,” he said. “This too can help build resilience.”

Roope pointed to Oxford as an example.

“The university assumed a central role in developing a COVID-19 vaccine, but some of that work began without any dedicated COVID-19 project funding,” Roope said.

“The relatively flexible nature of research infrastructure funding meant that research groups were able to rapidly divert resources from existing projects to address the crisis. Subsequently, many received significant funds from other sources, but without the initial infrastructure support critical time would have been lost,” he added.

Roope and other researchers are conducting a study across 13 different countries analyzing the willingness of the general public to pay taxes to bolster health systems to help deal with future pandemics.

Ireland

Irish health economist Brian Turner is skeptical that Ireland will be able to implement its long-awaited universal healthcare system — Sláintecare — without increasing taxes.

Universal healthcare in Ireland is a delicate subject. Ireland is the only EU member that lacks universal health coverage, but the government plan is underway. Four years ago, a coalition of lawmakers decided to implement universal healthcare after years of austerity caused an increase in healthcare costs and waiting times within the country’s public healthcare system. That public health system provides free care to low-income residents, and reduced cost care to others.

Sláintecare will create a new, single-tier health system by 2029. But the project has progressed in fits and starts, due to delayed funding, which will mostly come from general taxation. Earmarked taxes are also an option. However, an important breakthrough arrived in October: The government announced that it would fund an extra €4 billion for general health spending, some of which will go toward Sláintecare projects.

Turner, who has testified before Irish officials on Sláintecare, says that €4 billion is a promising start and will front-load a lot of Sláintecare investment. The money will be used for things like mental health services, new drugs, and COVID-19 related support for healthcare workers and the public. Importantly, that money will also boost Ireland’s dwindling hospital bed capacity by 2,600 units. Hospital bed capacity is an issue that predates COVID-19 — Ireland’s number of beds has decreased by one third since 1980 although the population has increased by about a third, Turner said.

“The additional spending on beds is going to fast track that element of Sláintecare which will probably pay dividends in the longer term,” Turner told Tax Notes. He noted, however, that the extra beds will only be sufficient if the government is able to implement its other Sláintecare reforms and reorient the public system away from hospitals and toward primary care.

In this vein, Turner says the country needs to have a real discussion about where funding may come from.

“I don’t think that conversation has been had to a great extent,” said Turner, a lecturer at University College Cork in Ireland. “In addition to Sláintecare and the health crisis, we also have a housing crisis and other infrastructure needs, so we’re going to have to find extra money. We won’t be able to simply shift from other areas of expenditure. I think we’re going to have to increase taxes.”

Turner suspects the easiest increase would be an income tax increase. He is skeptical of wealth tax proposals, telling Tax Notes he hasn’t seen a credible argument for a wealth tax that wouldn’t influence the wealthy to shift their tax base away.

Right now, the country’s ruling political parties seem ideologically opposed to tax increases, but the country is fortunate that it can avoid them for now because it can borrow at historically low levels, Turner said. But that can only last for so long.

Sláintecare is expected to cost an extra €2.8 billion in health spending per annum by the end of the plan, over and above the increases arising from medical inflation and demographic pressures, Turner said. Meanwhile, the government’s Sláintecare report anticipates that offsets from private health spending — out of pocket payments and private health insurance — will actually decrease by almost €1.5 billion if Sláintecare is fully implemented, Turner said. “Fewer people will buy private health insurance, and that kind of offsetting effect hasn’t really been talked about to any great extent,” he said.

“I think people wouldn’t mind paying a little bit more in taxation to fund Sláintecare if they were aware the idea is you will have to pay less out of pocket. And I think that’s a conversation the government will need to have with people sooner or later, but COVID has thrown everything into chaos.”

Turner is not alone in his general assessment. The chair of Ireland’s budget watchdog, the Irish Fiscal Advisory Council, is convinced the country will have to reassess its tax system in light of the COVID-19 crisis, according to national broadcaster RTÉ.

Philippines

It took the Philippines eight years to develop a universal healthcare regime, and just a few months for it to strain under pressure. The large question moving forward is whether the country will be able to fortify the system, which has been battered by COVID-19 and allegations of corruption, according to local reports.

The Philippines started to seriously consider universal healthcare in 2012, when lawmakers enacted a sin tax law that tightened the country’s alcohol and tobacco excise taxes to boost revenue for universal healthcare. The revenue was far better than expected — the government tripled the Department of Health’s budget, leading health policy lobbyists to campaign for even more tobacco excises.

As a result, the country’s universal healthcare system, which was signed into law in February 2019, is propped up by a network of excise taxes on tobacco, alcohol, and e-cigarettes.

But the country’s experience using excise taxes to fund universal healthcare could be a cautionary tale for others. According to a report in Healthcare Asia, the Philippines’ national health insurance program is expected to contract by at least a third this year because of the economy. Meanwhile, some Caribbean countries are thinking about adopting a similar strategy. In October the Pan American Health Organization and the Economic Commission for Latin America and the Caribbean hosted a webinar on how taxation can support COVID-19 responses, with excise taxation factored heavily in the conversation.

Global Outlook

By 2030 every country is supposed to provide universal healthcare — one of the U.N.’s 2030 sustainable development goals. The declaration couldn’t have come at a better time, considering that 90 percent of countries have seen their essential health services disrupted since the start of the COVID-19 pandemic.

Universal health coverage is a sustainable development goal because healthcare is unattainable for many around the world, although it is a fundamental human right. At least half the world’s population lacks full coverage for essential health services, and over 800 million people devote at least 10 percent of their household budgets to health care, according to the U.N.

At the heart of the 2030 goal is a “triple billion target”: attaining universal health coverage for an extra 1 billion people, ensuring that another 1 billion are better protected from health emergencies, and ensuring that a billion people have better health and well-being.

COVID-19 has expedited the discussion. U.N. Secretary-General Antonio Guterres says we are now in a global healthcare emergency and has urged countries to immediately speed up and scale up their investments in universal healthcare and health in general. But the job is easier said than done.

Two things are missing in the U.N.’s proclamation: how this universal healthcare goal will be paid for, and how to help countries build capacity in a way that is sustainable and affordable. The experiences of the countries above demonstrate that building universal healthcare is a multi-decade process with many setbacks along the way. But it’s worth pursuing. At the end of the day, discussions about healthcare and healthcare funding are about building resilience into our systems, Roope noted.

“It might not be another pandemic; it could be a bioterrorism incident, or a cyberattack. It could be any number of things that would have a big effect on our healthcare system,” Roope said. “I think building resilience is a bit like insurance as well. You know, in a sense, if nothing bad happens you’ve wasted your money on your insurance payments. But we all know that it’s generally a bad idea to not have insurance.”

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