How Will Single-Payer, State-Run Healthcare Fare Under a Pandemic?
03/24/2020
Nations are running a high-stakes experiment that may show how single-payer, state-run health-care systems fare under the strain of a pandemic.
Can systems comparable to Medicare-for-all in Britain, Canada, Denmark, South Korea and other countries do any better than the United States in slowing the coronavirus and treating those who become seriously ill from the novel pathogen?
The pandemic is only in its initial stages. Peak infections are weeks away in most countries, including the United States, according to the most recent forecasts. Vaccines and targeted antiviral medicines are not yet available.
It is too soon to see definite outcomes among competing health-care systems. But even in this early phase, public health experts say the single-payer, state-run systems are proving themselves relatively robust.
Unlike the United States, where a top health official told Congress the rollout of testing was “failing” and where Congress is only now moving through a bill that includes free testing, the single-payer countries have been especially nimble at making free, or low-cost, virus screening widely available for patients with coughs and fevers.
Denmark is offering some patients “drive-through” testing. South Korea is, too, and almost a quarter of a million people have been tested there. In Australia’s single-payer system, Hollywood couple Tom Hanks and Rita Wilson quickly learned they tested positive for the coronavirus.
Yet there are concerns about how well these health-care systems will cope if and when their caseloads surge and their hospitals, especially their intensive care units, become overwhelmed. Already in South Korea, doctors have had to ration care, based on the availability of beds.
And even more challenging: Countries such as Britain and Canada have far fewer ventilators, per capita, than the United States.
Here’s a snapshot of four countries with universal care.
Britain: Worries About Shortages of Staff & Intensive Care Beds
Founded after World War II, Britain’s taxpayer-funded National Health Service is free at the point of use for everyone in the country. It’s hard to overestimate just how proud Britons — across party lines — are of their health service. One indication: The NHS was celebrated at the 2012 London Olympics’ Opening Ceremonies with nurses and children dancing on hospital beds.
For all the love, the NHS has suffered under years of austerity budgets by Conservative Party governments. It faces a staffing shortage of about 100,000 caregivers, nurses and doctors. And there’s concern about the strains the coronavirus will place on a system without a lot of what analysts call “spare capacity.” Already, hospitals are more than 90 percent full without coronavirus sufferers.
Nor has the cash-strapped NHS invested in ventilators, which will soon be crucial for treating the very ill.
British officials revealed Sunday that they have 5,000 breathing machines for patients. By comparison, the United States has 160,000 ventilators available, according to the Center for Health Security at Johns Hopkins.
So desperate is the need in the United Kingdom that the health minister said the government will ask car manufacturers and army suppliers to shift their production lines to make ventilators.
“Have we got enough critical care beds? Is social care going to hold up?” said Helen Buckingham, director of strategy and operations at the Nuffield Trust, an independent think tank. “Those worries underline the importance of the plan of containment and delay. The longer we can push back the peak and the further we can squash it down, the less demand on critical care beds.”
During Britain’s last general election campaign, an image of a 4-year-old boy sleeping on a hospital floor drew national attention to the strains on the NHS. When a journalist tried to show Prime Minister Boris Johnson a photograph of the boy, he initially refused to look at it, then pocketed the reporter’s mobile phone.
Buckingham said the pressure the NHS is under “doesn’t mean it won’t be able to cope” with an escalation of coronavirus cases, but “it might mean that it needs to take some of the actions to enable it to cope sooner than it otherwise would have had to.”
During a public health emergency, she said, one advantage of a single-payer system such as the NHS is “there is no need for people to worry about the tests or vaccine or cost of care if people become ill.”
The top-down structure of the system can “sometimes be irritating because you want decisions taken at a local level,” Buckingham said. But for a major public health threat, “we have a very clear emergency planning structure. It means everybody knows what their responsibilities are and what the command and control structure is.
“The NHS comes into its own at a time like this,” she said.
Canada: Memories of the 2003 SARS Epidemic Have Made the System More Robust
In Canada, there is widespread consensus that its universal single-payer system has distinct advantages in this moment. Crucially, doctors say, people could seek care or get tested for the novel coronavirus from the outset without being scared off by any out-of-pocket costs. That has allowed the health system to isolate sick individuals quickly, conduct contact tracing and limit spread, at least in these early stages.
“It helps your control measures if people feel comfortable seeking health care,” said Michael Gardam, an infectious-disease expert and the chief of staff at Toronto’s Humber River Hospital.
“No one got turned away because they didn’t have the right insurance or because they showed up at a hospital in the wrong network,” said Isaac Bogoch, an infectious-disease specialist at Toronto General Hospital. “That’s helped.”
Canada has completed more than 17,000 tests since the outbreak began. As of Sunday night, 252 people had tested positive, including Sophie Grégoire Trudeau, the wife of Prime Minister Justin Trudeau; she might may have been exposed during a trip to London.
Canadian hospitals have been on high alert for the virus since the first reports of the disease emerged from China. Canada has on hand almost 5,000 ventilators — the same number as Britain for a population half the size of the United Kingdom’s — but the distribution is uneven across provinces.
Public health officials in Canada are keen to avoid a repeat of the 2003 SARS epidemic, which killed 44 people in Toronto — the highest number of deaths outside Asia.
An Ontario provincial commission that reviewed the outbreak blamed poor hospital infection-control procedures and an “unprepared” public health-care system for the illness’s rapid spread in Toronto.
Doctors said Ontario’s bungled response shouldn’t be blamed on Canada’s universal health-care system.
SARS “reflected undervaluation of hospital infection control in Ontario,” said David Fisman, an epidemiologist at the University of Toronto. “I note that British Columbia also had a public health system and dealt with the same burden of SARS importation as Toronto but flawlessly.”
Fisman said Canada’s system offers a further advantage over the U.S. model when confronting a pandemic.
“It’s a time of crisis,” he said, “and having a health-care system that’s a public strategic asset rather than a business run for profit allows for a degree of coordination and optimal use of resources.”
Denmark: Medical Students on the Front Lines and Drive-Through Testing for People With Symptoms
Scandinavian countries all offer a form of single-payer health care to their citizens, and medical professionals expect to see quick coordination during health crises such as this one.
Without a need to coordinate with insurance companies over costs, Denmark’s medical establishment was able to move quickly to address the coronavirus pandemic, said Jorgen Kurtzhals, the head of the University of Copenhagen medical school.
“The strength of the system is that you have a lot of really highly educated and well-trained staff, and given some quite un-detailed instructions, they can actually develop plans for an extremely rapid response,” Kurtzhals said.
Future doctors, nursing students and others training for medical roles have also been enlisted in the effort, he said.
“We don’t have to worry too much about whether this response or that response demands specific payments here and there,” Kurtzhals said. “We are aware that there will be huge expenditure within the system. But we’re not too concerned about it because we have a direct line of communication from the national government to the regional government to the hospital directors.”
Denmark has been able to provide widespread testing to its citizens; in some cities, it is offering drive-through tests to anyone with symptoms of the common cold. “A lot of people with regular cold symptoms got tested who never would have been tested elsewhere,” Kurtzhals said.
National authorities first tried to buy commercially available testing kits. When those were taking too long, authorities circulated the chemical formulas for diagnostic tests among labs across the country so that each lab could formulate the test itself.
Lawmakers on Thursday passed emergency legislation that gives national authorities sweeping powers to force citizens to get tested, stay quarantined and get vaccines if ever they become available — powers so all-encompassing that some officials said they were the most extensive since World War II.
As of Friday morning, Denmark had tested 3,747 people. By Sunday night, it had reported 875 cases and one death, an 81-year-old man who had a preexisting illness.
South Korea: Almost 250,000 Tested, Mostly Free, But Hospitals in Hard-Hit Area Are Overwhelmed
South Korea’s single-payer system has supported a massive testing endeavor that, along with extensive contact tracing, may be helping to lower the rate of coronavirus infections.
Limited availability of test kits was seen as one of the problems that aggravated the 2015 MERS outbreak in South Korea. After that, the country introduced an “emergency usage approval” system that expedited authorization of test kits for pathogens of pandemic potential. Its Centers for Disease Control and Prevention has moved quickly to work with local biotech companies to develop test kits and put them to use.
South Korea has administered a huge number of tests — more than 240,000 — about 10 times as many a day as Japan. As of Sunday night, the country had reported 8,162 cases and 75 deaths.
“Unhampered government intervention into the health-care sector is an advantage when the virus is spreading fast across the country,” said Choi Jae-wook, a professor of preventive medicine at Korea University in Seoul. “However, the centralized mechanism was slow to make use of the medical judgments of doctors on the ground.”
Free tests were initially granted to anyone who had traveled to China or had come into contact with other infected people. Others could still get a test but had to pay the cost, about $134. Now the tests are covered for anyone with a doctor’s referral.
“Many patients who didn’t qualify for the government-set criteria gave up on testing because of the cost,” Choi said. “If individual doctors could have approved coronavirus tests faster, many missed cases could have been detected in advance.”
South Korea has a large number of hospital beds, relative to its population size. But in Daegu, the southeastern city that accounts for over two-thirds of South Korea’s cases, the shortage of beds is a huge problem. So is the number of ventilators.
As patients with serious symptoms get priority in hospital bed assignment, about 2,000 coronavirus patients have been asked to quarantine themselves at home.
“The beds are allocated based on how symptomatic a virus patient is,” Daegu city spokesman Hong Heon-joo said. “It does not matter how much the patient is willing to pay for it out of his or her pocket.”
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